Background: The differentiation of acute coronary syndrome (ACS) requiring revascularization in the setting of acute heart failure (AHF) is challenging since the majority of patients presenting with AHF show elevations of high-sensitive troponin (hs-Tn). The aim of the present study was to assess the diagnostic value of hs-Tn for the identification of ACS with need for revascularization in patients with AHF.

Methods: Patients who were admitted to our institution due to AHF between 2012 and 2019 were retrospectively included. Clinical information was gathered from electronic and paper-based patient charts. For troponin assessment the high-sensitive troponin T (hs-TnT) assay was used and hs-TnT based NSTEMI diagnosis was made according to current guidelines (hs-TnT ≥14ng/l with rise or fall ≥20% or initial high hs-TnT ≥52ng/l). Patients without hs-TnT measurement and without invasive coronary angiography were excluded. 

Results: A total of 648 patients were enrolled into the present study. Of them, 384 patients did not have suspected NSTEMI and 264 patients fulfilled the diagnostic criteria for NSTEMI. Revascularization was necessary in 31% of patients without NSTEMI and in 40% with NSTEMI (p=0.02). Hs-TnT fulfilling the diagnostic criteria for NSTEMI showed a sensitivity and specificity for requiring revascularization of 47% and 63%, respectively (Figure 1). The area under the curve of maximum hs-TnT within 24h of admission was 0.57. Sensitivity and specificity were slightly higher in the subgroups of patients with ST segment and/or T wave changes (sensitivity 51%, specificity 62%) and wall motion abnormalities (sensitivity 58%, specificity 64%). With respect to clinical outcome, adjusted regression showed no differences regarding hospital mortality depending on the diagnosis of NSTEMI and revascularization status (OR 1.84 [95% CI 0.075-4.51]).

Conclusions: Hs-TnT based NSTEMI definition provided no adequate sensitivity and specificity regarding need for revascularization in patients presenting with AHF. Until new diagnostic tools will be available for the detection of ACS in AHF detailed diagnostic work-up and individual patient-based decision making regarding the indication for invasive coronary angiography remains necessary.