Peddada Krishi, Cruz-Flores Salvador, Goldstein Larry B, Feen Eliahu, Kennedy Kevin F, Heuring Timothy, Stolker Joshua M
Cardiology, Saint Louis University, St. Louis, Mo., USA.
Cerebrovasc Dis. 2016;42(3-4):213-23. doi: 10.1159/000445526. Epub 2016 May 3.
Among patients hospitalized for acute ischemic stroke, abnormal serum troponins are associated with higher risk of short-term mortality. However, most findings have been reported from European hospitals. Whether troponin elevation after stroke is independently associated with death among a more heterogeneous US population remains unclear. Furthermore, only a few studies have evaluated the association between the magnitude of troponin elevation and subsequent mortality, patterns of dynamic troponin changes over time, or whether troponin elevation is related to specific causes of death.
Using data collected in the American Heart Association's 'Get With The Guidelines' stroke registry between 2008 and 2012 at a tertiary care US hospital, we used logistic regression to evaluate the independent relationship between troponin elevation and mortality after adjusting for demographic and clinical characteristics. We then assessed whether the magnitude of troponin elevation was related to in-hospital mortality by calculating mortality rates according to tertiles of peak troponin levels. Dynamic troponin changes over time were evaluated as well. To better understand whether troponin elevation identified patients most likely to die due to a specific cause of death, investigators blinded from troponin values reviewed all in-hospital deaths, and the association between troponin elevation and mortality was evaluated among patients with cardiac, neurologic, or other causes of death.
Of 1,145 ischemic stroke patients, 199 (17%) had elevated troponin levels. Troponin-positive patients had more cardiovascular risk factors, more intensive medical therapy, and greater use of cardiac procedures. These individuals had higher in-hospital mortality rates than troponin-negative patients (27 vs. 8%, p < 0.001), and this association persisted after adjustment for 13 clinical and management variables (OR 4.28, 95% CI 2.40-7.63). Any troponin elevation was associated with higher mortality, even at very low peak troponin levels (mortality rates 24-29% across tertiles of troponin). Patients with persistently rising troponin levels had fewer anticoagulant and antiatherosclerotic therapies, with markedly worse outcomes. Furthermore, troponin-positive patients had higher rates of all categories of death: neurologic (17 vs. 7%), cardiac (5 vs. <1%), and other causes of death (5 vs. <1%; p < 0.001 for all comparisons).
Ischemic stroke patients with abnormal troponin levels are at higher risk of in-hospital death, even after accounting for demographic and clinical characteristics, and any degree of troponin elevation identifies this higher level of risk. Troponins that continue to rise during the hospitalization identify stroke patients at markedly higher risk of mortality, and both neurologic and non-neurologically mediated mortality rates are higher when troponin is elevated.
在因急性缺血性卒中住院的患者中，血清肌钙蛋白异常与短期死亡风险较高相关。然而，大多数研究结果来自欧洲医院。卒中后肌钙蛋白升高在更多样化的美国人群中是否与死亡独立相关仍不清楚。此外，只有少数研究评估了肌钙蛋白升高幅度与随后死亡率之间的关联、肌钙蛋白随时间的动态变化模式，或者肌钙蛋白升高是否与特定死因相关。
利用2008年至2012年在美国一家三级医疗医院收集的美国心脏协会“遵循指南”卒中登记数据，我们使用逻辑回归来评估在调整人口统计学和临床特征后肌钙蛋白升高与死亡率之间的独立关系。然后，我们根据肌钙蛋白峰值水平的三分位数计算死亡率，评估肌钙蛋白升高幅度是否与住院死亡率相关。还评估了肌钙蛋白随时间的动态变化。为了更好地了解肌钙蛋白升高是否能识别出最有可能因特定死因死亡的患者，对肌钙蛋白值不知情的研究人员审查了所有住院死亡病例，并在因心脏、神经或其他死因死亡的患者中评估了肌钙蛋白升高与死亡率之间的关联。
在1145例缺血性卒中患者中，199例（17%）肌钙蛋白水平升高。肌钙蛋白阳性患者有更多的心血管危险因素、更强化的药物治疗以及更多地使用心脏手术。这些患者的住院死亡率高于肌钙蛋白阴性患者（27%对8%，p<0.001），在调整13个临床和管理变量后，这种关联仍然存在（比值比4.28，95%置信区间2.40 - 7.63）。任何程度的肌钙蛋白升高都与较高的死亡率相关，即使在肌钙蛋白峰值水平非常低时也是如此（肌钙蛋白三分位数的死亡率为24% - 29%）。肌钙蛋白水平持续升高的患者接受抗凝和抗动脉粥样硬化治疗较少，预后明显更差。此外，肌钙蛋白阳性患者各类死亡的发生率更高：神经源性（17%对7%）、心脏源性（5%对<1%）和其他死因（5%对<1%；所有比较p<0.001）。
肌钙蛋白水平异常的缺血性卒中患者住院死亡风险较高，即使在考虑人口统计学和临床特征后也是如此，任何程度的肌钙蛋白升高都表明这种较高的风险水平。住院期间持续升高的肌钙蛋白表明卒中患者的死亡风险显著更高，当肌钙蛋白升高时，神经源性和非神经源性介导的死亡率均更高。
