Original Article

The Prognostic Value of Serum Troponin T in Unstable Angina

Christian W. Hamm, M.D., Jan Ravkilde, M.D., Willie Gerhardt, M.D., Poul Jørgensen, M.Sc., Edgar Peheim, D.V.M., Lars Ljungdahl, M.D., Britta Goldmann, M.D., and Hugo A. Katus, M.D.

N Engl J Med 1992; 327:146-150July 16, 1992

Abstract

Abstract

Background.

Cardiac troponin T is a regulatory contractile protein not normally found in blood. Its detection in the circulation has been shown to be a sensitive and specific marker for myocardial cell damage. We used a newly developed enzyme immunoassay for troponin T to determine whether its presence in the serum of patients with unstable angina was a prognostic indicator.

Full Text of Background....

Methods.

We screened 109 patients with unstable angina (25 with accelerated or subacute angina and 84 with acute angina at rest) for serum creatine kinase activity, creatine kinase isoenzyme MB activity, and troponin T every eight hours for two days after admission to the hospital. The outcomes of interest during the hospitalization were death and myocardial infarction.

Full Text of Methods....

Results.

Troponin T was detected (range, 0.20 to 3.64 μg per liter; mean, 0.78; median, 0.50) in the serum of 33 of the 84 patients (39 percent) with acute angina at rest. Only three of these patients had elevated creatine kinase MB activity (two were positive for troponin T, and one was negative). Of the 33 patients who were positive for troponin T, 10 (30 percent) had myocardial infarction (3 after coronary-artery bypass surgery), and 5 of these died during hospitalization. In contrast, only 1 of the 51 patients with angina at rest who were negative for troponin T had an acute myocardial infarction (P<0.001), and this patient died (P = 0.03). Thus, 10 of the 11 patients with myocardial infarctions had detectable levels of troponin T; only 1 had elevated creatine kinase MB activity. Troponin T was not detected in any of the 25 patients with accelerated or subacute angina, and none of these patients died.

Full Text of Results....

Conclusions.

Cardiac troponin T in serum appears to be a more sensitive indicator of myocardial-cell injury than serum creatine kinase MB activity, and its detection in the circulation may be a useful prognostic indicator in patients with unstable angina. (N Engl J Med 1992;327:146–50.)

Full Text of Conclusions....

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Media in This Article

Figure 1Representative Patterns of Release of Troponin T in Patients with Unstable Angina.

Table 1Clinical Data on 84 Patients with Angina at Rest (Braunwald Class 3), According to Whether They Were Negative or Positive for Troponin T.

Article Activity

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Article

UNSTABLE angina is a critical phase of ischemic heart disease associated with a high risk of myocardial infarction and sudden death.1 Postmortem studies reveal that these fatal events are frequently preceded by microinfarcts.2 , 3 They are the result of the fissuring of atheromatous plaques with subsequent activation of platelets,4 5 6 thrombus formation,7 8 9 10 11 12 and episodic embolization.2 , 3 Increased creatine kinase activity is found, however, in only a small percentage of patients with unstable angina.13

After the loss of integrity of myocardial-cell membranes in severe ischemia, proteins of the cardiac contractile apparatus, such as the regulatory contractile protein troponin T, are released into the circulation.14 Cardiac troponin T can be differentiated from its isoforms in skeletal muscle by immunologic techniques, and it is not detectable in the serum of healthy people. Circulating troponin T is therefore a highly sensitive and specific marker of myocardial-cell injury.

Previous enzyme immunoassays for serum troponin T were based on the use of affinity-purified polyclonal antiserum and monoclonal antibodies and were applied to patients with acute myocardial infarctions.15 , 16 Recently, a specific and even more sensitive assay has been developed that uses two monoclonal antibodies and provides highly reproducible results in routine clinical testing.17 We investigated the value of this assay for routine use in patients with unstable angina, to see whether the presence of cardiac troponin T might be a useful predictor of prognosis.

Methods

Patients

The study population consisted of 109 consecutive patients (29 women and 80 men; mean age [±SD], 62±11 years) who were hospitalized for unstable angina in four European centers (Aarhus, Denmark; Helsingborg, Sweden; and Heidelberg and Hamburg, Germany). When acute myocardial infarction that met the electrocardiographic and enzymatic criteria of the World Health Organization (creatine kinase activity, ≥200 U per liter)18 was excluded, the diagnosis of unstable angina was based on the clinical presentation of chest pain. Patients with myocardial infarction documented within the previous two weeks who had valvular heart disease or cardiomyopathy were also excluded. Reviewers unaware of the patients' troponin T values categorized them as follows, using Braunwald's19 classification of unstable angina: 11 patients were assigned to class 1 (severe or accelerated angina of new onset), 14 patients to class 2 (subacute angina at rest — i.e., not active within the previous 48 hours), and 84 patients to class 3 (angina at rest during the previous 48 hours).

