Yiu et al.

Cardiovascular Diabetology 2014, 13:63 CARDIO

http://www.cardiab.com/content/13/1/63 VASCULAR
DIABETOLOGY

ORIGINAL INVESTIGATION Open Access

Predictive value of high-sensitivity troponin-I for

future adverse cardiovascular outcome in stable
patients with type 2 diabetes mellitus
Kai-Hang Yiu1,2, Kui-Kai Lau2,3, Chun-Ting Zhao1, Yap-Hang Chan1, Yan Chen1, Zhe Zhen1, Arthur Wong1,
Chu-Pak Lau1 and Hung-Fat Tse1,2*

Abstract
Introduction: High-sensitivity cardiac troponin I(hs-TnI) and T levels(hs-TnT) are sensitive biomarkers of
cardiomyocyte turnover or necrosis. Prior studies of the predictive role of hs-TnT in type 2 diabetes mellitus(T2DM)
patients have yielded conflicting results. This study aimed to determine whether hs-TnI, which is detectable in a
higher proportion of normal subjects than hsTnT, is associated with a major adverse cardiovascular event(MACE) in
T2DM patients.
Methods and results: We compared hs-TnI level in stored serum samples from 276 consecutive patients (mean
age 65 ± 10 years; 57% male) with T2DM with that of 115 age-and sex-matched controls. All T2DM patients were
prospectively followed up for at least 4 years for incidence of MACE including heart failure(HF), myocardial
infarction(MI) and cardiovascular mortality. At baseline, 274(99%) patients with T2DM had detectable hs-TnI, and 57
(21%) had elevated hs-TnI (male: 8.5 ng/L, female: 7.6 ng/L, above the 99th percentile in healthy controls). A total of
43 MACE occurred: HF(n = 18), MI(n = 11) and cardiovascular mortality(n = 14). Kaplan-Meier analysis showed that an
elevated hs-TnI was associated with MACE, HF, MI and cardiovascular mortality. Although multivariate analysis
revealed that an elevated hs-TnI independently predicted MACE, it had limited sensitivity(62.7%) and positive
predictive value(38.5%). Contrary to this, a normal hs-TnI level had an excellent negative predictive value(92.2%) for
future MACE in patients with T2DM.
Conclusion: The present study demonstrates that elevated hs-TnI in patients with T2DM is associated with
increased MACE, HF, MI and cardiovascular mortality. Importantly, a normal hs-TnI level has an excellent negative
predictive value for future adverse cardiovascular events during long-term follow-up.
Keywords: Type 2 diabetes mellitus, High-sensitivity troponin I outcome

Introduction necrosis. These novel biomarkers have been shown to be

Cardiac troponin is a key biomarker for the diagnosis of associated with adverse clinical and cardiovascular
myocardial infarction (MI) and provides important prog- events in the general population [4-7], and in patients
nostic information in patients who present with acute with congestive heart failure [8], acute coronary syn-
coronary syndrome [1-3]. High-sensitivity cardiac tropo- drome [9] and stable atherosclerotic disease [10,11].
nin levels T (hs-TnT) and I (hs-TnI) are more sensitive Recent studies have demonstrated that patients with
biomarkers that can detect troponin below the clinical type 2 diabetes mellitus (T2DM) without prior cardiovas-
threshold, and reflect subtle cardiomyocyte turnover or cular disease [12] and a high hbA1c% had elevated
hs-TnT [13]. It has been proposed that chronic hypergly-
* Correspondence: [email protected] cemia contributes to subtle myocardial injury as detected
1
Cardiology Division, Department of Medicine, Queen Mary Hospital, the by hs-TnT that is beyond its effects on development of
University of Hong Kong, Block K, Pokfulam, Hong Kong
2
Research Centre of Heart, Brain, Hormone and Healthy Aging, Li Ka Shing
clinical atherosclerotic coronary disease [13]. The clinical
Faculty of Medicine, the University of Hong Kong, Hong Kong, SAR, China implications of an elevated high-sensitivity troponin assay
Full list of author information is available at the end of the article

