High-sensitivity troponin T and risk stratification in patients with atrial
fibrillation during treatment with apixaban or warfarin.
Author(s): Hijazi Z(1), Wallentin L(2), Siegbahn A(3), Andersson U(4), Alexander JH(5), Atar
D(6), Gersh BJ(7), Hanna M(8), Harjola VP(9), Horowitz JD(10), Husted S(11),
Hylek EM(12), Lopes RD(5), McMurray JJ(13), Granger CB(5); ARISTOTLE
Investigators.
Affiliation(s): Author information:
(1)Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Section of
Cardiology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
Electronic address: ziad.hijazi@ucr.uu.se.
(2)Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Section of
Cardiology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
(3)Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Section of
Clinical Chemistry, Department of Medical Sciences, Uppsala University, Uppsala,
Sweden.
(4)Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
(5)Duke Clinical Research Institute, Duke University Medical Center, Durham, North
Carolina.
(6)Department of Cardiology, Oslo University Hospital Ulleval and Faculty of
Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway.
(7)Mayo Clinic College of Medicine, Rochester, Minnesota.
(8)Bristol-Myers Squibb, Princeton, New Jersey.
(9)Division of Emergency Care, Department of Medicine, Helsinki University Central
Hospital, Helsinki, Finland.
(10)University of Adelaide, Adelaide, South Australia, Australia.
(11)Medical Department, Hospital Unit West, Herning/Holstbro, Denmark.
(12)Boston University Medical Center, Boston, Massachusetts.
(13)BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland,
United Kingdom.
Publication date & source: 2014, J Am Coll Cardiol. , 63(1):52-61
OBJECTIVES: The aim of this study was to evaluate the prognostic value of
high-sensitivity troponin T (hs-TnT) in addition to clinical risk factors and the
CHA2DS2VASc (congestive heart failure, hypertension, 75 years of age and older,
diabetes mellitus, previous stroke or transient ischemic attack, vascular
disease, 65 to 74 years of age, female) risk score in patients with atrial
fibrillation (AF).
BACKGROUND: The level of troponin is a powerful predictor of cardiovascular
events and mortality.
METHODS: A total of 14,897 patients with AF were randomized to treatment with
apixaban or warfarin in the ARISTOTLE (Apixaban for the Prevention of Stroke in
Subjects With Atrial Fibrillation) trial. The associations between baseline
hs-TnT levels and outcomes were evaluated using adjusted Cox regression models.
RESULTS: Levels of hs-TnT were measurable in 93.5% of patients; 75% had levels
>7.5 ng/l, 50% had levels >11.0 ng/l, and 25% had levels >16.7 ng/l. During a
median 1.9-year period, the annual rates of stroke or systemic embolism ranged
from 0.87% in the lowest hs-TnT quartile to 2.13% in the highest hs-TnT quartile
(adjusted hazard ratio [HR]: 1.94; 95% confidence interval [CI]: 1.35 to 2.78; p
= 0.0010). The annual rates in the corresponding groups ranged from 0.46% to
4.24% (adjusted HR: 4.31; 95% CI: 2.91 to 6.37; p < 0.0001) for cardiac death and
from 1.26% to 4.21% (adjusted HR: 1.91; 95% CI: 1.43 to 2.56; p = 0.0001) for
major bleeding. Adding hs-TnT levels to the CHA2DS2VASc score improved the C
statistic from 0.620 to 0.635 for stroke or systemic embolism (p = 0.0226), from
0.592 to 0.711 for cardiac death (p < 0.0001), and from 0.591 to 0.629 for major
bleeding (p < 0.0001). Apixaban reduced rates of stroke, mortality, and bleeding
regardless of the hs-TnT level.
CONCLUSIONS: Levels of hs-TnT are often elevated in patients with AF. The hs-TnT
level is independently associated with an increased risk of stroke, cardiac
death, and major bleeding and improves risk stratification beyond the CHA2DS2VASc
risk score. The benefits of apixaban as compared with warfarin are consistent
regardless of the hs-TnT level. (Apixaban for the Prevention of Stroke in
Subjects With Atrial Fibrillation [ARISTOTLE]; NCT00412984).
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