In a prespecified analysis of patients with ACS in the High-STEACS trial, the proportion of patients with elevated hs-cTnI increased six-fold as kidney function declined - from 10% at an eGFR of 90 or greater to 66% at an eGFR < 30 mL/min/1.73 m2 (P<0.001).
Yet, 35% of patients with kidney impairment and elevated hs-cTnI did not have myocardial infarction (MI) related to coronary thrombosis (type-1 MI), Dr. Nicolas Mills and the High-STEACS investigators report in JAMA Internal Medicine.
Following the implementation of hs-cTnI testing in the trial, the proportion of patients with an elevated troponin level rose from 37% to 47% in patients with kidney impairment and from 13% to 16% in those without kidney impairment (P<0.001 for both).
Yet, despite finding more patients with elevated troponin levels by hs-cTnI assay, one-year rates of type-1 MI or type-4b MI (occurring 48 hours or less after percutaneous coronary intervention) or cardiovascular death were unchanged before and after implementation of hs-cTnI testing in patients with (25% vs. 24%) and without kidney impairment (13% vs. 11%), they found.
The authors of an invited commentary, Dr. Keith Hemmert and Dr. Benjamin Sun of the University of Pennsylvania, in Philadelphia, say this study addresses a "pressing" issue.
The analysis highlights the need for "thoughtful use of hs-cTn testing, particularly in patients with kidney impairment," they write. "While hs-cTn testing has acceptable sensitivity as part of a workup to rule out MI, kidney impairment poses a particular challenge."
"Decreased kidney clearance of troponin often results in elevated serum levels that do not reflect true myocardial injury. However, patients with kidney disease are at elevated risk for cardiovascular disease, and kidney disease is often comorbid with conditions that are cardiovascular risk factors, such as hypertension, dyslipidemia, and diabetes. Thus, there is a need to accurately detect myocardial injury in this high-risk population, but the lower specificity of hs-cTn testing compared with conventional troponin assays for all populations has the potential to trigger unnecessary stress tests, angiograms, coronary revascularization procedures, and admissions for all patients, and this potential is particularly high in the population with kidney impairment."
"Despite these challenges, it is not operationally feasible to use different troponin assays (conventional vs high sensitivity) for different patient populations," they write.
Summing up, Dr. Hemmert and Dr. Sun say, "Further research focused on the performance characteristics of comprehensive strategies to rule in and rule out suspected MI in patients with kidney impairment, with an emphasis on composite cardiac outcomes, is necessary to guide clinical implementation."
The study had no commercial funding. The authors have indicated no relevant disclosures.
SOURCE: https://bit.ly/3ioisSN and https://bit.ly/3io2F6p JAMA Internal Medicine, online June 7, 2021.
By Reuters Staff
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