© 2014 Yiu et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Yiu et al. Cardiovascular Diabetology 2014, 13:63 Page 2 of 8
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in patients with T2DM nonetheless remain unclear. fasting total plasma cholesterol ≥4.9 mmol/liter or the
Hallen et al. [14] showed that elevated hs-TnT was fre- prescription of statins. Smoking status was recorded as
quently detected in diabetic patients but did not predict ever smoker (past or current) or nonsmoker. Duration of
future adverse outcomes over a 2 year follow-up period. T2DM and data on prescribed oral hypoglycemic agents
Conversely, recent results from the Women’s Health and insulin therapy were retrieved from patients’ medical
Study demonstrated that a detectable level of hs-TnT was records.
associated with increased cardiovascular morbidity and Serum HbA1c, total cholesterol, triglyceride, high-
mortality in diabetic women [12]. Compared with hs-TnT density lipoprotein cholesterol and low-density lipoprotein
measurement, higher proportions of normal subjects have cholesterol levels, fasting glucose, and HbA1c were mea-
a detectable level of hs-TnI, making it a more sensitive sured in all subjects in a fasting venous blood sample [18].
assay for subtle myocardial damage [15]. Currently, there Serum creatinine levels were used to assess eGRF calcu-
are no data on the predictive value of hs-TnI in patients lated with the Modified Diet in Renal Disease Equation
with T2DM. This study sought to investigate whether an [19]. Serum level of hs-TnI was determined using Chemo-
elevated hs-TnI is associated with a major adverse cardio- luminescent Microparticule ImmunoAssay (Architect
vascular event (MACE) in patients with T2DM. i1000SR AbbottW, Paris, France). The level of detection is
1.2 ng/L according to the manufacturer’s instruction and
Methods above such is considered to be a detectable hs-TnI. An
Study population elevated hs-TnI was defined as plasma level greater than
Consecutive T2DM patients (n = 293) as defined by the 99th percentile based on the hs-TnI of an age-matched
World Health Organization criteria [16,17] on stable healthy control for both genders, respectively.
hypoglycemic and cardiovascular medication for at least
3 months were recruited from the medical outpatient Follow-up
clinic. Exclusion criteria included recent acute coronary All patients were followed up for a minimum of 4 years.
syndrome, stroke, coronary intervention, hospitalization Outcome of patients was retrieved from the inter-hospital
for cardiac surgery or heart failure within the last computer system or by telephone interview. The MACE
6 months, dilated cardiomyopathy, significant valvular was a composite endpoint of heart failure requiring hos-
heart disease, chronic atrial fibrillation, New York Heart pital admission, myocardial infarction and cardiovascular
Association class III/IV heart failure, estimated glomeru- mortality. The definition of MI was based on the presence
lar filtration rate (eGFR) <30 mL/min per 1.73 m2, and of typical chest pain, elevated cardiac enzyme levels, and
refusal to participate (n = 17). A total of 276 patients typical electrocardiogram changes [1].
with T2DM were consequently eligible for this study.
During the study period, 115 age- and sex-matched Statistical analysis
Chinese controls without T2DM or established cardio- Data are expressed as mean ± standard deviation for
vascular disease were recruited from a community continuous variables and frequencies or proportions for
health screening programme. Written informed consent categorical variables. Continuous demographic variables
was obtained from all study subjects. The study was ap- of the two groups were compared using the Mann-
proved by the Institutional Review Board of the Univer- Whitney U test and categorical demographic variables
sity of Hong Kong/Hospital Authority Hong Kong West compared using Pearson Chi-square test or the Fisher’s
Cluster and was conducted according to the Declaration exact test if at least one cell had an expected cell count
of Helsinki. This study is part of the Chinese Diabetic below five. Cumulative incidence of the first occurrence
Heart Study (CDATS) to evaluate cardiovascular mani- of MACE for patients with elevated hs-TnI and normal
festation of Chinese patients with T2DM, in an attempt hs-TnI level was estimated using the Kaplan-Meier
to evaluate the pathophysiology and potential therapeu- method and compared with the log-rank test. First
tics in these patients. occurrence of heart failure, myocardial infarction and
cardiovascular mortality was evaluated. Multivariate ana-
Clinical parameters lyses for MACE, heart failure, myocardial infarction and
Baseline demographic data, clinical characteristics and cardiovascular mortality were performed using Cox re-
blood sampling were obtained on the same day from all gression models.
study subjects. Blood pressure, body weight, body height, Three levels of adjustment were made: (1) demographics
and body mass index (BMI) were also measured. Hyper- (age and gender); (2) demographic factors, cardiovascular
tension was defined as resting systolic or diastolic blood risk factors (hypertension, hyperlipidemia, smoking his-
pressure >140 mmHg or >90 mm Hg, respectively, at two tory, coronary heart disease); (3) demographic factors, risk
different clinic visits or the prescription of antihyperten- factors, cardiovascular risk factors and eGFR level. All
sive medication. Hypercholesterolemia was defined as statistical analyses were performed using the statistical
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package SPSS for windows (Version 18.0, SPSS, Chicago, Based on these cut-off values, 70 (25.4%) patients with
USA). All P values reported are 2-sided for consistency. A T2DM had an elevated serum hs-TnI level. As shown in
P value <0.05 was considered statistically significant. Table 1, T2DM patients with elevated serum hs-TnI level
were older, more likely to be male, smoke, have a history
Results of hypertension and coronary artery disease, low eGFR
Clinical characteristics level, and be treated with aspirin, angiotensin converting
Baseline characteristics of patients with T2DM and con- enzyme inhibitor/angiotensin receptor blocker and statin
trols are shown in Table 1. Patients with T2DM had a compared with T2DM patients with a normal serum hs-
higher BMI, were more likely to be a smoker and had a TnI level. Univariate analysis showed that elderly age,
history of hypertension and hypercholesterolemia com- male gender, smoking, a history of hypertension and cor-
pared with controls. In addition, the eGFR was lower, onary artery disease and low eGFR were associated with
and fasting glucose and HbA1c% were higher. elevated serum hs-TnI level in T2DM patients. Multi-
variate analysis nonetheless revealed that only history of
Serum level of hs-TnI coronary artery disease and low eGRF were independ-
The proportion of patients with T2DM and serum level of ently associated with an elevated serum hs-TnI level
hs-TnI at or above the limit of detection (1.2 ng/L) was (Table 2).
similar to controls (274/276, 99.3% versus 114/115, 99.1%,
P = 1.0). The median serum level of hs-TnI in patients Clinical outcomes
with T2DM was significantly higher (median [interquatile The median follow-up period was 4.9 years (interquartile
range]: 4.8 [3.2-8.4 ng/L] versus 2.9 [2.2-3.9 ng/L], range, 3.7 to 5.6 years), and none of the control subjects
P < 0.01). developed MACE. A total of 43 patients with T2DM de-
In this study, the 99th percentile value of serum hs-TnI veloped MACE during this follow-up period. Among
level in male and female control subjects was 8.5 ng/L those MACEs, there were 18 heart failure events (12 dia-
and 7.6 ng/L, respectively. These serum levels were de- stolic heart failure, 6 systolic heart failure), 11 myocar-
fined as the cut-off values for elevated serum hs-TnI. dial infarctions and 14 cases of cardiovascular mortality

Table 1 Baseline demographics of type 2 diabetes mellitus (T2DM) patients with and without elevated high sensitivity
Troponin I (hs-TnI) and controls
Parameters T2DM (n = 276) Controls (n = 115) P value Elevated hs-TnI (n = 70) Normal hs-TnI (n = 206) P value
Age, years 64.4 ± 10.0 63.4 ± 7.9 0.29 68.6 ± 9.2 62.9 ± 9.9 <0.01
Male, % (n) 154 (56) 53 (61) 0.35 70 (49) 30 (21) <0.01
2
Body mass index, kg/m 25.5 ± 3.5 23.6 ± 3.4 <0.01 25.4 ± 3.5 25.6 ± 3.6 0.72
Current smoker, % (n) 33 (92) 6 (7) <0.01 49 (34) 28 (58) <0.01
Hypertension, % (n) 70 (194) 15 (17) <0.01 89 (62) 132 (64) <0.01
Hypercholesterolemia, % (n) 63 (174) 30 (26) <0.01 70 (49) 61 (125) 0.10
Duration of DM, years 9.8 ± 7.6 – – 10.2 ± 8.7 9.7 ± 7.3 0.67
CAD, % (n) 29 (113) – – 60 (42) 35 (71) <0.01
Total cholesterol, mmol/L 4.6 ± 1.0 5.0 ± 0.9 <0.01 4.5 ± 1.1 4.7 ± 1.0 0.15
Triglycerides, mmol/L 1.6 ± 1.8 1.3 ± 0.8 <0.01 1.6 ± 1.1 1.6 ± 1.9 0.99
High density lipoprotein, mmol/L 1.3 ± 0.8 1.5 ± 0.4 <0.01 1.2 ± 0.4 1.3 ± 0.4 0.16
Low density lipoprotein, mmol/L 2.7 ± 0.8 3.0 ± 0.7 <0.01 2.6 ± 0.8 2.7 ± 0.8 0.55
eGFR, mL/min per 1.73 m2 81.8 ± 19.3 85.8 ± 14.1 0.03 72.0 ± 18.7 84.2 ± 18.7 <0.01
Fasting glucose, mmol/L 7.6 ± 2.3 5.1 ± 0.5 <0.01 7.6 ± 2.8 7.6 ± 2.1 0.96
HbA1c, % 7.8 ± 1.4 5.9 ± 0.4 <0.01 8.1 ± 1.7 7.7 ± 1.4 0.21
Medication
Insulin, % (n) 14 (38) 0 (0) <0.01 19 (13) 12 (25) 0.13
Aspirin, % (n) 40 (109) 0 (0) <0.01 56 (39) 34 (70) <0.01
ACEI/ARB, % (n) 60 (166) 1 (1) <0.01 77 (54) 54 (112) <0.01
Statin, % (n) 42 (115) 2 (2) <0.01 57 (40) 37 (75) <0.01
Abbreviation:
ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; CAD = coronary artery disease; eGFR = estimated glomerular filtration rate.
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Table 2 Predictors for high-sensitivity troponin I in patients with type 2 diabetes mellitus
Univariate analysis Multivariate analysis
Variables β 95% CI P value β 95% CI P value
Age 1.07 1.03-1.10 <0.01 1.02 0.97-1.06 0.46
Male gender 2.24 1.26-4.01 <0.01 2.08 0.82-5.28 0.12
Body mass index 0.99 0.91-1.07 0.72
Smoker 2.41 1.38-4.21 <0.01 1.58 0.64-3.87 0.32
Hypertension 4.35 1.97-9.57 <0.01 2.21 0.90-5.44 0.09
Duration of disease 1.01 0.97-1.05 0.64
History of CAD 2.85 1.63-4.98 <0.01 2.93 1.33-6.44 <0.01
Total Cholesterol 0.80 0.60-1.08 0.14
Triglyceride 0.99 0.84-1.19 0.99
High density lipoprotein 0.51 0.20-1.27 0.15
Low density lipoprotein 0.89 0.60-1.31 0.54
eGFR 0.97 0.95-0.98 <0.01 0.97 0.95-0.99 0.02
Fasting glucose 0.99 0.88-1.13 0.96
HbA1c 1.17 0.94-1.45 0.16
Insulin 1.65 0.79-3.44 0.18
Abbreviations as in Table 1.