All the patients were given bed rest and an intensive medical regimen that included nitrates (given orally in 84 patients and intravenously in 57), beta-blockers (63 patients), and calcium-channel blockers (78 patients). All the patients received aspirin or heparin according to local practice. Standard 12-lead electrocardiography was performed routinely at the time of admission and during episodes of chest pain. The electrocardiograms were evaluated blindly for evidence of reversible myocardial ischemia, defined as transient ST elevation, ST depression, and T-wave inversion.

Study Protocol

The study protocol was approved by the ethics committee at the University of Heidelberg. After informed consent was obtained from each patient, 10 ml of blood was collected within six hours of admission to the hospital and every eight hours thereafter for two days. The samples were kept at room temperature for 20 minutes to allow clotting, were centrifuged, and were then stored at — 20°C. The values listed for troponin T represent the peak concentrations during each collection period.

All the patients were followed at least until discharge from the hospital to record cardiac events (myocardial infarction or death) or the need for interventions (coronary angioplasty or bypass surgery). All therapeutic decisions were made without knowledge of the patients' troponin T levels. Patients with left main coronary artery disease and severe triple-vessel disease not stabilized with medical treatment were referred for bypass surgery. Coronary angioplasty was performed in patients with single-vessel disease and in selected patients with double- or triple-vessel disease.

Analytic Techniques

The biochemical analysis was performed by technicians unaware of the patients' histories. For the quantitative determination of serum troponin T, an enzyme immunologic assay (Boehringer, Mannheim, Germany) was used. Based on a technique using streptavidin, this single-step sandwich assay allows serial determination of blood samples to be made within two hours.17 The test is carried out in microprocessor-controlled photometers (ES 22, Boehringer) and requires streptavidin-coated tubes as the solid phase and two monoclonal antihuman cardiac troponin T antibodies.17 During a 60-minute incubation period, the antigen (in this case, troponin T) is bound by one biotinylated and one peroxidase-labeled antibody. This complex adheres to the test-tube wall because of the high-affinity streptavidin—biotin interaction. After two washing steps, the substrate chromogen solution (ABTS, Boehringer) is added. Substrate conversion is quantified by the occurrence of a change in color at 405 nm, which directly correlates with the concentration of troponin T in the blood sample. The level of sensitivity of this test is 0.20 μg per liter.20 Values ≥0.20 μg per liter were considered positive for troponin T in this study.

In the same serum samples, the activity of creatine kinase was measured colorimetrically at 37°C (NAC, Merck, Darmstadt, Germany) by the standard method of the European Committee for Clinical and Laboratory Standards and the Scandinavian Committee on Enzymes (reference range in normal people, <200 U per liter in men and <150 U per liter in women).20 , 21 Creatine kinase isoenzyme MB was assessed by an immunoinhibition assay (Merck) (reference range, <25 U per liter).23 , 24

Statistical Analysis

All the results are expressed as means ±SD, except as stated otherwise. An exploratory analysis of data was performed with the Freeman—Halton test (two-tailed)25 in the groups with and without detectable levels of troponin T. Continuous variables were analyzed with unpaired t-tests. P values <0.05 were considered to indicate statistical significance.

Positive predictive value was calculated as the number of true positive test results among all positive test results observed, and negative predictive value as the number of true negative test results among all negative test results observed.

Results

At the time of admission, none of the patients had elevated total creatine kinase activity or electrocardiographic abnormalities indicative of acute myocardial infarction. In the 25 patients with class 1 or 2 unstable angina, both creatine kinase and creatine kinase MB activity were within the normal range during the 48 hours of sampling. In none of the 150 blood samples from these patients was troponin T measurable, and these patients had no cardiac events during hospitalization.

