Cardiac Troponins And Mortality Risk In Emergency Room Visits For Geriatric Falls
Overview
The occurrence of emergency department (ED) visits following ground-level falls (GLF) is frequent, with potential links to myocardial infarction (MI), particularly in older adults who may experience unrecognized MIs. To explore this connection, we conducted a prospective, international, multicenter cohort study with a one-year follow-up, focusing on patients aged 65 years and older presenting to the ED after a GLF.
We assessed the prevalence of MI and elevated levels of high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of these biomarkers in detecting MI, and their prognostic value in predicting outcomes for older ED patients post-GLF.
Our study comprised 558 patients, with a median age of 83 years and a majority (67.7%) being female. Elevated hs-cTnT levels were observed in 68.8% of patients, while elevated hs-cTnI levels were found in 15.4% of patients. Only three patients (0.5%) were diagnosed with MI based on the gold standard assessment. Over a 30-day period, 18 patients (3.2%) died, with nonsurvivors exhibiting higher levels of both cardiac troponins hs-cTnT and hs-cTnI compared to survivors.
Although a significant proportion of patients (68.8%) presenting after a fall showed elevated hs-cTnT levels and 15.4% had elevated hs-cTnI levels, the incidence of MI was low (0.5%). Consequently, our findings do not support the notion that falls are commonly associated with MI presentation. We advise against routine troponin testing in this patient population. However, both hs-cTnT and hs-cTnI cardiac troponins demonstrate prognostic utility in predicting mortality up to one year following a GLF.
In conclusion, while falls are frequent reasons for ED visits among older adults, MI is a rare cause in this context. Cardiac troponins, specifically hs-cTnT and hs-cTnI, offer valuable prognostic information regarding mortality risk in this population.
Introduction
Ground-level falls (GLFs) represent a significant issue among older patients, often necessitating considerable healthcare resources. These falls frequently result in adverse outcomes such as institutionalization, functional decline, and even mortality. Despite recommendations to prioritize research and clinical efforts in this area, there remains a dearth of knowledge regarding the assessment, management, and post-fall interventions in emergency department (ED) settings. GLFs often present with nonspecific symptoms such as generalized weakness, potentially stemming from a combination of factors including weakness, falls, confusion, and frailty. Consequently, extensive and sometimes unnecessary testing for multiple conditions is common in these cases.
Additionally, myocardial infarction (MI), whether with or without ST-segment elevation (STEMI or NSTEMI), is a critical concern in older adults, as it may manifest with atypical symptoms such as dyspnea, weakness, diaphoresis, or nausea, rather than the classic chest pain. In fact, MI can go unnoticed or present without chest pain in up to 60% of older adults. The recent World Guidelines for Falls Prevention and Management for Older Adults suggest that a fall could be the first sign of MI, even in the absence of chest pain, though evidence for this assertion is lacking.
Given that cardiovascular disease is a leading cause of morbidity and mortality among older adults, the measurement of high-sensitivity cardiac troponins (hs-cTnT and hs-cTnI) has been proposed as a diagnostic tool for MI in this population following a GLF. However, concerns have been raised about the overuse of cardiac troponins, as various non-cardiac conditions can also lead to elevated levels.
Our study aims to address these gaps by investigating the prevalence of MI and elevated cardiac troponins hs-cTnT and hs-cTnI, as well as the diagnostic accuracy and prognostic value of these biomarkers in older ED patients who present after a recent GLF. Through our research, we seek to contribute valuable insights into the appropriate use of cardiac troponin testing in this population, ultimately enhancing the quality of care for older adults who experience GLFs.
Method
The study, conducted at four emergency departments (EDs) spanning Northwestern Switzerland and Germany, aimed to shed light on falls of unknown origin (GLF) among individuals aged 65 years and older. Over a span from November 2014 to January 2018, the research team enrolled patients who presented within 24 hours of experiencing a GLF, with the GLF being the primary reason for their visit to the ED. It’s noteworthy that individuals with specific excluded conditions such as syncopal events, transport accidents, and intentional self-harm were not included in the study, ensuring a focused investigation on falls and their potential underlying causes.
One key aspect of the data collection process was the meticulous approach taken by the study team. Patients were interviewed extensively about their symptoms, and their ability to perform activities of daily living was assessed using the Katz Activities of Daily Living (ADL) index. Moreover, demographic baseline data were collected, and blood samples were obtained from each patient for subsequent analysis. These samples were frozen at -80°C and later used to measure high-sensitivity cardiac troponins (hs-cTnT and hs-cTnI).
The measurement of troponin levels was carried out using specific assays, with cutoff values determined based on the 99th percentile of healthy reference populations. This allowed for the identification of potential myocardial injuries in patients following a GLF. Importantly, laboratory personnel conducting these analyses were blinded to the study aims and clinical patient data, ensuring objectivity in the assessment process.
The study’s outcomes were comprehensive, including mortality and gold standard diagnoses. Mortality data were collected through follow-ups with primary care physicians, hospital discharge reports, and electronic health records, extending up to one year post-presentation. Gold standard diagnoses were determined by expert ED physicians who meticulously reviewed electronic health records, hospital discharge letters, and questionnaires completed by patients’ family physicians. This process, carried out after a 30-day follow-up period, enabled the identification of underlying conditions contributing to the falls, including myocardial infarction (MI). MI diagnoses were based on validated International Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes, ensuring consistency and accuracy in the classification of cases.
