Author + information
- Gjin Ndrepepa, MD∗ (, )
- Roisin Colleran, MB, BCh and
- Adnan Kastrati, MD
- ↵∗Deutsches Herzzentrum München, Lazarettstrasse 36, 80636 Munich, Germany
We thank Dr. Ferreira and colleagues for their interest in our paper on prognostic value of high-sensitivity troponin T (hs-TnT) in patients undergoing elective percutaneous coronary intervention (PCI) (1). In their letter, they make several points.
First, the authors are concerned about the influence of pre-procedural therapy on baseline and post-procedural hs-TnT. Indeed, chronic medical therapy for patients with stable coronary artery disease includes mainly drugs that have a protective effect on the myocardium. Notwithstanding the authors’ remarks, these influences do not appear to distort the relationship between actual hs-TnT concentration and prognosis, and even in the presence of such medications, the biomarker predicts future coronary events and has the potential to assess cardiovascular risk and to monitor the effect of therapeutic interventions (2).
Second, procedural complications, including contrast-induced acute kidney injury and bleeding, may elevate post-procedural hs-TnT through increased stress on myocardium. Full evaluation of all possible confounders was beyond the scope of this study. However, the association between post-procedural hs-TnT elevation and mortality was nonsignificant and remained so after adjustment, albeit for a potentially incomplete list of confounders, despite the possibility that post-procedural hs-TnT might have absorbed some prognostic information from such procedure-related complications. Further adjustment for these potential confounders would not be expected to strengthen the association.
Third, data for medical therapy at discharge are shown, although we have no information for adherence to this therapy at follow-up. Mortality following PCI is multifactorial, and the impact of coronary interventions on mortality is not entirely clear. Prior studies have shown no association between troponin concentration after PCI and the subsequent need for revascularization (3). Notably, multivessel disease, a correlate of the future need for coronary revascularization, was not independently associated with mortality, a finding that may attenuate any eventual impact of this factor.
The authors have correctly pointed out that the displayed hazard ratios in Figure 1 were erroneously switched. Risk estimates were, in fact, correctly shown in the text, and we have asked the journal to publish a correction of this error. Finally, the authors commented on the prognostic value of post-procedural hs-TnT elevation in patients with nonelevated baseline hs-TnT concentration. However, this information has already been reported and can be found on page 2264 (1) in both the text and Figure 1 (the lower curves show mortality estimates in patients with nonelevated baseline hs-TnT).
Dr. Ferreira and colleagues concur with, rather than dispute, the findings from our study. PCI-related increase (fraction) in hs-TnT concentration and post-procedural hs-TnT are not synonymous, and they may differ in their association with prognosis after elective PCI. By stating that post-procedural hs-TnT concentration did not offer prognostic information beyond that provided by the baseline concentration of the biomarker, we do not negate the prognostic value of post-procedural hs-TnT. Post-procedural hs-TnT may be associated with prognosis simply because post-procedural hs-TnT consists of both PCI-related and baseline hs-TnT fractions, and of the 2, the latter is the main determinant of prognostic information.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
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