1. Patients with abnormal troponin T levels had a significantly higher rate of death from all causes at the 5-year follow up.
2. Early revascularization of patients with elevated levels of troponin T did not lower the risk of death.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Troponin T levels are elevated in patients with acute coronary syndromes and are often used to identify patients who need to undergo immediate revascularization. New high sensitivity assays allow for detection of small changes in troponin levels. The authors hypothesized that using troponin T levels may allow identifying more patients who can benefit from early intervention.
This study, the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes trial (BAR 2D trial), found that in patients with type II diabetes and stable ischemic heart disease, elevated baseline levels of troponin T was a predictor of death within 5 years. Of the patients that had high troponin T, a subgroup was randomized to undergo early revascularization. They found that this early intervention did not change the mortality rate at the 5-year follow up. These results support using conservative treatment in patients with stable coronary disease.
In-Depth [randomized controlled]: This study enrolled a total of 2368 patients who had both type 2 diabetes and stable ischemic heart disease. Patients with high levels of troponin T (>14 ng per liter) were then randomized to prompt coronary revascularization plus intensive medical therapy or intensive medical therapy alone. The primary end point was a composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke.
After adjusting for confounding factors, the hazard ratio for the composite end point in patients with abnormal baseline troponin T concentrations was significant (HR=1.85; 95% [CI], 1.48 to 2.32; P<0.001). In patients with elevated troponin T levels who underwent prompt revascularization, their primary composite endpoint was not significantly different than those who received only medical management (HR = 0.98; 95% CI, 0.80 to 1.19, P=0.83).
It should be considered that lack of statistical power to detect a treatment effect of revascularization in subgroups based on baseline troponin T levels and lack of follow-up troponin T values for 13% of participants are limiting factors for this study.
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