Unstable Angina Pectoris With Myocardial Injury Versus Myocardial Infarction in the Era of High-Sensitivity Cardiac Troponin

It is unknown whether outcomes in patients with unstable angina pectoris (UAP) and myocardial injury are different from outcomes in patients with non-ST-segment myocardial infarction (NSTEMI) with low peak concentrations of high-sensitivity cardiac troponin T (hs-cTnT). This study aimed to compare the prognosis in patients with UAP and evidence of myocardial injury, with prognosis in patients with NSTEMI and different peak hs-cTnT concentrations. All visits to 7 different emergency departments in Sweden from December 9, 2009 to December 31, 2016 were identified (n = 5,225,075). We included all hospitalized patients with hs-cTnT >14 ng/L and a diagnosis of UAP or NSTEMI, with ≥2 hours-cTnT measurements. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for all-cause mortality and cardiovascular events, in patients with NSTEMI categorized according to peak hs-cTnT concentrations, compared with patients with UAP. Altogether, 11,944 patients were included, of whom 1,253 (10%) received a diagnosis of UAP. During a median follow-up of 3.0 years (interquartile [IQR] 1.6 to 4.7), 3,297 patients died. There was no difference comparing patients with NSTEMI with peak hs-cTnT of 15 to 49 ng/L to patients with UAP, with regards to long-term cardiovascular mortality (HR 1.15; 95% CI, 0.85 to 1.56), but the risk of recurrent myocardial infarction was higher in patients with NSTEMI (HR, 1.61; 95% CI, 1.29 to 2.00), and the risk of heart failure hospitalization slightly lower (HR 0.80, 95% CI, 0.64 to 0.99). In conclusion, patients with UAP and myocardial injury have a similar risk of death after discharge, but a lower risk of recurrent myocardial infarction and a marginally higher risk of heart failure, compared with patients with NSTEMI with moderately elevated hs-cTnT levels. It is unknown whether outcomes in patients with unstable angina pectoris (UAP) and myocardial injury are different from outcomes in patients with non-ST-segment myocardial infarction (NSTEMI) with low peak concentrations of high-sensitivity cardiac troponin T (hs-cTnT). This study aimed to compare the prognosis in patients with UAP and evidence of myocardial injury, with prognosis in patients with NSTEMI and different peak hs-cTnT concentrations. All visits to 7 different emergency departments in Sweden from December 9, 2009 to December 31, 2016 were identified (n = 5,225,075). We included all hospitalized patients with hs-cTnT >14 ng/L and a diagnosis of UAP or NSTEMI, with ≥2 hours-cTnT measurements. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for all-cause mortality and cardiovascular events, in patients with NSTEMI categorized according to peak hs-cTnT concentrations, compared with patients with UAP. Altogether, 11,944 patients were included, of whom 1,253 (10%) received a diagnosis of UAP. During a median follow-up of 3.0 years (interquartile [IQR] 1.6 to 4.7), 3,297 patients died. There was no difference comparing patients with NSTEMI with peak hs-cTnT of 15 to 49 ng/L to patients with UAP, with regards to long-term cardiovascular mortality (HR 1.15; 95% CI, 0.85 to 1.56), but the risk of recurrent myocardial infarction was higher in patients with NSTEMI (HR, 1.61; 95% CI, 1.29 to 2.00), and the risk of heart failure hospitalization slightly lower (HR 0.80, 95% CI, 0.64 to 0.99). In conclusion, patients with UAP and myocardial injury have a similar risk of death after discharge, but a lower risk of recurrent myocardial infarction and a marginally higher risk of heart failure, compared with patients with NSTEMI with moderately elevated hs-cTnT levels. The spectrum of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) includes non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina pectoris (UAP).1Collet J Thiele H Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM Kastrati A Mamas MA Aboyans V Angiolillo DJ Bueno H Bugiardini R Byrne RA Castelletti S Chieffo A Cornelissen V Crea F Delgado V Drexel H Gierlotka M Halvorsen S Haugaa KH Jankowska EA Katus HA Kinnaird T Kluin J Kunadian V Landmesser U Leclercq C Lettino M Meinila L Mylotte D Ndrepepa G Omerovic E Pedretti RFE Petersen SE Petronio AS Pontone G Popescu BA Potpara T Ray KK Luciano F Richter DJ Shlyakhto E Simpson IA Sousa-Uva M Storey RF Touyz RM Valgimigli M Vranckx P Yeh RW Barbato E Barthélémy O Bauersachs J Bhatt DL Dendale P Dorobantu M Edvardsen T Folliguet T Gale CP Gilard M Jobs A Jüni P Lambrinou E Lewis BS Mehilli J Meliga E Merkely B Mueller C Roffi M Rutten FH Sibbing D Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.Eur Heart J. 2021; 42: 1289-1367Google Scholar,2Thygesen K Alpert JS Jaffe AS Chaitman BR Bax JJ Morrow DA White HD Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018).J Am Coll Cardiol. 