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Conway et al. Vessel Plus 2020;4:25 I http://dx.doi.org/10.20517/2574-1209.2020.19 Page 9 of 11

were associated with a higher mortality rate and longer hospital and ICU length of stay. A study in acute
[49]
respiratory distress syndrome reported a high prevalence of elevated cardiac markers and an associated
increased 60-day mortality and organ failure. Thus, occult or subclinical myocardial disease could be
implicated as a cause of death in acute respiratory distress syndrome. Other areas, where elevated troponin
[50]
values have been demonstrated to be predictive of in-hospital mortality have included ischaemic stroke ,
[54]
[53]
[52]
intra-cerebral haemorrhage , gastro-intestinal haemorrhage , non-cardiac surgery , renal failure ,
[51]
[55]
and following renal transplant .
The strengths of our study include the large number of included patients, the comprehensive assessment
of all admitted medical patients, and the collection of large volumes of relevant clinical data. The exclusion
of patients admitted with ACS is another strength as risk stratification of patients with ACS has been
well described and is a potential confounder in any study of this nature. As with any study, there are also
potential limitations to our work. We have shown that hscTnT predicts outcome in our multivariable
model after adjustment for known collected variables; it is possible that residual unknown or unmeasured
confounders remain. This may even be a probable explanation for some of our results, particularly for
the association between the performance of hscTnT and mortality, which is likely to be explained by
unmeasured factors that are incorporated into the clinicians’ gestalt decision to perform a hscTnT test.
Our study, while large, was performed in a single centre and the results will require external validation
in other settings. We did not have the ability to assess the possibility that patients originally admitted to
St. James’ may have subsequently been admitted to other hospitals; this may be particularly relevant for
those resident outside our catchment area Additionally, we have examined the relationship in emergency
medical admissions only; admissions under other disciplines may not necessarily demonstrate the
same relationship. The demonstration of a relationship does not imply that the variable is amenable to
intervention, nor does it follow that any attempted intervention may not have deleterious consequences .
[56]

In conclusion, we have demonstrated the prognostic value of hscTnT in emergency medical admissions.
This suggests potential additive benefit to the inclusion of hscTnT in risk prediction models.

DECLARATIONS
Acknowledgments
We acknowledge the contributions of our consultant colleagues and the non-consultant members of
the medical teams without which the AMAU initiative would not have been successful. The dedicated
contributions of the clinical nurse managers, nurses, and allied health professionals in the AMAU is also
gratefully acknowledged.

Authors’ contributions
Made substantial contributions to the conception and design of the study and performed data analysis and
interpretation: Conway R, