Cardiac troponin T: an important predictor of late death and myocardial infarction following hip fracture: an eight-year prospective observational cohort study

  • Alexander Izhaki
  • Yuri Slesarenko
  • Mona Boaz
  • Yaron Haimovich
  • Yoseph Rozenman
Original Article

Abstract

Background

Cardiac troponin is an accurate marker of minimal myocardial injury and has been shown to predict adverse outcomes in various non-acute coronary disease settings. Patients with hip fracture (HF), an osteoporotic, mostly octogenarian population, are prone to sustain myocardial injury through both peri-fracture stress and subsequent surgery (osteosynthesis or hemiarthroplasty).

Objective

To assess the frequency and magnitude of myocardial injury on admission and in-hospital (post-surgery) as measured by troponin T (TnT) and to evaluate the long-term prognostic value of TnT on cardiovascular morbidity and mortality.

Methods

TnT levels were measured on admission (adTnT) and during hospital stay in 148 patients with HF and followed them prospectively until December 27, 2009. Each patient’s highest TnT value was designated peak TnT. TnT >0.1 ng/ml levels were identified as elevated, using ROC analysis to predict death. Survival was assessed using Cox regression analysis.

Results

The study population was 81.3 ± 8.2 years of age, 32 men. Elevated adTnT and peak TnT were observed in 34 (22.9%) and 51 (34.4%) of patients, respectively. On December 27, 2009, 112 (75.7%) patients had died. After controlling for age, serum on-admission creatinine and CHF, adTnT emerged as a significant independent predictor of death (HR = 1.07, 1.02–1.12 95% CI P = 0.01). Late myocardial infarction (MI) observed in 13 patients at 1,314 ± 659 days was predicted by peak TnT (HR = 1.3, CI 1.06–1.57, P = 0.027).

Conclusions

Myocardial injury as evidenced by elevated TnT levels was observed in 1/3 of our patients with HF. TnT elevation, mostly observed on admission, reflected peri-fracture stress rather than surgery-related factors. Death and MI during the 8-year follow-up period were positively associated with magnitude of TnT levels during the 8-year follow-up period; Study contribution: We have demonstrated a continuous and graded association between increasing troponin levels on admission and risk of death. Previous studies have examined this association using a threshold effect. Additionally, the present study features a long follow-up time (8 years), suggesting that troponin levels on admission increase the risk of death over a prolonged period of time.

Keywords

Troponin T Hip fracture Cardiovascular events Survival 

Notes

Acknowledgments

The authors express their sincere gratitude to Mr. Yosi Abuhav for his indispensable investment enabling manuscript’s creation.

Conflict of interest

None.