(11 systolic heart failure, 2 myocardial infarction and 1 and cardiovascular mortality (3.5% vs. 0.2%) than those
sudden death). For the whole population, the annual T2DM patients with normal serum hs-TnI level (P <
MACE event rate was 3.3%, heart failure event rate was 0.01). As shown in Figure 1, T2DM patients with ele-
1.4%, myocardial infarction event rate was 1.3% and car- vated serum level of hs-TnI had a significantly higher
diovascular mortality event rate was 1.0%. More import- risk for MACEs (Hazard ratio [HR] 8.9, 95% confidence
antly, T2DM patients with elevated hs-TnI had a higher interval [CI] 4.3-18.4 , P < 0.01); heart failure (HR 19.6,
annual event rate for MACE (9.3% vs. 1.6%), heart fail- 95% CI 4.0-40.6 , P < 0.01), and cardiovascular mortality
ure (3.8% vs.0.6%), myocardial infarction (1.5% vs.0.6%) (HR 17.1 95% CI 5.3-55.5 , P < 0.01), but not myocardial

Figure 1 Kaplan-Meier Curve reflecting cumulative proportion of patients with type 2 diabetes mellitus free of (a) major adverse
cardiovascular events [MACE]; (b) heart failure; (c) myocardial infarction; and (d) cardiovascular mortality.
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infarction (HR 2.9, 95% CI 0.7-11.5, P = 0.14) than those negative predictive value (92.2%) for future MACE in
with normal serum hs-TnI level during follow-up. T2DM patients.