In contrast, 33 (39 percent) of the 84 patients with acute angina at rest (class 3) had measurable levels of troponin T (0.79±0.80 μg per liter; range, 0.20 to 3.64; median, 0.50). In 28 of these 33 patients, troponin T was measurable (at levels ≥0.20 μg per liter) in the first or second sample obtained after admission. In the remaining five patients, the first serum sample with a detectable level of troponin T was obtained 16 to 24 hours after admission and was associated with recurrent episodes of angina at rest. Two representative patterns of troponin T release are shown in Figure 1Figure 1Representative Patterns of Release of Troponin T in Patients with Unstable Angina.. In 51 of the 84 patients with angina at rest (61 percent), no troponin T could be measured. In only 3 of the 84 patients (4 percent), of whom 1 was negative and 2 were positive for troponin T, was creatine kinase MB activity increased (to 25, 29, and 32 U per liter).

The patients with and those without measurable levels of troponin T did not differ with respect to baseline clinical characteristics and treatment (Table 1Table 1Clinical Data on 84 Patients with Angina at Rest (Braunwald Class 3), According to Whether They Were Negative or Positive for Troponin T.). Coronary angiography in 63 patients with class 3 angina revealed comparable degrees of coronary disease in the groups positive and negative for troponin T (Table 1). The six patients with normal coronary arteries had no measurable troponin T in serum.

During hospitalization, coronary angioplasty was necessary in 31 patients (15 negative and 16 positive for troponin T), and bypass surgery was performed in 17 patients (9 negative and 8 positive). The differences between the groups were not statistically significant (Table 2Table 2Interventions and Cardiac Events during Hospitalization in Patients with Angina at Rest, According to Whether They Were Negative or Positive for Troponin T.).

Clinical outcomes during hospitalization (duration, 21±7 days) were related to the presence of detectable levels of serum troponin T. Of the 33 patients who were positive for troponin T, 10 (30 percent) had acute myocardial infarctions within 2 to 10 days after hospitalization that were associated with new ST elevations (Table 3Table 3Major Cardiac Events during Hospitalization and Date of Occurrence.*). All patients with infarction were treated with aspirin. In two patients (Patients 10 and 11, Table 3) the vessel with an infarct could be opened by coronary angioplasty within two hours after the onset of symptoms. Three infarcts occurred after coronary-bypass surgery and resulted in death. Five of the 33 patients who were positive for troponin T (15 percent) died during hospitalization. In contrast, only 1 of the 51 patients who were negative for troponin T (2 percent) had an acute myocardial infarction; it occurred seven days after admission, and the patient died. The incidence of myocardial infarction (P<0.001) and death (P = 0.03) was significantly different between the groups positive and negative for troponin T (Table 2).

Ten of the 11 acute myocardial infarctions were preceded by the detection of measurable levels of serum troponin T. Creatine kinase MB activity was elevated in only one of these patients, however, and the total creatine kinase activity was normal in all. Accordingly, the positive predictive value of a detectable level of troponin T for acute myocardial infarction in this population of patients was 30 percent, and the negative predictive value was 98 percent. Of the 11 patients with myocardial infarctions, 8 had measurable levels of troponin T in the serum sample obtained within six hours of admission. In two other patients (Patients 1 and 7), troponin T was first detected in the fourth sample (on day 2), after recurrent episodes of angina at rest (Table 3). Of the 62 serum samples obtained from these 11 patients, 51 had measurable levels of troponin T.

Discussion

Unstable angina is a critical phase of ischemic heart disease, but there are no reliable, noninvasive methods of assigning patients to different prognostic categories. An unfavorable outcome has been linked with the occurrence of frequent episodes of symptomatic26 or silent27 , 28 myocardial ischemia during 48 hours of intensive medical therapy. A subgroup of high-risk patients can be identified by the detection of transient shifts of the ST-T segment on serial electrocardiograms.29 30 31 Minor elevations of creatine kinase and creatine kinase MB activity have not been found to be consistently related to adverse outcomes.13 , 32 Histologic findings, however, strongly suggest that minor myocardial-cell necrosis occurs in high-risk patients more frequently than is suggested by determinations of serum creatine kinase activity.2 , 3

Previous studies in patients have shown that higher sensitivity and specificity for the detection of myocardial-cell injury are provided by measurements of circulating levels of cardiac contractile proteins, which are normally absent from the blood.14 In cardiac muscle, multiple isoforms of the contractile proteins myosin and actin and the regulatory proteins tropomyosin and the troponin complex have been found.33 34 35 Among these proteins, troponin T and troponin I appear to be unique cardiac antigens.14 , 15 Recently, specific monoclonal antibodies have been developed against cardiac troponin T that have essentially no cross-reactivity with their isoforms in skeletal muscle.17 The assay for troponin T used in this study allows measurements in serum samples to be made within two hours,17 and it therefore appears suitable for routine use. The assay's analytic sensitivity and specificity have previously been established17 and were further confirmed by the present results. Comparable analytic sensitivity may be obtained only by a recently introduced serologic assay for creatine kinase MB.20 , 36

