High-sensitivity cardiac troponin and the diagnosis of myocardial infarction in patients with kidney impairment

Abstract

The benefit and utility of high-sensitivity cardiac troponin (hs-cTn) in the diagnosis of myocardial infarction in patients with kidney impairment is unclear. Here, we describe implementation of hs-cTnI testing on the diagnosis, management, and outcomes of myocardial infarction in patients with and without kidney impairment. Consecutive patients with suspected acute coronary syndrome enrolled in a stepped-wedge, cluster-randomized controlled trial were included in this pre-specified secondary analysis. Kidney impairment was defined as an eGFR under 60mL/min/1.73m2. The index diagnosis and primary outcome of type 1 and type 4b myocardial infarction or cardiovascular death at one year were compared in patients with and without kidney impairment following implementation of hs-cTnI assay with 99th centile sex-specific diagnostic thresholds. Serum creatinine concentrations were available in 46,927 patients (mean age 61 years; 47% women), of whom 9,080 (19%) had kidney impairment. hs-cTnIs were over 99th centile in 46% and 16% of patients with and without kidney impairment. Implementation increased the diagnosis of type 1 infarction from 12.4% to 17.8%, and from 7.5% to 9.4% in patients with and without kidney impairment (both significant). Patients with kidney impairment and type 1 myocardial infarction were less likely to undergo coronary revascularization (26% versus 53%) or receive dual anti-platelets (40% versus 68%) than those without kidney impairment, and this did not change post-implementation. In patients with hs-cTnI above the 99th centile, the primary outcome occurred twice as often in those with kidney impairment compared to those without (24% versus 12%, hazard ratio 1.53, 95% confidence interval 1.31 to 1.78). Thus, hs-cTnI testing increased the identification of myocardial injury and infarction but failed to address disparities in management and outcomes between those with and without kidney impairment. The benefit and utility of high-sensitivity cardiac troponin (hs-cTn) in the diagnosis of myocardial infarction in patients with kidney impairment is unclear. Here, we describe implementation of hs-cTnI testing on the diagnosis, management, and outcomes of myocardial infarction in patients with and without kidney impairment. Consecutive patients with suspected acute coronary syndrome enrolled in a stepped-wedge, cluster-randomized controlled trial were included in this pre-specified secondary analysis. Kidney impairment was defined as an eGFR under 60mL/min/1.73m2. The index diagnosis and primary outcome of type 1 and type 4b myocardial infarction or cardiovascular death at one year were compared in patients with and without kidney impairment following implementation of hs-cTnI assay with 99th centile sex-specific diagnostic thresholds. Serum creatinine concentrations were available in 46,927 patients (mean age 61 years; 47% women), of whom 9,080 (19%) had kidney impairment. hs-cTnIs were over 99th centile in 46% and 16% of patients with and without kidney impairment. Implementation increased the diagnosis of type 1 infarction from 12.4% to 17.8%, and from 7.5% to 9.4% in patients with and without kidney impairment (both significant). Patients with kidney impairment and type 1 myocardial infarction were less likely to undergo coronary revascularization (26% versus 53%) or receive dual anti-platelets (40% versus 68%) than those without kidney impairment, and this did not change post-implementation. In patients with hs-cTnI above the 99th centile, the primary outcome occurred twice as often in those with kidney impairment compared to those without (24% versus 12%, hazard ratio 1.53, 95% confidence interval 1.31 to 1.78). Thus, hs-cTnI testing increased the identification of myocardial injury and infarction but failed to address disparities in management and outcomes between those with and without kidney impairment. see commentary on page 20 see commentary on page 20 The diagnosis of myocardial infarction has evolved following the adoption of high-sensitivity cardiac troponin assays into clinical practice.1Thygesen K. Alpert J.S. Jaffe A.S. et al.Fourth Universal Definition of Myocardial Infarction.J Am Coll Cardiol. 2018; 72: 2231-2264Crossref PubMed Scopus (2130) Google Scholar Improved assay precision has enabled implementation of lower diagnostic thresholds and increased the identification of patients with myocardial infarction and nonischemic myocardial injury secondary to other conditions.1Thygesen K. Alpert J.S. Jaffe A.S. et al.Fourth Universal Definition of Myocardial Infarction.J Am Coll Cardiol. 2018; 72: 2231-2264Crossref PubMed Scopus (2130) Google Scholar, 2Mills N.L. Churchhouse A.M. Lee K.K. et al.Implementation of a sensitive troponin I assay and risk of recurrent myocardial infarction and death in patients with suspected acute coronary syndrome.JAMA. 2011; 305: 1210-1216Crossref PubMed Scopus (277) Google Scholar, 3Shah A.S.V. Sandoval Y. Noaman A. et al.Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study.BMJ. 2017; 359: j4788Crossref PubMed Scopus (93) Google Scholar, 4Shah A.S.V. Anand A. Strachan F.E. et al.High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial.Lancet. 2018; 392: 919-928Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar, 5Chapman A.R. Adamson P.D. Shah A.S. et al.High-sensitivity cardiac troponin and the universal definition of myocardial infarction.Circulation. 2020; 141: 161-171Crossref PubMed Scopus (123) Google Scholar In patients with kidney impairment, the interpretation of cardiac troponin testing is particularly challenging.6deFilippi C.R. Herzog C.A. Interpreting cardiac biomarkers in the setting of chronic kidney disease.Clin Chem. 2017; 63: 59-65Crossref PubMed Scopus (61) Google Scholar, 7Parikh R.H. Seliger S.L. deFilippi C.R. Use and interpretation of high sensitivity cardiac troponins in patients with chronic kidney disease with and without acute myocardial infarction.Clin Biochem. 2015; 48: 247-253Crossref PubMed Scopus (55) Google Scholar, 8Stacy S.R. Suarez-Cuervo C. Berger Z. et al.Role of troponin in patients with chronic kidney disease and suspected acute coronary syndrome: a systematic review.Ann Intern Med. 2014; 161: 502-512Crossref PubMed Scopus (87) Google Scholar While high-sensitivity cardiac troponin is effective at ruling out myocardial infarction in these patients,9Miller-Hodges E. Anand A. Shah A.S.V. et al.High-sensitivity cardiac troponin and the risk stratification of patients with renal impairment presenting with suspected acute coronary syndrome.Circulation. 2018; 137: 425-435Crossref PubMed Scopus (75) Google Scholar,10Twerenbold R. Badertscher P. Boeddinghaus J. et al.0/1-Hour triage algorithm for myocardial infarction in patients with renal dysfunction.Circulation. 2018; 137: 436-451Crossref PubMed Scopus (115) Google Scholar cardiac troponin concentrations are often chronically elevated in kidney impairment,7Parikh R.H. Seliger S.L. deFilippi C.R. Use and interpretation of high sensitivity cardiac troponins in patients with chronic kidney disease with and without acute myocardial infarction.Clin Biochem. 2015; 48: 247-253Crossref PubMed Scopus (55) Google Scholar potentially as a result of underlying cardiovascular disease.11Jacobs L.H. van de Kerkhof J. Mingels A.M. et al.Haemodialysis patients longitudinally assessed by highly sensitive cardiac troponin T and commercial cardiac troponin T and cardiac troponin I assays.Ann Clin Biochem. 2009; 46: 283-290Crossref PubMed Scopus (94) Google Scholar,12deFilippi C. Wasserman S. Rosanio S. et al.Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis.JAMA. 2003; 290: 353-359Crossref PubMed Scopus (357) Google Scholar High-Sensitivity Troponin in the Evaluation of patients with suspected Acute Coronary Syndrome (High-STEACS) was a randomized controlled trial that evaluated the introduction of high-sensitivity cardiac troponin testing into clinical practice.4Shah A.S.V. Anand A. Strachan F.E. et al.High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial.Lancet. 2018; 392: 919-928Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar In a brief report, we recently demonstrated that outcomes did not improve in patients with kidney impairment, which is consistent with the main trial’s findings.13Gallacher P.J. Miller-Hodges E. Shah A.S.V. et al.Use of high-sensitivity cardiac troponin in patients with kidney impairment: a randomized clinical trial.JAMA Intern Med. 2021; 181: 1237-1239Crossref PubMed Scopus (8) Google Scholar One potential explanation for this is that patients with kidney impairment are more likely to have nonischemic myocardial injury or type 2 myocardial infarction. In this prespecified secondary analysis of the original trial, we evaluate the diagnosis, management, and outcomes of patients with and without kidney impairment identified as having myocardial injury or infarction before and after implementation of a high-sensitivity cardiac troponin assay. High-STEACS was a stepped-wedge, cluster-randomized controlled trial4Shah A.S.V. Anand A. Strachan F.E. et al.High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial.Lancet. 2018; 392: 919-928Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar that evaluated the implementation of a high-sensitivity cardiac troponin I assay in consecutive patients presenting with suspected acute coronary syndrome across 10 secondary and tertiary hospitals in Scotland (ClinicalTrials.gov number, NCT01852123). This was a prespecified secondary analysis of the original High-STEACS trial and was designed specifically to evaluate the diagnosis, management, and outcomes of patients with kidney impairment presenting with suspected acute coronary syndrome. The trial design has been described previously,4Shah A.S.V. Anand A. Strachan F.E. et al.High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial.Lancet. 