Predictive value of serum hs-TnI level Discussion

Cox proportional hazard models were used to evaluate The present study demonstrates that up to 25% of
the impact of elevated serum hs-TnI level on adverse T2DM patients without clinical evidence of active car-
clinical outcome (Table 3). In both the unadjusted model diovascular disease have ongoing subtle myocardial in-
and adjusted models for demographic factors and car- jury/necrosis as detected by an elevated serum level of
diovascular risk factors, an elevated serum hs-TnI level hs-TnI. An elevated serum hs-TnI level in patients with
in patients with T2DM was predictive of MACE, heart T2DM, above the gender-specific cut-off value in the
failure and cardiovascular mortality. Even after adjusting control population, was associated with a more than 2-
for demographic factors, cardiovascular risk factors and fold increase in the adjusted risk of MACE. Importantly,
eGFR, an elevated serum hs-TnI level remained an inde- a normal serum hs-TnI level had an excellent negative
pendent predictor for MACE and heart failure. predictive value for future adverse cardiovascular out-
In order to evaluate the clinical application of hs-TnI come in patients with T2DM after up to 4 years of
level, the sensitivity, specificity, positive predictive value follow-up.
and negative predictive value of an elevated serum hs- Elevated high sensitivity troponin level suggested myo-
TnI level was determined to predict future MACE. In cardial injury that has been shown to be related with ar-
patients with T2DM, an elevated serum hs-TnI level had terial stiffening in patients with T2DM [20]. In addition
a high specificity (84.4%) but limited sensitivity (62.7%) to detect subtle myocardial necrosis, its clinical value
and positive predictive value (38.5%) for MACE. Con- has also been shown to provide important prognostic in-
versely, a normal serum hs-TnI level had an excellent formation in various groups of patients. Several studies

