• Matthew A Cavender, William B White, Petr Jarolim, George L Bakris, William C Cushman, Stuart Kupfer, Qi Gao, Cyrus R Mehta, Faiez Zannad, Christopher P Cannon, and David A Morrow.
• From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical Research, Boston, MA (Q.C., C.P.C.); Harvard School of Public Health, Boston, MA (C.R.M.); and Inserm 1143, Université de Lorraine, Nancy, France (F.Z.). matt.cavender@unc.edu.
• Circulation. 2017 May 16; 135 (20): 1911-1921.

BackgroundWe aimed to describe the relationship between changes in high-sensitivity cardiac troponin I (hsTnI) and cardiovascular outcomes.MethodsThe EXAMINE trial (Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care) was a phase IIIb clinical outcomes trial designed to evaluate the cardiovascular safety of alogliptin, a nonselective dipeptidyl peptidase 4 inhibitor. Patients with type 2 diabetes mellitus, glycohemoglobin between 6.5% and 11% (or between 7% and 11% if they were on insulin), and a recent acute coronary syndrome (between 15 and 90 days before randomization) were eligible for the trial. hsTnI was measured using the Abbott ARCHITECT assay at baseline and 6 months in patients randomized in the EXAMINE trial. This analysis was restricted to patients randomized ≥30 days after qualifying acute coronary syndrome to mitigate the potential for persistent hsTnI elevation after acute coronary syndrome (n=3808). The primary end point of the trial was cardiovascular death, myocardial infarction, or stroke. Cardiovascular death or heart failure was a prespecified, adjudicated secondary end point.ResultsAt baseline, hsTnI was detectable (≥1.9 ng/L) in 93% of patients and >99th percentile upper reference limit in 16%. There was a strong relationship between increasing hsTnI, both at baseline and 6 months, and the incidence of cardiovascular events through 24 months (P<0.001 for each). Patients with undetectable hsTnI at baseline and 6 months were at the lowest risk of future cardiovascular events. Stable patients with hsTnI ≥99th percentile upper reference limit at 6 months were at increased risk of cardiovascular death, myocardial infarction, or stroke compared with patients with hsTnI <99 percentile upper reference limit irrespective of whether hsTnI was newly elevated (28.1% versus 8.8%; adjusted hazard ratio, 2.65; 95% confidence interval, 1.64-4.28; P<0.001) or persistently so (22.5% versus 8.8%; adjusted hazard ratio, 1.90; 95% confidence interval, 1.33-2.70; P<0.001). Alogliptin neither increased nor decreased the risk of cardiovascular events compared with placebo in patients with high baseline hsTnI (22.3% versus 23.0%; hazard ratio, 0.87; 95% confidence interval, 0.60-1.25; P=0.44).ConclusionsSerial assessment of hsTnI revealed a substantial proportion of patients with type 2 diabetes mellitus without clinically recognized events had dynamic or persistently elevated values and were at high risk of recurrent events. hsTnI may have a role in personalizing preventive strategies in patients with diabetes mellitus based on risk.Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT00968708.© 2017 American Heart Association, Inc.

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