2018; 392: 919-928Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar and a detailed description is provided in the Supplementary Methods. In brief, consecutive patients with suspected acute coronary syndrome underwent cardiac troponin testing at presentation and again 6 to 12 hours after the onset of symptoms at the discretion of the attending clinician consistent with national1Thygesen K. Alpert J.S. Jaffe A.S. et al.Fourth Universal Definition of Myocardial Infarction.J Am Coll Cardiol. 2018; 72: 2231-2264Crossref PubMed Scopus (2130) Google Scholar and international2Mills N.L. Churchhouse A.M. Lee K.K. et al.Implementation of a sensitive troponin I assay and risk of recurrent myocardial infarction and death in patients with suspected acute coronary syndrome.JAMA. 2011; 305: 1210-1216Crossref PubMed Scopus (277) Google Scholar guidelines. In this trial, the hospital site was the unit of randomization. Cluster randomization was necessary to avoid the risk of clinical error due to reporting of different troponin assays and thresholds simultaneously. During both phases of the trial, all patients underwent testing with contemporary cardiac troponin I (ARCHITECTSTAT troponin I, Abbott Laboratories) and high-sensitivity cardiac troponin I (ARCHITECTSTAT high-sensitive troponin I, Abbott Laboratories) assays. During a validation phase of at least 6 months, results of the high-sensitivity assay were suppressed from attending clinicians; during the implementation phase of the trial, results of the contemporary were suppressed. For the contemporary assay, a single threshold (based on interassay coefficient of variation) for the diagnosis of myocardial infarction in men and was to clinical during the validation phase of the were to or implementation of the high-sensitivity cardiac troponin assay. For the high-sensitivity assay, sex-specific 99th thresholds in in for the diagnosis of myocardial infarction were to clinical during the implementation phase of the that implementation of a high-sensitivity cardiac troponin I assay myocardial infarction or cardiovascular death at 1 year by more patients with suspected acute coronary syndrome at risk and Patients attending the were identified as having suspected acute coronary syndrome by the attending clinician at the cardiac troponin was an the clinical Patients were for with suspected acute coronary syndrome and had cardiac troponin the contemporary and trial assays. Patients were had been during the trial or were not in For this prespecified patients were a of creatinine was not Patients were as having myocardial injury high-sensitivity cardiac troponin I concentrations were the for this assay for for In patients with myocardial those by the contemporary assay were defined as patients with cardiac troponin I than the diagnostic threshold of this assay. by the high-sensitivity cardiac troponin I assay were defined as patients with an increased high-sensitivity cardiac troponin I for for in whom cardiac troponin I concentrations were the diagnostic threshold of the contemporary assay. to phase all clinical and the index diagnosis in all patients with high-sensitivity cardiac troponin I concentrations in with the Universal Definition of Myocardial K. Alpert J.S. Jaffe A.S. et al.Fourth Universal Definition of Myocardial Infarction.J Am Coll Cardiol. 2018; 72: 2231-2264Crossref PubMed Scopus (2130) Google A.R. Adamson P.D. Shah A.S. et al.High-sensitivity cardiac troponin and the universal definition of myocardial infarction.Circulation. 2020; 141: 161-171Crossref PubMed Scopus (123) Google Scholar were by a 1 myocardial infarction was defined as myocardial high-sensitivity cardiac troponin I above the 99th with a in high-sensitivity cardiac troponin I testing was in the of a presentation with suspected acute coronary syndrome with symptoms or of myocardial on the 2 myocardial infarction was defined as myocardial with symptoms or of myocardial due to increased or secondary to an as or 4b myocardial infarction was defined as myocardial injury with symptoms or of myocardial secondary to demonstrated on coronary Patients with high-sensitivity cardiac troponin I concentrations above the 99th without symptoms or of myocardial were as having nonischemic myocardial was from creatinine the Kidney A.S. et to Intern Med. 2009; PubMed Scopus Google Scholar Kidney impairment was defined as an eGFR Patients were to to to or was a to and to A.S.V. Anand A. Strachan F.E. et al.High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial.Lancet. 2018; 392: 919-928Abstract Full Text Full Text PDF PubMed Scopus (247) Google E. Anand A. Shah A.S.V. et al.High-sensitivity cardiac troponin and the risk stratification of patients with renal impairment presenting with suspected acute coronary syndrome.Circulation. 