In the present study, troponin T was more sensitive than creatine kinase MB activity in the detection of minor myocardial-cell injury in patients with unstable angina. Neither troponin T nor creatine kinase MB was elevated in serum samples from patients with subacute or accelerated angina (classes 1 and 2 of Braunwald19). However, troponin T was found in 39 percent of patients with persistent angina at rest when blood samples were obtained at eight-hour intervals for two days after admission to the hospital. In contrast, creatine kinase MB activity was increased in only 3 percent of these patients. Ten of 11 in-hospital myocardial infarctions occurred in patients whose serum was positive for troponin T, whereas creatine kinase MB activity was elevated in only 1 patient. When no troponin T was measurable, the hospital course was uneventful in 50 of 51 patients. Accordingly, the predictive value of a positive test result for an adverse outcome was 30 percent, and that of a negative test result for a favorable outcome was 98 percent.

Technetium-99m stannous pyrophosphate scintigraphy has detected limited and diffuse subendocardial necrosis in one third of patients with unstable angina37 and can identify high-risk patients.38 Our findings are consistent with these data and also with a previous report39 that described adverse outcomes in a smaller series of patients with circulating myosin light chains.

Besides the unfavorable outcomes in patients with measurable levels of troponin T who were treated medically, our patients appeared to be at higher risk during coronary-artery bypass surgery. Surgery in patients with angina at rest that is refractory to medical treatment is known to be associated with higher complication rates.40 , 41 All three fatal perioperative myocardial infarctions in our series occurred in patients with measurable levels of troponin T in the serum.

In unstable angina, reversible as well as irreversible cell injury may occur. Troponin T is found in myocytes in both a small free cytosolic pool and a larger, structurally bound fraction.16 A loss of cell-membrane integrity during severe ischemia results in only transient leakage from the cytosolic pool. Irreversible cell damage with degradation of myofilaments, however, is followed by a delayed but continuous liberation of the bound troponin T fraction. Accordingly, in acute myocardial infarction, a biphasic pattern of release with peaks at 14 hours and three to five days has been demonstrated.15 The presence of circulating cardiac proteins in patients with unstable angina may be explained by the intermittent critical reduction of flow as a result of intracoronary thrombus formation, resulting in reversible damage to the cell membrane, and also by minor local cell necrosis due to thrombotic microembolization.2 , 3

The present results suggest that measurement of troponin T in serum allows a useful prediction of risk in patients with unstable angina. Cardiac risk during hospitalization may be estimated by measurement of troponin T soon after admission to the hospital, and such measurement may help to guide decisions about management.

Presented in part at the 63rd Scientific Session of the American Heart Association, Dallas, November 12–15, 1990.

We are indebted to Professor Dr. Berger, director of the Institute of Biostatistics at the University of Hamburg, for statistical advice; to Mrs. Kim Chen and Michael Schlueter, Ph.D., for review of the manuscript; and to Mrs. Carola Franke for assistance in the preparation of the manuscript.

Source Information

From the Department of Cardiology, Medical Clinic, University Hospital of Hamburg (C.W.H., B.G.), and the Department of Medicine, University Hospital of Heidelberg (H.A.K.), both in Germany; the Department of Internal Medicine and Cardiology, University Hospital of Aarhus (J.R.), and the Department of Clinical Chemistry, University Hospital, Odense (P.J.), both in Denmark; the Departments of Clinical Chemistry (W.G.) and Cardiology (L.L.), Nya Lasarettet, Helsingborg, Sweden; and the Department of Clinical Chemistry, Inselspital, University of Bern, Switzerland (E.P.). Address reprint requests to Dr. Hamm at the University Hospital Eppendorf, Medical Clinic, Dept. of Cardiology, Martinistrasse 52, 2000 Hamburg 20, Germany.

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   Andrew J.S. Coats. (2010) Retraction of a paper containing plagiarized material: The prognostic value of serum troponin T in unstable angina. Gökhan Cin V, Gök H, Kaptanoğlu B. Int J Cardiol. 1996 Mar;53(3):237–44. International Journal of Cardiology 145:3, e81-e82
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