Cardiac Biomarkers to Refine Pre-Test Probability for Coronary Obstruction and Predict Survival after Revascularisation in Chronic Coronary Syndrome

Background and aimsThe utility of cardiovascular and inflammatory biomarkers to detect coronary obstruction and predict survival benefit of revascularisation in chronic coronary syndrome (CCS) remains unclear. MethodsPatients undergoing coronary angiography for suspected CCS were studied. High-sensitivity cardiac troponin T (hsTnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and copeptin were measured. Diagnostic performance to detect anatomical coronary stenosis (i.e. [&ge;]50%) was assessed using Receiver Operating Characteristic (ROC) analysis with Net Reclassification Improvement (NRI). Survival analysis using multivariate Cox regression assessed treatment-stratified biomarker performance and biomarker x treatment interaction. ResultsAmong 2,251 patients, 888 (39.4%) had coronary obstruction. Only hsTnT provided meaningful diagnostic capacity (Area Under the Curve; AUC 0.669), comparable with risk factor-weighted clinical likelihood (RF-CL) estimate recommended by the current guidelines (AUC 0.663). Reclassification value demonstrated an inverse relationship to RF-CL: very low (NRI=38.4%), low (NRI=19.3%), and intermediate/high likelihood (NRI=12.4%). NT-proBNP was the strongest universal mortality predictor across all treatment categories: Optimal Medical Therapy (OMT; HR 1.488, 95%CI:1.288-1.720, p<0.001), Percutaneous Coronary Intervention (PCI; HR 1.220, 95%CI:1.020-1.458, p=0.029), Coronary Artery Bypass Grafting (CABG; HR 1.220, 95%CI:1.049-1.420, p=0.010). Interaction analysis (p=0.024) demonstrated that in patients with NT-proBNP <150 pg/mL the revascularisation group has an improved survival (HR 0.64, 95%CI:0.47-0.87, p=0.005), whilst this was not observed for the patients with NT-proBNP [&ge;]150 pg/mL (HR 0.96, 95%CI:0.71-1.30, p=0.782). ConclusionsHsTnT provides meaningful diagnostic value with RF-CL category-specific incremental benefit following an inverse gradient pattern. The NT-proBNP 150 pg/mL threshold identifies patients with improved survival after revascularisation. Clinical Trial RegistrationClinicalTrials.gov NCT00497887 KEY LEARNING POINTSO_ST_ABSWhat is already knownC_ST_ABS- Cardiac biomarkers predict outcomes in chronic coronary syndrome - ESC 2024 guidelines introduced risk-factor weighted clinical likelihood assessment - The incremental value of biomarkers to detect coronary stenosis and guide risk stratification after revascularization remains uncertain What this study adds- High-sensitivity troponin T diagnostic utility follows an inverse gradient pattern, with greatest incremental benefit in very low baseline risk patients - NT-proBNP <150 pg/mL identifies a patient subgroup with significant survival improvement after revascularisation - Cardiac biomarker patterns provide biological validation of ESC 2024 guideline evolution