2018; 137: 425-435Crossref PubMed Scopus (75) Google A.S. Lee K.K. et sensitivity cardiac troponin and the of myocardial infarction in prospective cohort study.BMJ. 2015; PubMed Google Scholar The primary outcome was type 1 or type 4b myocardial infarction or cardiovascular death at 1 outcomes included cardiovascular myocardial for and at 1 and at outcomes were by to were and to eGFR for all patients and to eGFR and phase for those with elevated cardiac troponin The index diagnosis was compared in those with and without kidney impairment and by eGFR in those identified by the contemporary cardiac troponin I assay. The index diagnosis was compared in those the high-sensitivity cardiac troponin I assay with above the sex-specific 99th but the diagnostic threshold by the contemporary assay. were to the risk of myocardial infarction or cardiovascular death at 1 year to kidney by diagnosis during the index included eGFR as a and for of disease and and the high-sensitivity cardiac troponin I In patients with type 1 myocardial an analysis was to evaluate the of coronary dual or and to kidney by eGFR Supplementary the of we evaluated the that the of a the of the primary outcome at 1 the but with a and of a as the primary analysis was in The trial was in with the of and with the of the Scotland the and for and and randomization was at the hospital was not Serum creatinine concentrations were available for 46,927 of patients 61 years; 47% enrolled into the Kidney impairment was in patients of had an eGFR of to and of had an eGFR troponin concentrations were elevated in 46% of and 16% of of patients with and without kidney impairment, the patients with elevated cardiac troponin of had kidney impairment patients were more likely to and were less likely to with a primary of than patients with kidney risk and of cardiovascular increased in as eGFR of patients with concentrations above the sex-specific 99th by eGFR 1 Myocardial revascularization at presentation from or or and at was in patients and were available in patients Myocardial and were available in patients and clinical as 2 or more hours of was to in of patients with hs-cTnI concentrations above the sex-specific 99th 1 (55) 2 Acute myocardial myocardial coronary high-sensitivity cardiac troponin myocardial coronary are or from or and was in patients and were available in patients as 2 or more hours of The was to in of patients with hs-cTnI concentrations above the sex-specific 99th in a coronary high-sensitivity cardiac troponin myocardial coronary are or The high-sensitivity cardiac troponin assay of of patients with myocardial injury or infarction were not identified by the contemporary assay Kidney impairment was in of of patients identified by the contemporary assay and in 46% of of patients by the high-sensitivity assay The of patients with high-sensitivity cardiac troponin concentrations sex-specific were before and after implementation of high-sensitivity cardiac troponin testing the of patients with kidney impairment undergoing cardiac troponin testing did not change following implementation of of increased from of to of in patients without kidney impairment. diagnosis of type 1 myocardial infarction was less in patients with kidney impairment than in patients with kidney In type 2 myocardial infarction and nonischemic myocardial injury were more in patients with kidney impairment than in those with kidney the of patients with myocardial infarction or injury of the of kidney impairment The with a diagnosis of type 1 myocardial infarction increased from 12.4% of to of in patients with kidney impairment, and from 7.5% of to 9.4% of in patients without kidney impairment. 2 myocardial infarction increased following implementation from of to of in patients with kidney impairment and from of to of without kidney impairment. the with acute myocardial injury increased from of to of in patients with and from of to of in patients without kidney impairment, the with chronic myocardial injury increased from of to 7.5% of and from of to of in those with and without kidney impairment, of increased in patients with kidney impairment and elevated cardiac troponin concentrations While management in patients without kidney impairment following the of patients with kidney impairment undergoing coronary undergoing or did not of had an elevated cardiac troponin had been with type 1 myocardial infarction or had been by the high-sensitivity cardiac troponin assay and outcomes of patients with concentrations above the sex-specific 99th to eGFR of Coronary by or the validation and implementation phases in the management of or by or the validation and implementation phases in the management of by or the validation and implementation phases in the management of by or the validation and implementation phases in the management of by or the validation and implementation phases