Table 3 Association of elevated high-sensitivity troponin I (hs-TnI) with subsequent major adverse cardiovascular
events (MACE), heart failure, myocardial infarction and cardiovascular mortality
Univariate analysis
Variables HR 95% CI P value
MACE
Unadjusteda 5.69 3.05-10.62 <0.01
Adjusted for demographic factorsb 3.81 2.01-7.24 <0.01
Adjusted for demographic, cardiovascular risk factorsc 3.70 1.91-7.18 <0.01
Adjusted for demographic, cardiovascular risk factors and eGFRd 2.85 1.15-7.03 0.02
Heart failure
Unadjusteda 7.21 2.70-19.25 <0.01
b
Adjusted for demographic factors 4.98 1.80-13.83 <0.01
Adjusted for demographic, cardiovascular risk factorsc 4.88 1.71-13.96 <0.01
d
Adjusted for demographic, cardiovascular risk factors and eGFR 4.88 1.12-21.31 0.03
Myocardial infarction
Unadjusteda 2.45 0.72-8.31 0.15
Adjusted for demographic factorsb 1.70 0.48-5.99 0.41
c
Adjusted for demographic, cardiovascular risk factors 1.34 0.36-5.04 0.67
Adjusted for demographic, cardiovascular risk factors and eGFRd 0.84 0.12-6.17 0.87
Cardiovascular mortality
Unadjusteda 15.90 3.52-71.87 <0.01
b
Adjusted for demographic factors 10.0 2.13-47.19 <0.01
Adjusted for demographic, cardiovascular risk factorsc 9.14 1.92-43.60 <0.01
d
Adjusted for demographic, cardiovascular risk factors and eGFR 6.19 0.50-76.59 0.16
Abbreviations as in Table 1; HR = hazard ratio.
a
All models additionally adjusted for hs-TnI.
b
Adjusted for age and gender.
c
Adjusted for modelb and hypertension, hyperlipidemia, smoking history and coronary heart disease.
d
Adjusted for modelc and eGFR.
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have demonstrated the predictive value for future car- independently predictive of death, heart failure and
diovascular events by hs-TnT in the general population major cardiovascular events, but not coronary heart dis-
[4,5,21], patients with stable and unstable angina [22], ease [7]. Similarly, Omland et al. showed that among pa-
acute coronary syndrome [23] and heart failure [24]. tients with stable coronary artery disease, an elevated
Similarly, hs-TnI has been shown to provide prognostic hs-TnI was strongly associated with cardiovascular death
information in the general population [6], patients with and heart failure but only weakly with non-fatal myocar-
stable atherosclerotic disease [10,11] and acute coronary dial infarction [11]. Collectively, these findings support
syndrome [25]. Although these studies have consistently the hypothesis that a measurable circulating troponin
demonstrated that high sensitivity troponin can predict level reflects chronic myocardial damage/myocardial
future adverse cardiovascular events in different groups stress, rather than acute ischemic insult or vascular
of patients, its prognostic value has not been well stud- stress. It can thereby identify an increased risk for patho-
ied in patients with T2DM. A recent report from the logical cardiac remodeling and subsequent heart failure.
Women Health Study demonstrated that among diabetic In patients with T2DM, a number of mechanisms
women without cardiovascular disease (n = 512), a de- might explain the presence of ongoing subtle myocardial
tectable hs-TnT was associated with total cardiovascular injury, including coronary microvascular dysfunction
disease (adjusted hazard ratio [HR] = 1.76) and cardio- [28], depletion of endothelial progenitor cells [9], ele-
vascular death (adjusted HR = 3.13) [12]. Conversely, an- vated oxidative stress [9,28], and advanced glycation
other study using elevated hs-TnT above 99th percentile end-products [29]. This is further evidenced by a study
reference could not demonstrate a statistical association that showed that chronic hyperglycaemia, as measured
with adverse cardiovascular outcome [14]. The contra- by HbA1c, was independently associated with subclinical
dictory results from these studies may suggest the poten- myocardial injury in subjects without clinically evident
tially limited prognostic value of hs-TnT in patients with coronary artery disease, as assessed by elevated levels of
T2DM. Because of the different biological characteristics hs-TnT [13]. In addition, this study also showed that the
[26], the clinical relevance and strength of detecting association of HbA1c with hs-TnT extends to subjects
myocardial injury between hs-TnT and hs-TnI may dif- below the diagnostic threshold of 6.5%, and suggests that
fer. Indeed, it has been shown that the prognostic value hyperglycaemia-related myocardial injury may begin be-
of hs-TnI may be superior to hs-TnT in a cohort of pa- fore the onset of clinically evident diabetes. The circulat-
tients with stable coronary artery disease [11]. The prog- ing troponin detected by these high sensitive assays in
nostic implication of hs-TnI may thus be more robust patients with T2DM thus represents an intermediate
than hs-TnT in patients with T2DM. phenotype of subtle myocardial injury, rather than an
A prior study demonstrated that a low level of circula- acute ischemic event.
tory TnI (9 ng/L to 30 ng/L) was predictive of MACE In patients with T2DM, a number of different cardiovascu-
(death, MI or stroke) in patients with T2DM who under- lar investigations, including treadmill testing [30], computed
went elective coronary angiography [27]. Nonetheless no tomography angiography [31] and electrocardiogram-gated
study has evaluated the predictive value for MACE using single photon emission computed tomography [32] have
a high sensitivity assay of TnI (level of detection = 1.2 been shown to provide excellent negative predictive
ng/L). The present study included an expanded and clinic- value for future cardiovascular events. Nevertheless
ally relevant population, consisting of both male and fe- their widespread clinical use for risk stratification is lim-
male T2DM patients, with and without underlying ited by the need for an experienced operator; prolonged
cardiovascular disease. Our results demonstrate that ele- study duration and prohibitive cost. One of the most in-
vated hs-TnI independently predicted MACE (adjusted triguing findings of the present report was that a normal
HR = 2.85) in patients with T2DM, and thus provides fur- hs-TnI had a high negative predictive value for future
ther evidence that elevated hs-TnI is closely associated adverse cardiovascular events in patients with T2DM
with and predictive for future adverse events in patients after up to four years of follow-up. The present study
with T2DM. thus suggests that a single serum measurement of hs-TnI
In this study, the high prevalence of MACE in T2DM provides a simple and inexpensive means to accurately
patients with elevated hs-TnI was mainly driven by more risk stratify patients with T2DM, particularly identifying
frequent heart failure and cardiovascular death. In con- those at low risk for intermediate-term (>4 years) adverse
trast, an elevated hs-TnI was not associated with future cardiovascular events.
myocardial infarction. Indeed, prior studies have shown Interpretation of both hs-TnI and hs-TnT level can be
that among patients with stable chronic cardiovascular done using a cut-off value either above the level of detec-
disease, an elevated troponin level better predicts heart tion or above the 99th percentile of a reference population
failure than ischemic events [2,4,5,7,11,21]. In the Fra- [2]. Even within the same study population, the proportion
mingham Offspring Study, an elevated hs-TnI was of subjects with detectable hs-TnI is greater than hs-TnT
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