High-sensitivity troponin-T concentrations and long-term risk of death in patients with acute pulmonary embolism

Abstract Background Cardiac troponin elevation is associated with adverse short-term prognosis in patients with pulmonary embolism (PE). However, it is unknown whether high-sensitivity troponin concentrations predict long-term outcomes and whether serial measurements offer additional prognostic information in this setting. Purpose To determine short- and long-term prognostic implications of high-sensitivity troponin-T (hsTnT) concentrations and their changes from baseline, in patients with acute PE. Methods Retrospective cohort study based on Danish national registries. We identified all patients discharged from the hospital with a PE from 2013 through 2019 and merged them with all records of at least one hsTnT (99th percentile upper reference limit, 13.5 ng/l) measurement obtained during the same hospitalization. Absolute and relative risks for death from any cause at days 0-30 and 31-365 were calculated through multivariable logistic regression with average treatment effect modeling. Moreover, we tested whether hsTnT changes (in those who had a second measurement available ≥1 hour and ≤7 hours after the first measurement) were associated with additional prognostic information. Results At least one hsTnT measurement was available in 4611 individuals. Median age (25th-75th percentile) was 70.8 (58.6-79.5) years, and 2312 (50.1%) were women. One-hundred and forty-one (3.1%) patients had a prior venous thromboembolic event, 731 (15.9%) had known coronary artery disease, and 1001 (21.7%) had a history of cancer. Median baseline hsTnT was 29 (25th-75th percentile, 14-79) ng/l, and 1082 (76.5%) had an elevated concentration. Four-hundred and thirty-one (9.3%) individuals had died at 30 days, while an additional 614 (14.7% of 30-day survivors) died between days 31-365. hsTnT concentration displayed a significant, non-linear association with death (P<0.001). Figure 1 shows the unadjusted 30-day risk of death stratified for hsTnT quartiles, while Figure 2 shows the risk at days 31-365 (with 0 on the x-axis representing day 30 from the index event). Upon multivariable adjustment (including absence or presence of acute cor pulmonale), the risk of death at both timepoints remained significantly higher among individuals in each of quartiles 3 and 4 versus quartile 1 (P<0.05), with quartile 2 showing a trend (P=0.06 and P=0.07 for short- and long-term death, respectively). In 1247 subjects with two hsTnT measurements available, absolute and relative changes from baseline did not appear to carry additional prognostic information, nor did switching from normal to elevated hsTnT or vice versa, though the latter was only observed in very few persons. Conclusions In patients with acute PE, elevated hsTnT concentrations were associated with both short- and long-term mortality, but unlike in acute coronary syndromes, the utility of drawing a second sample appeared limited.Figure 1Figure 2