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Acad Emerg Med. 2019 Feb 5. doi: 10.1111/acem.13709. [Epub ahead of print]

Do High-sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope?

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Department of Emergency Medicine, William Beaumont Hospital-Royal Oak, Royal Oak, MI.
Department of Biostatistics, University of California Los Angeles, Fielding School of Public Health, Los Angeles, CA.
Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Heath, & Science University, Portland, OR.
Department of Emergency Medicine, University of Rochester, Rochester, NY.
Department of Emergency Medicine, William Beaumont Hospital-Troy, Troy, MI.
Department of Emergency Medicine, Brigham& Women's Hospital, Boston, MA.
Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
Department of Emergency Medicine, University of Texas-Southwestern, Dallas, TX.
Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA.
Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC.
Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA.
Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI.
Department of Emergency Medicine, Northeast Ohio Medical University, Rootstown, OH.
Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.



An estimated 1.2 million annual emergency department (ED) visits for syncope/near syncope occur in the United States. Cardiac biomarkers are frequently obtained during the ED evaluation, but the prognostic value of index high-sensitivity troponin (hscTnT) and natriuretic peptide (NT-proBNP) are unclear. The objective of this study was to determine if hscTnT and NT-proBNP drawn in the ED are independently associated with 30-day death/serious cardiac outcomes in adult patients presenting with syncope.


A prespecified secondary analysis of a prospective, observational trial enrolling participants ≥ age 60 presenting with syncope, at 11 United States hospitals, was conducted between April 2013 and September 2016. Exclusions included seizure, stroke, transient ischemic attack, trauma, intoxication, hypoglycemia, persistent confusion, mechanical/electrical invention, prior enrollment, or predicted poor follow-up. Within 3 hours of consent, hscTnT and NT-proBNP were collected and later analyzed centrally using Roche Elecsys Gen 5 STAT and 2010 Cobas, respectively. Primary outcome was combined 30-day all-cause mortality and serious cardiac events. Adjusting for illness severity, using multivariate logistic regression analysis, variations between primary outcome and biomarkers were estimated, adjusting absolute risk associated with ranges of biomarkers using Bayesian Markov Chain Monte Carlo methods.


The cohort included 3,392 patients; 367 (10.8%) experienced the primary outcome. Adjusted absolute risk for the primary outcome increased with hscTnT and NT-proBNP levels. HscTnT levels ≤ 5 ng/L were associated with a 4% (95% confidence interval [CI] = 3%-5%) outcome risk, and hscTnT > 50 ng/L, a 29% (95% CI = 26%-33%) risk. NT-proBNP levels ≤ 125 ng/L were associated with a 4% (95% CI = 4%-5%) risk, and NT-proBNP > 2,000 ng/L a 29% (95% CI = 25%-32%) risk. Likelihood ratios and predictive values demonstrated similar results. Sensitivity analyses excluding ED index serious outcomes demonstrated similar findings.


hscTnT and NT-proBNP are independent predictors of 30-day death and serious outcomes in older ED patients presenting with syncope.


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