Prognostic value of cardiac troponin in patients with chronic kidney disease without suspected acute coronary syndrome: A systematic review and meta-analysis

Erin Donnelly Michos, Lisa Wilson, Hsin Chieh Yeh, Zackary Berger, Catalina Suarez-Cuervo, Sylvie R. Stacy, Eric B Bass

Research output: Contribution to journalArticle

Abstract

Background: Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS).

Purpose: To systematically review the literature on troponin testing in patients with CKD without ACS.

Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014.

Study Selection: Studies examining elevated versus normal troponin levels in patients with CKD without ACS.

Data Extraction: Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Metaanalyses were conducted when studies had sufficient homogeneity of key variables.

Data Synthesis: Ninety-eight studies met inclusion criteria. Elevated troponin levels were associated with all-cause and cardiovascular mortality among patients receiving dialysis (moderate SOE). Pooled hazard ratios (HRs) for all-cause mortality from studies that adjusted for age and coronary artery disease or a risk equivalent were 3.0 (95% CI, 2.4 to 4.3) for troponin T and 2.7 (CI, 1.9 to 4.6) for troponin I. The pooled adjusted HRs for cardiovascular mortality were 3.3 (CI, 1.8 to 5.4) for troponin T and 4.2 (CI, 2.0 to 9.2) for troponin I. Findings were similar for patients with CKD who were not receiving dialysis, but there were fewer studies. No study tested treatment strategies by troponin cut points.

Limitation: Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up.

Conclusion: In patients with CKD without suspected ACS, elevated troponin levels were associated with worse prognosis. Future studies should focus on whether this biomarker is more appropriate than clinical models for reclassifying risk of patients with CKD and whether such classification can help guide treatment in those at highest risk for death.

Primary Funding Source: Agency for Healthcare Research and Quality.

Original languageEnglish (US)
Pages (from-to)491-501
Number of pages11
JournalAnnals of Internal Medicine
Volume161
Issue number7
DOIs
StatePublished - Oct 7 2014

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Troponin
Acute Coronary Syndrome
Chronic Renal Insufficiency
Meta-Analysis
Troponin T
Troponin I
Mortality
Dialysis
Information Storage and Retrieval
Health Services Research
MEDLINE
Uncertainty
Coronary Artery Disease
Biomarkers
Therapeutics

ASJC Scopus subject areas

  • Internal Medicine
  • Medicine(all)

Cite this

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title = "Prognostic value of cardiac troponin in patients with chronic kidney disease without suspected acute coronary syndrome: A systematic review and meta-analysis",
abstract = "Background: Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS).Purpose: To systematically review the literature on troponin testing in patients with CKD without ACS.Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014.Study Selection: Studies examining elevated versus normal troponin levels in patients with CKD without ACS.Data Extraction: Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Metaanalyses were conducted when studies had sufficient homogeneity of key variables.Data Synthesis: Ninety-eight studies met inclusion criteria. Elevated troponin levels were associated with all-cause and cardiovascular mortality among patients receiving dialysis (moderate SOE). Pooled hazard ratios (HRs) for all-cause mortality from studies that adjusted for age and coronary artery disease or a risk equivalent were 3.0 (95{\%} CI, 2.4 to 4.3) for troponin T and 2.7 (CI, 1.9 to 4.6) for troponin I. The pooled adjusted HRs for cardiovascular mortality were 3.3 (CI, 1.8 to 5.4) for troponin T and 4.2 (CI, 2.0 to 9.2) for troponin I. Findings were similar for patients with CKD who were not receiving dialysis, but there were fewer studies. No study tested treatment strategies by troponin cut points.Limitation: Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up.Conclusion: In patients with CKD without suspected ACS, elevated troponin levels were associated with worse prognosis. Future studies should focus on whether this biomarker is more appropriate than clinical models for reclassifying risk of patients with CKD and whether such classification can help guide treatment in those at highest risk for death.Primary Funding Source: Agency for Healthcare Research and Quality.",
author = "Michos, {Erin Donnelly} and Lisa Wilson and Yeh, {Hsin Chieh} and Zackary Berger and Catalina Suarez-Cuervo and Stacy, {Sylvie R.} and Bass, {Eric B}",
year = "2014",
month = "10",
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doi = "10.7326/M14-0743",
language = "English (US)",
volume = "161",
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T1 - Prognostic value of cardiac troponin in patients with chronic kidney disease without suspected acute coronary syndrome

T2 - A systematic review and meta-analysis

AU - Michos, Erin Donnelly

AU - Wilson, Lisa

AU - Yeh, Hsin Chieh

AU - Berger, Zackary

AU - Suarez-Cuervo, Catalina

AU - Stacy, Sylvie R.

AU - Bass, Eric B

PY - 2014/10/7

Y1 - 2014/10/7

N2 - Background: Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS).Purpose: To systematically review the literature on troponin testing in patients with CKD without ACS.Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014.Study Selection: Studies examining elevated versus normal troponin levels in patients with CKD without ACS.Data Extraction: Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Metaanalyses were conducted when studies had sufficient homogeneity of key variables.Data Synthesis: Ninety-eight studies met inclusion criteria. Elevated troponin levels were associated with all-cause and cardiovascular mortality among patients receiving dialysis (moderate SOE). Pooled hazard ratios (HRs) for all-cause mortality from studies that adjusted for age and coronary artery disease or a risk equivalent were 3.0 (95% CI, 2.4 to 4.3) for troponin T and 2.7 (CI, 1.9 to 4.6) for troponin I. The pooled adjusted HRs for cardiovascular mortality were 3.3 (CI, 1.8 to 5.4) for troponin T and 4.2 (CI, 2.0 to 9.2) for troponin I. Findings were similar for patients with CKD who were not receiving dialysis, but there were fewer studies. No study tested treatment strategies by troponin cut points.Limitation: Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up.Conclusion: In patients with CKD without suspected ACS, elevated troponin levels were associated with worse prognosis. Future studies should focus on whether this biomarker is more appropriate than clinical models for reclassifying risk of patients with CKD and whether such classification can help guide treatment in those at highest risk for death.Primary Funding Source: Agency for Healthcare Research and Quality.

AB - Background: Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS).Purpose: To systematically review the literature on troponin testing in patients with CKD without ACS.Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014.Study Selection: Studies examining elevated versus normal troponin levels in patients with CKD without ACS.Data Extraction: Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Metaanalyses were conducted when studies had sufficient homogeneity of key variables.Data Synthesis: Ninety-eight studies met inclusion criteria. Elevated troponin levels were associated with all-cause and cardiovascular mortality among patients receiving dialysis (moderate SOE). Pooled hazard ratios (HRs) for all-cause mortality from studies that adjusted for age and coronary artery disease or a risk equivalent were 3.0 (95% CI, 2.4 to 4.3) for troponin T and 2.7 (CI, 1.9 to 4.6) for troponin I. The pooled adjusted HRs for cardiovascular mortality were 3.3 (CI, 1.8 to 5.4) for troponin T and 4.2 (CI, 2.0 to 9.2) for troponin I. Findings were similar for patients with CKD who were not receiving dialysis, but there were fewer studies. No study tested treatment strategies by troponin cut points.Limitation: Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up.Conclusion: In patients with CKD without suspected ACS, elevated troponin levels were associated with worse prognosis. Future studies should focus on whether this biomarker is more appropriate than clinical models for reclassifying risk of patients with CKD and whether such classification can help guide treatment in those at highest risk for death.Primary Funding Source: Agency for Healthcare Research and Quality.

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