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Cardiac Biomarkers for Syncope Risk Stratification?

March 4, 2019

Written by Clay Smith

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Two cardiac biomarkers, high sensitivity troponin T (hsTnT) and natriuretic peptide (NT-pro-BNP), were independently associated with increased 30-day mortality and serious cardiac outcome in patients ≥ age 60 with syncope.

Why does this matter?
We recently covered an article that found presyncope was as bad as syncope in regard to death or other adverse outcomes. This was a planned secondary analysis of that data. Prior syncope risk stratification tools have incorporated biomarkers, such as ROSE and the Canadian Syncope Risk Score. So, how well do cardiac biomarkers independently predict bad outcomes in patients with syncope?

Biomarkers for syncope?
They took samples of blood for hsTnT and NT-proBNP from 3,392 patients ≥60 years presenting to the ED with syncope. Clinicians were not made aware of these results. They found that elevated hsTnT or NT-proBNP were both independently associated with a composite of 30-day death or serious cardiac outcome and doubled the odds of this outcome when markedly elevated. Specifically, a hsTnT ≤ 5 ng/L had a 4% outcome risk (negative likelihood ratio [NLR] 0.35), whereas a hsTnT >50 ng/L had a 29% risk (positive LR 3.2). Also, NT-proBNP levels ≤ 125 ng/L had a 4% risk (NLR 0.32); > 2000 ng/L had a 29% risk (PLR 3).

I don’t plan to start using troponin or natriuretic peptide in isolation for syncope risk stratification. I think the Canadian Syncope Risk Score plus ECG monitoring and physician judgment would be better. Lauren Westafer said it well on Journal Watch, “In the ED setting, cardiac biomarkers should be used to test for acute cardiac disease, not to screen for subsequent all-cause mortality.” Yeah, what she said…

Do High Sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope? Acad Emerg Med. 2019 Feb 5. doi: 10.1111/acem.13709. [Epub ahead of print]

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Reviewed by Thomas Davis

What are your thoughts?