in the management of by or the validation and implementation phases in the management of or by or the validation and implementation phases in the management of by or the validation and implementation phases in the management of coronary dual high-sensitivity cardiac coronary are or by or the validation and implementation phases in the management of in a coronary dual high-sensitivity cardiac coronary are or both of increased as eGFR in patients with elevated cardiac troponin concentrations to patients with an eGFR patients with an eGFR the of coronary and coronary revascularization of with eGFR patients with kidney impairment had been with type 1 myocardial infarction were less likely to undergo coronary revascularization (26% or receive than patients without kidney impairment and outcomes of patients with concentrations above the sex-specific 99th during hospital by eGFR of Coronary or or outcome type 1 or type 4b myocardial infarction. or cardiovascular outcomes type 1 or type 4b myocardial as or coronary or coronary from to 1 year for type or type hospital at type 1 or type 4b myocardial coronary dual high-sensitivity cardiac myocardial coronary are or type 1 or type 4b myocardial as or coronary or coronary from to 1 year type or type type 1 or type 4b myocardial infarction. in a coronary dual high-sensitivity cardiac myocardial coronary are or The primary outcome of type 1 or 4b myocardial infarction or cardiovascular death at 1 year occurred in of of all patients and in of of those with elevated cardiac troponin concentrations those with elevated cardiac troponin the primary outcome occurred in of those with kidney impairment and in of those without hazard 95% confidence interval 1.31 to 1.78). eGFR the was in patients with an eGFR of compared with the other diagnostic eGFR was with the in patients with type 1 myocardial infarction for 10 in eGFR in these the risk of the primary outcome at 1 year increased by hazard 95% secondary outcome occurred more as eGFR For death at 1 year occurred in with an eGFR versus with an eGFR In patients with type 1 myocardial infarction underwent coronary revascularization or dual the of the primary outcome at 1 year was in those with and without kidney impairment with patients did not undergo the risk of the primary outcome was lower in those undergoing 95% and at all of kidney in those with an eGFR in those with an eGFR to and in those with an eGFR the of the primary outcome was lower in patients dual compared with patients did 95% and at all of kidney in those with an eGFR in those with an eGFR to and in those with an eGFR In patients with type 1 myocardial infarction did and did not receive a of a during the index was in the primary outcome at 1 year 95% evaluated the diagnosis, management, and outcomes of patients with and without kidney impairment were to have myocardial injury or infarction before and after implementation of high-sensitivity cardiac troponin that elevated cardiac troponin concentrations were more in patients with kidney impairment than in those with kidney In patients with kidney impairment compared to those type 1 myocardial infarction was twice as type 2 myocardial infarction and nonischemic myocardial injury were to more implementation of high-sensitivity cardiac troponin of coronary and the of increased in patients with kidney but this was not the in patients with kidney impairment. Patients with type 1 myocardial infarction and kidney impairment less likely to undergo revascularization or to receive than those with kidney and as a were more likely to have a myocardial infarction or cardiovascular death at 1 The has a of was from selection patients with suspected acute coronary syndrome were enrolled across of or kidney the diagnosis of myocardial infarction was to the Universal Definition of Myocardial was and reporting and to the of particularly those with an eGFR is and with other et between renal and outcomes in patients with acute coronary syndrome: from the and Intern Med. PubMed Scopus Google Scholar, Herzog C.A. et myocardial infarction and renal a Intern Med. 137: PubMed Scopus Google Scholar, et and hospital outcomes in patients with acute coronary from the of acute coronary 2003; PubMed Scopus Google Scholar we is and to we that outcomes of patients with kidney impairment and suspected acute coronary syndrome did not improve following implementation of high-sensitivity cardiac troponin the identification of more patients are at P.J. Miller-Hodges E. Shah A.S.V. et al.Use of high-sensitivity cardiac troponin in patients with kidney impairment: a randomized clinical trial.JAMA Intern Med. 2021; 181: 1237-1239Crossref PubMed Scopus (8) Google Scholar to clinical analysis that implementation increased the identification of all of myocardial infarction and injury in patients with and without kidney impairment, particularly type 1 myocardial infarction. implementation failed to address the disparities in management between those with and without kidney impairment. The for this are but likely are to the that of all patients with elevated cardiac troponin concentrations and kidney impairment had a diagnosis of nonischemic myocardial injury or myocardial infarction secondary to other While have identified kidney impairment as a risk for type 2 myocardial infarction and acute and chronic myocardial K. J. et 2 myocardial infarction in clinical 2015; PubMed Scopus Google Scholar, Y. A. et 1 and 2 myocardial infarction and myocardial clinical to high-sensitivity cardiac troponin Med. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar, et and outcomes of patients with myocardial myocardial and Med. Full Text Full Text PDF PubMed Scopus Google Scholar, A.R. N.L. et and of patients with type 2 myocardial infarction and acute nonischemic myocardial PubMed Scopus Google Scholar this is than those in Y. A. et 1 and 2 myocardial infarction and myocardial clinical to high-sensitivity cardiac troponin Med. 2017; Full Text Full Text PDF PubMed Scopus Google et and outcomes of patients with myocardial myocardial and Med. Full Text Full Text PDF PubMed Scopus Google Scholar and is the with these A.R. Adamson P.D. Shah A.S. et al.High-sensitivity cardiac troponin and the universal definition of myocardial infarction.Circulation. 2020; 141: 161-171Crossref PubMed Scopus (123) Google Scholar and the of available to the management of A.R. N.L. et and of patients with type 2 myocardial infarction and acute nonischemic myocardial PubMed Scopus Google Scholar in the diagnosis and management of type 1 myocardial C. et for the management of acute coronary in patients presenting without for the of Acute Coronary in Patients without of the of J. PubMed Scopus Google Scholar that patients with kidney impairment to a risk of and cardiovascular death in the of high-sensitivity cardiac troponin Herzog C.A. risk stratification of high-sensitivity C-reactive and cardiac troponin T and I in renal disease for Chem. PubMed Scopus Google Sandoval Y. et the diagnostic and of high-sensitivity cardiac troponin Am 2018; PubMed Scopus Google Scholar In compared to those with kidney patients with elevated cardiac troponin concentrations and kidney impairment had a increased risk of the primary While eGFR was with outcomes for all diagnostic the in type 1 myocardial we have the to improve are at least to the in the of in patients with kidney impairment. This is R. Y. The renal with coronary and Am Coll Cardiol. Google Scholar and was in For in patients with type 1 myocardial of those with kidney underwent coronary compared to one of those with kidney impairment. in with other R. S. et of long-term after revascularization in patients with chronic kidney disease presenting with acute coronary Cardiol. 2003; Full Text Full Text PDF PubMed Scopus Google Scholar, K. P. et between and outcome in to renal in of myocardial 2011; Full Text Full Text PDF PubMed Scopus Google Scholar, et and of for long-term secondary of in to renal from the J. Google Scholar, S. et in patients with acute coronary and a from the and J. PubMed Scopus Google Scholar both coronary revascularization and were with a lower risk of the primary outcome in patients with type 1 myocardial of the of kidney impairment. is likely that the we in the of randomized trial in patients with type 1 myocardial infarction and kidney R. et of kidney disease in controlled of cardiovascular disease in the contemporary Am 2018; PubMed Scopus Google Scholar the of in patients with kidney have the cardiovascular S. Herzog C. disease in renal disease Kidney Full Text Full Text PDF PubMed Scopus Google and a for was not to between acute and chronic kidney injury a single of creatinine was available for While both are with increased cardiovascular these are and result in cardiovascular disease different A. et and long-term risk for cardiovascular and Am 2017; PubMed Scopus Google R. et kidney disease and cardiovascular and Full Text Full Text PDF PubMed Scopus Google Scholar creatinine were in of all enrolled patients with kidney impairment underwent following index presentation with suspected acute coronary and diagnostic have been more in this as with all the trial was not for the primary the main of this prespecified secondary analysis was to the trial was and to into the diagnosis and management of patients with kidney impairment and suspected acute coronary syndrome. cardiac troponin concentrations were more in patients with kidney impairment than in those with kidney Implementation of high-sensitivity cardiac troponin testing increased the diagnosis of type 1 myocardial infarction in both patients with and without kidney impairment. patients with kidney impairment were more likely to undergo or or to receive and to outcomes than those with kidney

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