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Cardiac Troponins Used as Diagnostic and Prognostic Tests in Patients With Kidney Disease
Comparative Effectiveness Review, No. 135
Investigators: Erin D Michos, MD, MHS, Zackary Berger, MD, PhD, Hsin-Chieh Yeh, PhD, Catalina Suarez-Cuervo, MD, Lisa M Wilson, ScM, Sylvie Stacy, MD, and Eric B Bass, MD, MPH.
Author Information and AffiliationsStructured Abstract
Objective:
To systematically review the literature on the use of cardiac troponin levels in patients with chronic kidney disease (CKD) regarding four Key Questions (KQ): (1) diagnosis of acute coronary syndrome (ACS), (2) management decisions for ACS, (3) prognosis after presenting with ACS, and (4) risk stratification in patients without symptoms of ACS.
Data sources:
MEDLINE®, Embase®, and the Cochrane Central Register of Controlled Trials from January 1990 through September 2013.
Review Methods:
We included studies that compared a cardiac troponin elevation with a nonelevation in terms of diagnostic accuracy, mortality, or cardiovascular events among patients with CKD. Two reviewers evaluated studies for eligibility; abstracted data using standardized forms; and independently evaluated study quality and graded strength of evidence (SOE). We conducted meta-analyses when there were sufficient data and studies were sufficiently homogenous.
Results:
We included 124 studies (130 articles). KQ 1: Fourteen studies evaluated diagnostic accuracy. The sensitivity of troponin T for ACS diagnosis in CKD patients ranged from 71 to 100 percent, and specificity from 31 to 86 percent (6 studies; low SOE). The sensitivity of troponin I for ACS diagnosis ranged from 43 to 94 percent, and specificity from 48 to 100 percent (8 studies; low SOE). KQ 2: One study indirectly addressed management decisions. We could not draw any conclusions about whether troponin levels affect management strategies, such as timing of intervention, in CKD patients with ACS (SOE: insufficient). KQ 3: Twelve studies examined the prognostic value of troponin in CKD patients. Elevated troponin I and T were associated with higher risk of short-term mortality and cardiac outcomes (low SOE). A similar trend was observed for long-term mortality with troponin I (low SOE), but less evidence was found for long-term cardiac events for troponin I and long-term outcomes for troponin T (insufficient SOE). Patients with advanced stages of CKD tended to have worse prognosis with elevated troponin I than those without elevation (moderate SOE). KQ 4: Ninety-eight studies met inclusion criteria. Elevated troponin was associated with all-cause and cardiovascular mortality among dialysis patients with moderate SOE. Hazard ratios (HR) adjusted at least for age and coronary artery disease or risk equivalents were pooled: All-cause mortality, troponin T (HR 3.0 [95% CI 2.4 to 4.3]), troponin I (HR 2.7 [1.9 to 4.6]); Cardiovascular mortality, troponin T (HR 3.3 [95% CI 1.8 to 5.4]), troponin I (HR 4.2 [2.0 to 9.2]). Findings were similar for non-dialysis CKD patients, with fewer studies. No study tested management strategies by troponin cut-points. KQs 1–4: Few studies evaluated high-sensitivity troponin T and I assays in CKD patients. KQs 1–4: We found substantial heterogeneity across studies in terms of study design, troponin assays, troponin cutpoints, patient populations, and adjustment for potential confounders. For ACS populations, the studies varied in the pretest probability descriptions and ACS definitions and adjudication. We found no studies that carried out direct a priori comparisons of troponin testing in patients with CKD versus patients with normal renal function.
Conclusions:
Cardiac troponin elevations are associated with a worse prognosis for CKD patients with and without suspected ACS. However, the wide variation in assays and cutoffs, along with the lack of comparative studies, prevents clear conclusions about how this association should change management, compared with management based on clinical factors or evidence derived from the non-CKD population. Future research should compare various management strategies that incorporate measuring cardiac troponins in their algorithms, including using different cutoffs or assays. For this research to be effective, troponin assays and cutpoints need to be standardized and harmonized so that results can be pooled, compared, and applied in practice.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Background
- Cardiac Troponin Assays
- Troponin Elevation in Chronic Kidney Disease
- Use of Troponin for the Diagnosis of Acute Coronary Syndrome in Patients With Chronic Kidney Disease (Background for Key Question 1)
- Use of Troponin Level as a Management Strategy for Patients With Chronic Kidney Disease and Acute Coronary Syndrome (Background for Key Question 2)
- Use of Troponin Level as a Prognostic Indicator in Patients With Chronic Kidney Disease Following Acute Coronary Syndrome (Background for Key Question 3)
- Use of Troponins in Adults With Chronic Kidney Disease Who Do Not Have Symptoms of Acute Coronary Syndrome: A Role for Risk Stratification (Background for Key Question 4)
- Types of Troponin Assays and Special Subgroups of Patients With Chronic Kidney Disease (Key Questions 1–4)
- Scope and Key Questions
- Methods
- Results
- Search Results
- KQ 1 Use of Troponin for Diagnosis of Acute Coronary Syndrome Among Chronic Kidney Disease Patients
- KQ 2 Management of Acute Coronary Syndrome by Troponin Levels
- KQ 3 Short- and Long-Term Prognosis After Presentation with Acute Coronary Syndrome by Troponin Levels
- KQ 4 Use of Troponin for Risk Stratification Among Chronic Kidney Disease Patients Without Acute Coronary Syndrome
- Discussion
- References
- Appendix A Detailed Electronic Database Search Strategies
- Appendix B Forms
- Appendix C Exclusion Report
- Appendix D Evidence Tables
- Appendix E Overview of Studies Included in the Meta-Analyses
- Appendix F List of Covariate Adjustment per Individual Studies
- Appendix G Troponin Assays for Background Reference
- Appendix H References for Appendixes
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2012-0007-I. Prepared by: Johns Hopkins University Evidence-based Practice Center, Baltimore, MD
Suggested citation:
Michos ED, Berger Z, Yeh HC, Suarez-Cuervo C, Wilson LM, Stacy S, Bass EB. Cardiac Troponins Used as Diagnostic and Prognostic Tests in Patients With Kidney Disease. Comparative Effectiveness Review No. 135. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 290-2012-00007-I.) AHRQ Publication No. 14-EHC030-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2014. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Johns Hopkins University Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00007-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
This report may periodically be assessed for the urgency to update. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
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.ahrq.gov
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