2018; 72: 2231-2264Google Scholar The use of high-sensitivity cardiac troponin (hs-cTn) assays has improved the low-end accuracy for the myocardial infarction (MI) diagnosis,3Giannitsis E Becker M Kurz K Hess G Zdunek D Katus HA High-sensitivity cardiac troponin T for early prediction of evolving non-ST-segment elevation myocardial infarction in patients with suspected acute coronary syndrome and negative troponin results on admission.Clin Chem. 2010; 56: 642-650Google Scholar, 4Reichlin T Hochholzer W Bassetti S Steuer S Stelzig C Hartwiger S Biedert S Schaub N Buerge C Potocki M Noveanu M Breidthardt T Twerenbold R Winkler K Bingisser R Mueller C. 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Patients with a suspected UAP often have moderate, non-dynamic hs-cTn elevations, and can be difficult to distinguish from those with NSTEMI and low peak hs-cTn concentrations and/or small rise and/or falls of hs-cTn.2Thygesen K Alpert JS Jaffe AS Chaitman BR Bax JJ Morrow DA White HD Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018).J Am Coll Cardiol. 2018; 72: 2231-2264Google Scholar,10Eggers KM Jernberg T Lindahl B. Unstable angina in the era of cardiac troponin assays with improved sensitivity-A clinical Dilemma.Am J Med. 2017; 130: 1423-1430.e5Google Scholar We hypothesized that patients with UAP and evidence of myocardial injury have a similar prognosis as patients with NSTEMI and low peak concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and tested this hypothesis in a large cohort study. The study was based on data from 7 large emergency departments (ED) in Stockholm and Göteborg, Sweden, between December 9, 2009, and December 31, 2016. Information on all visits to the was from the of the data were from the of the all the was to hs-cTnT levels. The assay has a of of an the of a of and a of of E Kurz K K J Jaffe AS Katus of a high-sensitivity cardiac troponin T Chem. 2010; 56: Scholar A with all visits in patients years of was to the of and for of data on use of and mortality of from the the and the of E A M JL C M PO and of the M J H M R The of death J 2017; Scholar data on coronary and were from The for and of in Heart to T K T S A B Lindahl B U L The for and of in heart to 2010; Scholar The study was the of and the study with the of the of In all visits which in the included those the received a diagnosis of NSTEMI or UAP. patients were to have hours-cTnT concentrations in with the of which of the hs-cTnT concentrations was >14 ng/L the for the hs-cTnT E A M JL C M PO and of the Scholar We included the hospitalization for the the hospitalization were based on the in the according to the of The were the was in of and and were for A diagnosis of UAP was as the diagnosis was as or in the and/or as an diagnosis in the the time of the were according to all from all the according to in the Previous heart was as coronary diagnosis or heart failure, or was as ≥2 the the The relative of hs-cTnT was as the relative between the hs-cTnT and the peak hs-cTnT the to the patients with NSTEMI, the was categorized according to the peak hs-cTnT 15 to to to to and The was a but with that included the of hs-cTnT and were large to All patients with a UAP diagnosis were as the The was long-term all-cause mortality after discharge, as as all-cause mortality the and from mortality was the of M J H M R The of death J 2017; Scholar death was as death with an of death in the or according to outcomes were long-term cardiovascular and recurrent and heart failure hospitalization after the on outcomes were from the was as a with a diagnosis of from the K Alpert JS Jaffe AS Chaitman BR Bax JJ Morrow DA White HD Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018).J Am Coll Cardiol. 