Incidence of CAD in asymptomatic cancer patients with elevated Troponin

Background and Aims
Oncological patients undergoing various cancer treatments such as chemotherapy, radiotherapy, or surgery experience physiological and metabolic cardiac challenges. This potentially increases the risk of developing or exacerbating existing coronary disease (CAD). Additional presence of pre-existing cardiovascular risk factors, such as obesity, smoking, hypertension, and diabetes can further increase the risk for CAD in this patient population. Elevation of high-sensitive cardiac troponin T (hs-cTnT), which is validated to diagnose myocardial infarction and stenosing CAD is not well studied in asymptomatic cancer patients. The aim of the study was to evaluate the impact of elevated cardiac biomarker on the presence of CAD in cancer patients.  

Methods
Patients admitted to the cardio-oncology unit at the University Hospital Heidelberg between 2016 and 2023 were evaluated by medical history, physical examination, 12-lead-ECG, 2D-echocardiography and cardiac biomarkers (high-sensitive cardiac Troponin T (hs-cTnT); N-terminal brain natriuretic peptide (NT-proBNP)). All eligible patients’ cases with hs-cTnT level of 14 ng/l (ULN) or more were analyzed.   

Results
Of 3332 screened patients, 1035 (31.0%) cardio-oncological patients presented with an asymptomatic hs-cTnT-elevation ≥14ng/l. Elevation of hs-cTnT was associated to atrial fibrillation, renal dysfunction, reduced LVEF or cardiac valve disease in 385/1035 (37.2%) patients. 83 patients (83/1035; 8.0%) had a known history of CAD and in 135 (13.0%) cases no further diagnostics was indicated based on presentation, troponin levels and ongoing chemotherapy. 432/1035 (41.7%) patients were scheduled for further CAD diagnostics (stress cMRI; coronary CT, stress echocardiography or cardiac catheterization). Of these, 71 patients (71/1035; 8,9%) declined further invasive or non-invasive diagnostics and 25 patients (25/1035; 2.4%) were excluded for missing documentation. 336/1035 (32.5%) patients of unexplained hs-cTnT elevation received further CAD diagnostic. From 249/336 (73.7%) patients with CAD, 163/336 (48.3%) patients were newly diagnosed to have a CAD. 46 patients presented with relevant CAD and a need for intervention (PCI). Meanwhile PCI did not significantly affect the mortality in this cohort (median follow-up time 676.5 d, p=0.50). In multivariate analysis, CAD associated significantly with reduced LVEF of <50 (OR 2.95; p=0.004), arterial hypertension (OR 2.41; p=0.003), male gender (OR 2.62; p=0.001) and age (>65years; OR 2.26; p=0.005).   Conclusions In cancer patients, increased cardiac biomarkers and cardiac risk factors associate with the presence of CAD. CAD should be considered in asymptomatic oncological patients with elevated cardiac biomarkers.   

Keywords
Cardio-oncology, Coronary arterial disease, Cardiac Biomarkers, Coronary heart disease, Heart failure, Cardiotoxicity, Cancer survivors, risk stratification