Incremental prognostic value of serum levels of troponin T and C-reactive protein on admission in patients with unstable angina pectoris

Management of unstable angina is largely determined by symptoms, yet some symptomatic patients stabilize, waning of symptoms. Therefore, markers of short-term risk, available,on admission, are needed. The value of 4 prognostic indicators available on admission (pain in the last 24 hours, electrocardiogram [ECG], troponin T, and C-reactive protein [CRP]), and of Holter monitoring available during the subsequent 24 hours was analyzed in 102 patients with Braunwald class IIIB unstable angina hospitalized in 4 centers. The patients were divided into 3 groups: group 1, 27 with pain during the last 24 hours and ischemic electrocardiographic changes; group 2, 45 with pain or electrocardiographic changes; group 3, 30 with neither pain nor electrocardiographic changes. Troponin T, CRP, ECG on admission and Halter monitoring were analyzed blindly in the core laboratory. Fifteen patients developed myocardial infarction: 22% in group 1, 13% in group 2, and 10% in group 3. Twenty-eight patients underwent revascularization: 37% in group 1, 35% in group 2, and 7% in group 2 (p <0.01 between groups 1 or 2 vs group 3). Myocardial infarction was more frequent in patients with elevated tropanin T (50% vs 9%, p = 0.001) and elevated CRP (24% vs 4%, p = 0.01). Positive troponin T or CRP identified all myocardial infarctions in group 3. Only 1 of 46 patients with negative troponin T and CRP developed myocardial infarction. Among the indicators available on admission, multivariate analysis showed that troponin T (p = 0.02) and CRP (p = 0.04) were independently associated with myocardial infarctian. Troponin T had the highest specificity (92%), and CRP the highest sensitivity (87%). Positive results on Holter monitoring were also associated with myocardial infarction (p = 0.003), but when added to troponin T and CRP, increased specificity and positive predictive value by only 3%. Thus, in patients with class IIIB unstable angina, among data, potentially available on admission, serum levels of tropanin T and CRP have a significantly greater prognostic accuracy than symptoms and ECGs. Halter monitoring, available 24 hours later, adds no significant information. (C) 1998 by Excerpta Medica, Inc.