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Original Articles

Use of Guidelines-Recommended Management and Outcomes Among Women and Men With Low-Level Troponin Elevation

Insights From CRUSADE

Sharif A. Halim, MD; Jyotsna Mulgund, MS; Anita Y. Chen, MS; Matthew T. Roe, MD, MHS; Eric D. Peterson, MD, MPH; W. Brian Gibler, MD; E. Magnus Ohman, MD and L. Kristin Newby, MD, MHS

From the Department of Medicine (S.A.H.) and the Duke Clinical Research Institute (J.M., A.Y.C., M.T.R., E.D.P., E.M.O., L.K.N.), Duke University Medical Center, Durham, NC; and the Department of Emergency Medicine (W.B.G.), University of Cincinnati School of Medicine, Cincinnati, Ohio.

Correspondence to L. Kristin Newby, MD, MHS, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715-7969. E-mail newby001{at}mc.duke.edu

Received July 29, 2008; accepted February 9, 2009.

Background— Troponin elevation above the upper limit of normal (ULN) is diagnostic of myocardial infarction, but interpretation of "gray-zone" troponin elevations (1 to 1.5x ULN) remains uncertain. Using the CRUSADE database, we explored relationships between sex and treatment and outcomes among patients with troponin 1 to 1.5x ULN.

Methods and Results— We compared treatment and outcomes among women and men using logistic generalized estimating equation method. Overall, 5049 of 85 671 (5.9%) non–ST-segment elevation acute coronary syndromes patients (2156 women, 2893 men) had troponin 1 to 1.5x ULN within 24 hours of presentation. Compared with troponin >1.5x ULN, "gray-zone" patients less often received all guidelines-indicated acute (mean composite score, 63% versus 72%) and discharge therapies (mean composite score, 73% versus 78%), but received them more frequently than patients with troponin <1x ULN (mean composite scores, 58% acute and 67% discharge). Among "gray-zone" patients, acute and discharge therapy use was similar between women and men, except acute aspirin (adjusted odds ratio, 0.80 [95% CI, 0.65 to 0.98]) and discharge angiotensin-converting enzyme inhibitors (adjusted odds ratio, 0.77 [95% CI, 0.67 to 0.88]). "Gray-zone" patients had lower mortality (2.3%) than the >1.5x ULN (4.5%) group but higher than the <1x ULN group (1.1%). Outcomes were similar among "gray-zone" women and men (adjusted odds ratios: death, 0.88 [95% CI, 0.58 to 1.35]; death/myocardial infarction, 0.77 [95% CI, 0.55 to 1.06]; transfusion, 1.04 [95% CI, 0.85 to 1.27]).

Conclusions— Patients with non–ST-segment elevation acute coronary syndromes and low-level troponin elevations had lower overall risk and received less aggressive guidelines-based treatment than those with greater troponin elevations, but treatment patterns were largely similar by sex across troponin elevation groups.

Key Words: troponin • acute coronary syndrome • outcomes

The online-only Data Supplement is available at http://circoutcomes.ahajournals.org/cgi/content/full/10.1161/CIRCOUTCOMES.108.810127/DC1.

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