In summary, the study employed a rigorous methodology to investigate falls of unknown origin among older adults, with a particular focus on identifying potential cardiac events such as myocardial infarction. The findings generated from this research have the potential to enhance our understanding of the complex interplay between falls and cardiovascular health in the elderly population, ultimately contributing to improved patient care and outcomes.
Statistical Analysis
Descriptive statistics were utilized to present data in terms of counts, percentages, and medians with interquartile ranges (IQRs). Group comparisons were made using either the Mann–Whitney U test or the exact Fisher test, depending on appropriateness. Significance was determined at a level of 0.05 (alpha). The accuracy of cardiac troponins hs-cTnT and hs-cTnI as diagnostic and prognostic tests for acute coronary syndrome and 30-day mortality, respectively, was assessed through sensitivity, specificity, positive and negative likelihood ratios, as well as negative and positive predictive values. In cases where test sensitivity reached 100%, a bootstrapping method was employed to estimate LR− and its 95% confidence interval (CI). Logistic regression was utilized to analyze the association between hs-cTn (T and I) and 30-day mortality, with sex (categorical), age (continuous), and the Katz ADL index (ordinal) serving as covariates. Similarly, logistic regression was used to explore the association between cardiac troponins hs-cTn (T and I) and myocardial infarction (MI), though adjustment for covariates was not feasible due to the low number of events in this category. Kaplan–Meier survival curves were generated for visualization purposes, with survival analysis conducted over a 1-year follow-up period, measured in days.
Result
The study encompassed an extensive screening process involving 817 patients, from which 210 individuals were excluded for various reasons, such as declining participation, inability to provide informed consent, absence of recent falls, or incomplete data. This meticulous selection process ensured the inclusion of 558 patients, among whom the median age was 83 years, with a notable majority being female, constituting 67.7% of the study population. This demographic distribution reflects the higher prevalence of certain health conditions in elderly populations, particularly among women.
Upon presentation, patients exhibited a range of symptoms, with pain, gait disturbance, and fatigue/weakness being the most commonly reported. These symptoms, often indicative of underlying health concerns, underscore the complexity of geriatric patient care and the importance of comprehensive assessment strategies.
Of particular interest were the findings related to high-sensitivity cardiac troponins (hs-cTn) levels measured during emergency department (ED) evaluations. Approximately 26.9% of patients had at least one elevated hs-cTn level, with a substantial proportion showing persistently elevated levels. This observation highlights the potential clinical utility of hs-cTn assays in identifying patients at risk for adverse cardiac events, even in the absence of typical symptoms like chest pain or dyspnea.
Notably, three patients were diagnosed with myocardial infarction (MI) by outcome assessors, despite lacking classic symptoms. These cases underscore the importance of considering alternative presentations of MI, particularly in older adults who may present with atypical symptoms or be less likely to report typical chest pain.
Furthermore, the study revealed a significant association between elevated hs-cTn levels and increased mortality risk within 30 days. Patients with elevated hs-cTnT levels exhibited a 30-day mortality rate of 4.7%, while those with elevated hs-cTnI levels had a substantially higher rate of 9.3%. This underscores the prognostic value of hs-cTn assays in identifying patients at heightened risk for adverse outcomes.
The Kaplan-Meier survival curves provided a visual representation of overall survival rates, further emphasizing the impact of elevated hs-cTn levels on mortality outcomes. Sensitivity and specificity analyses demonstrated the diagnostic accuracy of hs-cTnT and hs-cTnI in identifying both MI and predicting short-term mortality, providing clinicians with valuable tools for risk stratification and clinical decision-making.
In conclusion, the study elucidates the intricate relationship between elevated hs-cTn levels, adverse outcomes, and diagnostic accuracy in geriatric populations. These findings underscore the importance of incorporating hs-cTn assays into routine clinical practice for risk assessment and prognostication in older adults, thereby facilitating early intervention and improved patient outcomes.
Conclusion
In a multicenter cohort study focusing on older patients who visited the emergency department (ED) following a fall, findings indicated that a significant portion of patients had elevated levels of high-sensitivity cardiac troponins T (hs-cTnT) and (hs-cTnI). However, the incidence of myocardial infarction (MI) among these patients was notably low. Therefore, the study suggests that falls are not a common indicator of MI, and routine high-sensitivity cardiac troponins testing might not be warranted without specific clinical suspicion.
Although elevated troponin levels were associated with increased mortality risk, it’s important to note that such elevation doesn’t necessarily signify acute myocardial injury. Troponin elevation can stem from various conditions beyond heart issues, such as renal failure or sepsis. Thus, while elevated troponin levels can serve as a prognostic indicator for mortality, they should be interpreted cautiously in the absence of acute myocardial injury.
The study also raises concerns about excessive cardiac troponins testing, which could lead to unnecessary downstream investigations, treatments, and hospitalizations. Therefore, it suggests that troponin testing should be conducted at the discretion of the treating physician, particularly in cases of suspected blunt cardiac injury, symptoms suggestive of MI, or ECG changes consistent with ischemia.
However, the study acknowledges its limitations, including its predominantly Caucasian patient population, potential selection bias, and the inability to determine the exact cause of elevated troponin levels for every patient. Additionally, the low number of MIs diagnosed and mortality events limited the statistical analysis.
In conclusion, while a significant portion of older ED patients following a fall exhibit elevated troponin levels, the incidence of MI is low. Therefore, routine troponin testing without specific clinical suspicion may not be warranted. However, elevated troponin levels can serve as prognostic indicators for mortality, and their use should be judicious to avoid unnecessary interventions and hospitalizations.
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