503 troponin t and quantitative st segment depression

Troponin T and Quantitative ST-segmentTroponin T and Quantitative ST-segment
Depression Offer ComplementaryDepression Offer Complementary
Prognostic Information in the RiskPrognostic Information in the Risk
Stratification of Acute CoronaryStratification of Acute Coronary
Syndrome PatientsSyndrome Patients
Padma Kaul; L. Kristin Newby; Yuling Fu; VicPadma Kaul; L. Kristin Newby; Yuling Fu; Vic
Hasselblad; Ken W. Mahaffey; Robert H.Hasselblad; Ken W. Mahaffey; Robert H.
Christenson; Robert A. Harrington; E. MagnusChristenson; Robert A. Harrington; E. Magnus
Ohman; Eric J. Topol; Robert M. Califf; Frans Van deOhman; Eric J. Topol; Robert M. Califf; Frans Van de
Werf; Paul W. Armstrong; for the PARAGON-BWerf; Paul W. Armstrong; for the PARAGON-B
InvestigatorsInvestigators

cTnT and STcTnT and ST↓↓ in Predicting Outcomes:in Predicting Outcomes:
ObjectivesObjectives
 Assess incremental value of cTnT and ECG forAssess incremental value of cTnT and ECG for
risk-stratification of non-ST-segment elevationrisk-stratification of non-ST-segment elevation
ACS patientsACS patients
 Examine whether ST-segment depressionExamine whether ST-segment depression
provided additional insight into therapeuticprovided additional insight into therapeutic
efficacy of GPIIb/IIIa therapyefficacy of GPIIb/IIIa therapy

Unstable Angina/NQWMI
(n=5225)
Lamifiban 500 µg Bolus
1.0 - 2.0 µg/min x 3 days or d/c +
weight-adjusted IV heparin
Placebo Bolus/Infusion
+ weight-adjusted IV heparin
All patients receive aspirin 150 - 325 QD
Lamifiban infusion rate based on renal function
Endpoint:
Composite of 30-day death, MI,
recurrent ischemia with urgent intervention
Trial Design

Patient PopulationPatient Population
T -
2 6 2 ( 6 8 % )
T +
1 2 5 ( 3 2 % )
N o S T - d e p
3 8 7 ( 4 0 % )
T -
2 5 9 ( 6 0 % )
T +
1 7 4 ( 4 0 % )
1 m m S T - d e p
4 3 3 ( 4 5 % )
T -
5 7 ( 4 1 % )
T +
8 2 ( 5 9 % )
+ 2 m m S T - d e p
1 3 9 ( 1 5 % )
9 5 9 p a t i e n t s w i t h
n o E C G c o n f o u n d e r s
1 1 4 0 w i t h b a s e l i n e E C G d a t a
1 1 6 0 T n T s u b - s t u d y p a t i e n t s
P A R A G O N - B S t u d y
5 2 2 5 p a t i e n t s

MethodsMethods
 cTnT assays performed at acTnT assays performed at a core laboratorycore laboratory
 TnT positive: TnT levels greater than 0.1TnT positive: TnT levels greater than 0.1
ng/mlng/ml
 ECGECG evaluated centrallyevaluated centrally..
 ST-segment depression (STST-segment depression (ST↓↓) :) :
 1) no ST1) no ST↓↓
 2) 1mm ST2) 1mm ST↓↓ in two contiguous leadsin two contiguous leads
 3) ST3) ST↓↓ ≥≥ 2 mm in two contiguous leads2 mm in two contiguous leads
 Patients with ECG confounders werePatients with ECG confounders were
excludedexcluded

Selected Baseline CharacteristicsSelected Baseline Characteristics
Variable No ST-dep 1mm ST-dep 2mm ST-dep
N 387 433 139
Age 61 (51, 68) 65 (55, 73) 69 (61, 74)*
Female 35.1 42.0 28.8*
Diabetes 17.6 20.8 23.0
Previous MI 26.4 27.5 41.7*
Troponin+ 32.3 40.2 59.0*
*p<0.05*p<0.05

Relationship between ST-segmentRelationship between ST-segment
depression and outcomesdepression and outcomes
0
5
10
15
20
25
No ST-dep 1mm ST-dep 2mm ST-dep
Death/MIRate
6-Month Dth 6-Month Dth/ MIχχ2 dth=17.1; p<0.012 dth=17.1; p<0.01
χχ2 dth/MI=13.8;2 dth/MI=13.8;
N=387N=387
N=433N=433
N=139N=139

Relationship between cTnT quartilesRelationship between cTnT quartiles
and 6M death/(re)-MIand 6M death/(re)-MI
0
5
10
15
20
25
0.0 ng/ dL 0.01 - 0.047 0.048 - 0.277 0.278 +
Death/MIRate
6-Month Dth 6-Month Dth/ MI
N=365N=365
N=113N=113
N=241N=241
N=240N=240
χχ2 dth=18.5; p<0.012 dth=18.5; p<0.01
χχ2 dth/MI=30.6;2 dth/MI=30.6;

6M Survival by ST6M Survival by ST ↓↓ and cTnTand cTnT
categoriescategories
Follow-up in days
1801501209060300
1.00
.95
.90
.85
.80
.75
.70
Troponin negative
Troponin positive
p=0.03
Follow-up in days
1801501209060300
1.00
.95
.90
.85
.80
.75
.70
No ST-dep
1mm ST-dep
2mm ST-dep
p=0.04
p=0.03 p<0.01
p<0.01

6M Death/(re)-MI rates by cTnT and ST6M Death/(re)-MI rates by cTnT and ST ↓↓
0
5
10
15
20
25
30
35
No ST-dep (N=387) 1mm ST-dep (N=433) 2mm ST-dep(N=139)
T- T+
p=0.20p=0.20
p=0.13p=0.13
p=0.15p=0.15

Multivariable Predictors of 6M Death/Multivariable Predictors of 6M Death/
(re)-MI(re)-MI
Worse outcomeWorse outcomeBetter outcomeBetter outcome
Age (10 year)
Prior PTCA
PVD
1mm ST-dep
2mm ST-dep
T+ (0.01 - 0.047)
T+ (0.048 0 0.277)
T+ (0.278 - 8.37)
876543210
Model c-index = 0.70Model c-index = 0.70

Treatment Effect - 6month Death/(re)-MITreatment Effect - 6month Death/(re)-MI
0
5
10
15
20
25
T- T+
Rx Placebo
0
5
10
15
20
25
No ST-dep 1mm 2mm
Rx Placebo
387387 433433 139139578578 381381
p=0.18p=0.18
p=0.69p=0.69
p=0.13p=0.13
p=0.68p=0.68
p=1.0p=1.0

ConclusionsConclusions
 Quantitative STQuantitative ST↓↓ and +TnT status areand +TnT status are
complementary in assessing risk among ACScomplementary in assessing risk among ACS
patientspatients
 Levels of TnT lower than 0.10 ng/ml containLevels of TnT lower than 0.10 ng/ml contain
important prognostic information and shouldimportant prognostic information and should
be incorporated into risk-assessment analysisbe incorporated into risk-assessment analysis

ConclusionsConclusions
 While both ST-segment depression and cTnT
positivity are effective markers of risk, cTnT
appears superior to ST-depression in assisting
treatment decisions.

503 troponin t and quantitative st segment depression

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503 troponin t and quantitative st segment depression