References

  1. 1.
    Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD (2008) Surgical management of hip fractures: an evidence-based review of the literature. I: femoral neck fractures. J Am Acad Orthop Surg 16(10):596–607PubMedGoogle Scholar
  2. 2.
    Icks A, Haastert B, Wildner M, Becker C, Meyer G (2007) Trend of hip fracture incidence in Germany 1995–2004: a population-based study. Osteoporosis Int 19(8):1139–1145CrossRefGoogle Scholar
  3. 3.
    Roberts SE, Goldacre MJ (2003) Time trends and demography of mortality after fractured neck of femur in an English population, 1968–98: database study. BMJ 327(7418):771–775PubMedCrossRefGoogle Scholar
  4. 4.
    Von Friesendorff M, Besjakov J, Akesson K (2008) Long-term survival and fracture risk after hip fracture: a 22-year follow-up in women. J Bone Miner Res 23(11):1832–1841CrossRefGoogle Scholar
  5. 5.
    Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB (2009) Incidence and mortality of hip fractures in the United States. JAMA 302(14):1573–1579PubMedCrossRefGoogle Scholar
  6. 6.
    Rosencher N, Vielpeau C, Emmerich J, Fagnani F, Samama CM (2005) the ESCORTE group. Venous thromboembolism and mortality after hip fracture surgery: the ESCORTE study. J Thromb Haemost 3(9):2006–2014PubMedCrossRefGoogle Scholar
  7. 7.
    Jaffe AS, Babuin L, Apple FS (2006) Biomarkers in acute cardiac disease: the present and the future. J Am Coll Cardiol 48(1):1–11PubMedCrossRefGoogle Scholar
  8. 8.
    James P, Ellis CJ, Whitlock RM, McNeil AR, Henley J, Anderson NE (2000) Relation between troponin T concentration and mortality in patients presenting with an acute stroke: observational study. BMJ 3;320 (7248):1502–1504Google Scholar
  9. 9.
    Giannitsis E, Müller-Bardorff M, Kurowski V, Weidtmann B, Wiegand U, Kampmann M, Katus HA (2000) Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism. Circulation 102(2):211–217PubMedGoogle Scholar
  10. 10.
    Scott EC, Ho HC, Yu M, Chapital AD, Koss W, Takanishi DM Jr (2008) Pre-existing cardiac disease. Troponin I elevation and mortality in patients with severe sepsis and septic shock. Anaesth Intensive Care 36(1):51–59PubMedGoogle Scholar
  11. 11.
    Kalla C, Raveh D, Algur N, Rudensky B, Yinnon AM, Balkin J (2008) Incidence and significance of a positive troponin test in bacteremic patients without acute coronary syndrome. Am J Med 121(10):909–915PubMedCrossRefGoogle Scholar
  12. 12.
    Edouard AR, Felten ML, Hebert JL, Cosson C, Martin L, Benhamou D (2004) Incidence and significance of cardiac troponin I release in severe trauma patients. Anesthesiology 101(6):1262–1268PubMedCrossRefGoogle Scholar
  13. 13.
    Oscarsson A, Eintrei C, Anskär S, Engdahl O, Fagerström L, Blomqvist P, Fredriksson M, Swahn E (2004) Troponin T-values provide long-term prognosis in elderly patients undergoing non-cardiac surgery. Acta Anaesthesiol Scand 48(9):1071–1079PubMedCrossRefGoogle Scholar
  14. 14.
    Higham H, Sear JW, Sear YM, Kemp M, Hooper RJ, Foex P (2004) Peri-operative troponin I concentration as a marker of long-term postoperative adverse cardiac outcomes—a study in high-risk surgical patients. Anaesthesia 59(4):318–323PubMedCrossRefGoogle Scholar
  15. 15.
    Lopez-Jimenez F, Goldman L, Sacks DB, Thomas EJ, Johnson PA, Cook EF, Lee TH (1997) Prognostic value of cardiac troponin T after noncardiac surgery: 6-month follow-up data. J Am Coll Cardiol 29(6):1241–1245PubMedCrossRefGoogle Scholar
  16. 16.
    Ausset S, Auroy Y, Lambert E, Vest P, Plotton C, Rigal S, Lenoir B, Benhamou D (2008) Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome. Eur J Anaesthesiol 25(2):158–164PubMedCrossRefGoogle Scholar
  17. 17.