2018; 72: 2231-2264Google Scholar after was as from The of follow-up for all-cause mortality was December 31, and for all outcomes December 31, for recurrent in for which follow-up were to ratios (HRs) with 95% confidence intervals for all patients with UAP as the The was and for the the heart failure, and and with cardiovascular We calculated with mortality comparing the different NSTEMI with patients with UAP. were in which the peak hs-cTnT was as a with a to the with all clinical outcomes in patients with In patients were categorized according to the heart and relative of hs-cTnT or relative hs-cTnT A of 11,944 patients were included, of whom 1,253 (10%) received a diagnosis of UAP, and received a diagnosis of NSTEMI Patients with an NSTEMI diagnosis and a peak hs-cTnT in the lower were slightly and a lower of heart failure and compared with patients with higher peak concentrations. Patients with UAP similar and of cardiovascular as patients with NSTEMI and a peak hs-cTnT of to Previous use of cardiovascular was in patients with hs-cTnT concentrations of median of hs-cTnT concentrations median hs-cTnT median in hs-cTnT between and peak hs-cTnT concentrations the median median median with or with or with or with or = hs-cTnT = high-sensitivity cardiac troponin = = myocardial = NSTEMI = myocardial = = UAP = unstable are as or median with between and peak hs-cTnT concentrations the with or with or with or with or = hs-cTnT = high-sensitivity cardiac troponin = = myocardial = NSTEMI = myocardial = = UAP = unstable are as or median with in a 7 the were in of The relative from the hs-cTnT and the hs-cTnT the was lower in patients with UAP in patients with NSTEMI There were a of and and after discharge, The of patients was higher in patients with NSTEMI in all peak hs-cTnT compared with patients with UAP, in whom The risk of death from was similar in patients with UAP and patients with NSTEMI and peak hs-cTnT from 15 to in patients with unstable angina and non-ST-segment elevation myocardial hs-cTnT concentrations of after all-cause of was for myocardial heart failure, and with and and and = confidence hs-cTnT = high-sensitivity cardiac troponin = NSTEMI = non-ST-segment elevation myocardial UAP = unstable are as of was for myocardial heart failure, and with and and and = confidence hs-cTnT = high-sensitivity cardiac troponin = NSTEMI = non-ST-segment elevation myocardial UAP = unstable are as of cardiovascular was for myocardial heart failure, and with and and and = confidence hs-cTnT = high-sensitivity cardiac troponin = NSTEMI = non-ST-segment elevation myocardial UAP = unstable are as of was for myocardial heart failure, and with and and and = confidence hs-cTnT = high-sensitivity cardiac troponin = NSTEMI = non-ST-segment elevation myocardial UAP = unstable are as was for myocardial heart failure, and with and and and = confidence hs-cTnT = high-sensitivity cardiac troponin = NSTEMI = non-ST-segment elevation myocardial UAP = unstable are as in a During a median follow-up of 3.0 1.6 to after discharge, patients with UAP and with NSTEMI with peak hs-cTnT concentrations in patients with The was similar in patients with UAP and NSTEMI with peak hs-cTnT of 15 to 49 ng/L and years patients with NSTEMI with higher peak mortality was and higher in patients with UAP. difference in the risk of and mortality was between patients with NSTEMI with peak hs-cTnT of 15 to 49 ng/L and patients with UAP A of recurrent a median follow-up of years to The risk of recurrent was higher in patients with NSTEMI, in patients with peak hs-cTnT in the 15 to 49 ng/L and in patients with peak hs-cTnT compared with patients with UAP. During a median follow-up of to of hospitalization for heart failure The risk of heart failure hospitalization in UAP was slightly lower the risk in patients with NSTEMI with peak hs-cTnT of 15 to 49 and with the risk in NSTEMI with peak hs-cTnT of to myocardial infarction and heart failure hospitalization in patients with unstable angina and elevation myocardial hs-cTnT concentrations myocardial was as an from the the of patients risk not patients from the was as an from the the of patients risk not patients from the was as an from the the of patients risk not patients from the was as an from the the of patients risk not patients from the was as an from the the of patients risk not patients from the was as an from the the of patients risk not patients from the of was for myocardial heart failure, and with and and and = confidence = hs-cTnT = high-sensitivity cardiac troponin NSTEMI = non-ST-segment elevation myocardial UAP = unstable are as failure of was for myocardial heart failure, and with and and and = confidence = hs-cTnT = high-sensitivity cardiac troponin NSTEMI = non-ST-segment elevation myocardial UAP = unstable are as was as an from the the of patients risk not patients from the was for myocardial heart failure, and with and and and = confidence = hs-cTnT = high-sensitivity cardiac troponin NSTEMI = non-ST-segment elevation myocardial UAP = unstable are as in a The of death and cardiovascular with peak hs-cTnT concentrations in patients with NSTEMI, with the the lower of hs-cTnT The with and outcomes were similar the to patients with UAP with peak hs-cTnT of ng/L and a relative of hs-cTnT The of long-term all-cause mortality in patients with UAP were with those in patients with NSTEMI with peak hs-cTnT the risk of recurrent was and the risk of heart failure slightly in the The of patients coronary the hospitalization was similar in patients with UAP and patients with NSTEMI in the peak hs-cTnT a of patients with UAP and data that the of coronary was compared with to patients with NSTEMI with peak hs-cTnT of 15 to 49 ng/L The of recurrent were similar in of patients with and without hospitalization The outcomes in patients coronary were with those in the In patients with on similar for death and recurrent were and the risk of heart failure was not higher in patients with UAP a slightly higher risk compared with patients with NSTEMI with peak hs-cTnT in the lower coronary and in patients with and hs-cTnT concentrations all patients were in the from which data was data patients without on while not patients that no was in the all patients were in the from which data was data patients without on while not patients that no was in the on after with or with of and with or with or = = hs-cTnT = high-sensitivity cardiac troponin = coronary = = = NSTEMI = myocardial = UAP = unstable are as all patients were in the from which data was data patients without on while not patients that no was in the with or with of and with or with or = = hs-cTnT = high-sensitivity cardiac troponin = coronary = = = NSTEMI = myocardial = UAP = unstable are as in a The of was similar in patients with UAP and NSTEMI with peak hs-cTnT large in cardiovascular after were between The long-term mortality was similar in different and in patients with and without a were similar patients were as or hs-cTnT concentrations. the long-term mortality not in between patients with UAP and patients with NSTEMI and peak hs-cTnT of 15 to 49 this large cohort of patients with UAP and NSTEMI, that patients with myocardial injury and UAP a lower risk of recurrent and slightly higher risk of heart failure but a similar all-cause and cardiovascular mortality as patients with NSTEMI and low peak hs-cTnT levels. on long-term mortality were in different patients without hs-cTnT The of a lower risk of death in patients with UAP is with from KM Jernberg T Lindahl B. Unstable angina in the era of cardiac troponin assays with improved sensitivity-A clinical Dilemma.Am J Med. 2017; 130: 1423-1430.e5Google C M Adamson PD A Chapman AR Anand A J T Twerenbold R K P M S L Mueller D L N D J O B G Osswald S T Mills NL Mueller C and outcomes of unstable angina compared with myocardial E Biener M H M Vafaie M J C J Katus HA KM and outcomes of patients with unstable angina with or Res Cardiol. Scholar mortality was higher in patients with was as patients with suspected the an a similar long-term all-cause and cardiovascular mortality in patients with UAP and NSTEMI with peak hs-cTnT the of NSTE-ACS UAP and NSTEMI, in the era of high-sensitivity as and prognosis with to with the hs-cTn a of all-cause mortality in KM Jernberg T Lindahl B. Unstable angina in the era of cardiac troponin assays with improved sensitivity-A clinical Dilemma.Am J Med. 2017; 130: 1423-1430.e5Google E Biener M H M Vafaie M J C J Katus HA KM and outcomes of patients with unstable angina with or Res Cardiol. FS Jaffe AS Collinson P M J Lindahl B J M M Federation of Task Force on of on and clinical of cardiac troponin Scholar The of patients with of is the of UAP and the clinical management of patients presenting with ischemic and/or clinical of myocardial on an of the cardiovascular risk on KM Jernberg T Lindahl B. Unstable angina in the era of cardiac troponin assays with improved sensitivity-A clinical Dilemma.Am J Med. 2017; 130: 1423-1430.e5Google Scholar a higher risk of recurrent in patients with NSTEMI with low peak hs-cTnT in patients with UAP, the similar and patients with UAP coronary no impact on the of was are with results from studies based on KM Jernberg T Lindahl B. Unstable angina in the era of cardiac troponin assays with improved sensitivity-A clinical Dilemma.Am J Med. 2017; 130: 1423-1430.e5Google Scholar while have lower and in patients with E Biener M H M Vafaie M J C J Katus HA KM and outcomes of patients with unstable angina with or Res Cardiol. M L L O N S J K H of unstable angina pectoris has with the of sensitive troponin J Med. B P S. The high-sensitivity cardiac troponin T assay risk in acute coronary Heart J. 2010; Scholar The on the risk of recurrent were different from those in a large which no difference between C M Adamson PD A Chapman AR Anand A J T Twerenbold R K P M S L Mueller D L N D J O B G Osswald S T Mills NL Mueller C and outcomes of unstable angina compared with myocardial Scholar in cardiac death or of follow-up the of an diagnosis of UAP in that C M Adamson PD A Chapman AR Anand A J T Twerenbold R K P M S L Mueller D L N D J O B G Osswald S T Mills NL Mueller C and outcomes of unstable angina compared with myocardial Scholar the for the risk of recurrent in patients with NSTEMI in this study is In a marginally higher risk of heart failure hospitalization was in patients with UAP compared with patients with NSTEMI in the of peak The of patients and a was slightly higher in patients with UAP, but after was In the era of hs-cTn the of data on of cardiovascular outcomes in patients with NSTE-ACS and moderately elevated and non-dynamic hs-cTnT concentrations the of and risk to be Patients with ischemic of UAP not with non-dynamic hs-cTn KM Jernberg T Lindahl B. Unstable angina in the era of cardiac troponin assays with improved sensitivity-A clinical Dilemma.Am J Med. 2017; 130: 1423-1430.e5Google C M Adamson PD A Chapman AR Anand A J T Twerenbold R K P M S L Mueller D L N D J O B G Osswald S T Mills NL Mueller C and outcomes of unstable angina compared with myocardial Scholar of heart or to myocardial KC Collinson PO from myocardial infarction to 2017; Scholar, R A CR cardiac troponin T as an early for clinical and heart of 2017; Scholar, G S Mueller D W Giannitsis E Katus HA of troponin in patients with coronary from of Scholar, A N M O R high-sensitivity cardiac troponin T and outcomes in patients Am Coll Cardiol. 2017; Scholar of patients with UAP and elevated non-dynamic hs-cTn with myocardial injury from those with an and in whom hs-cTn be is K Alpert JS Jaffe AS Chaitman BR Bax JJ Morrow DA White HD Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018).J Am Coll Cardiol. 2018; 72: 2231-2264Google Apple FS High-sensitivity cardiac troponin assays and unstable Heart J 2018; Scholar Information on hs-cTnT concentrations from visits be in Apple FS High-sensitivity cardiac troponin assays and unstable Heart J 2018; Scholar In study patients with UAP a lower median relative between the hs-cTnT and the hs-cTnT compared with patients with NSTEMI and low peak hs-cTnT concentrations and The prognostic and use of data on hs-cTnT in clinical to be this is the study comparing outcomes in patients with UAP and myocardial injury with those in patients with NSTEMI according to the magnitude of ischemic injury and of hs-cTnT levels. The study was based on data from with on and The of and UAP were not based on a of diagnosis is which have led to in outcomes between the data are of clinical and how compare in a patients with NSTEMI after have hs-cTnT concentrations in C M P M Lindahl B O in troponin T are in patients with non-ST-segment elevation myocardial infarction and are to higher Am Coll Cardiol. 2013; Scholar patients with UAP have elevated non-dynamic hs-cTnT to with myocardial injury or in hs-cTnT concentrations. The in the of is the in the relative of between study C M Adamson PD A Chapman AR Anand A J T Twerenbold R K P M S L Mueller D L N D J O B G Osswald S T Mills NL Mueller C and outcomes of unstable angina compared with myocardial E Biener M H M Vafaie M J C J Katus HA KM and outcomes of patients with unstable angina with or Res Cardiol. M L L O N S J K H of unstable angina pectoris has with the of sensitive troponin J Med. 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