    Ausset S, Minville V, Marquis C, Fourcade O, Rosencher N, Benhamou D, Auroy Y (2009) Postoperative myocardial damages after hip fracture repair are frequent and associated with a poor cardiac outcome: a three-hospital study. Age Ageing 38(4):473–476PubMedCrossRefGoogle Scholar
  18. 18.
    Dawson-Bowling S, Chettiar K, Cottam H, Worth R, Forder J, Fitzgerald-O’Connor I, Walker D, Apthorp H (2008) Troponin T as a predictive marker of morbidity in patients with fractured neck of femur. Injury 39(7):775–780PubMedCrossRefGoogle Scholar
  19. 19.
    Fisher AA, Southcott EN, Goh SL, Srikusalanukul W, Hickman PE, Davis MW, Potter JM, Budge MM, Smith PN (2008) Elevated serum cardiac troponin I in older patients with hip fracture: incidence and prognostic significance. Arch Orthop Trauma Surg 128(10):1073–1079PubMedCrossRefGoogle Scholar
  20. 20.
    Mouzopoulos G, Kouvaris C, Antonopoulos D, Stamatakos M, Tsembeli A, Mouratis G, Tzurbakis M, Safioleas M (2007) Perioperative creatine phosphokinase (CPK) and troponin I trends after elective hip surgery. J Trauma 63(2):388–393PubMedCrossRefGoogle Scholar
  21. 21.
    Oscarsson A, Fredrikson M, So¨rliden M, Anska¨r S, Eintrei C (2009) N- terminal fragment of pro-B-type natriuretic peptide is a predictor of cardiac events in high-risk patients undergoing acute hip fracture surgery. Br J Anaesth 103(2):206–212Google Scholar
  22. 22.
    Wallace TW, Abdullah SM, Drazner MH, Das SR, Khera A, McGuire DK, Wians F, Sabatine MS, Morrow DA, de Lemos JA (2006) Prevalence and determinants of troponin T elevation in the general population. Circulation 113(16):1958–1965PubMedCrossRefGoogle Scholar
  23. 23.
    Troponin T STAT, cardiac T, Roche ™ Diagnostics, Manheim, GermanyGoogle Scholar
  24. 24.
    Chong CP, Lam QT, Ryan JE, Sinnappu RN, Lim WK (2009) Incidence of post-operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients. Age Ageing 38(2):168–174PubMedCrossRefGoogle Scholar
  25. 25.
    Thygesen K, Alpert JS, White HD, Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction (2007) Universal definition of myocardial infarction. J Am Coll Cardiol 50(22):2173–2195Google Scholar
  26. 26.
    E Centers for Disease control and Prevention (2003) MMWR series on public health and aging. MMWR 52:101–106Google Scholar
  27. 27.
    Schwartz JB, Zipes DP (2008) Cardiovascular disease in the elderly. From: chapter 75, Braunwald’s heart disease, a textbook of cardiovascular medicine, 8th edn. Saunders Elsevier, Philadelphia, PAGoogle Scholar
  28. 28.
    Alcalai R, Planer D, Culhaoglu A, Osman A, Pollak A, Lotan C (2007) Acute coronary syndrome vs. nonspecific troponin elevation: clinical predictors and survival analysis. Arch Intern Med 167(3):276–281PubMedCrossRefGoogle Scholar
  29. 29.
    Shargorodsky M, Boaz M, Luckish A, Matas Z, Gavish D, Mashavi M (2008) Osteoprotegerin as an independent marker of subclinical atherosclerosis in osteoporotic postmenopausal women. Atherosclerosis 204(2):608–611PubMedCrossRefGoogle Scholar
  30. 30.
    Varma R, Aronow WS, Basis Y, Singh T, Kalapatapu K, Weiss MB, Pucillo AL, Monsen CE (2008) Relation of bone mineral density to frequency of coronary heart disease. Am J Cardiol 101(8):1103–1104PubMedCrossRefGoogle Scholar
  31. 31.
    Tekin GO, Kekilli E, Yagmur J, Uckan A, Yagmur C, Aksoy Y, Turhan H, Yetkin E (2008) Evaluation of cardiovascular risk factors and bone mineral density in post menopausal women undergoing coronary angiography. Int J Cardiol 131(1):66–69PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Alexander Izhaki
    • 1
  • Yuri Slesarenko
    • 2
  • Mona Boaz
    • 3
  • Yaron Haimovich
    • 2
  • Yoseph Rozenman
    • 1
  1. 1.Heart InstituteThe Edith Wolfson Medical CenterHolonIsrael
  2. 2.Orthopaedics DepartmentThe Edith Wolfson Medical CenterHolonIsrael
  3. 3.Epidemiology UnitThe Edith Wolfson Medical CenterHolonIsrael

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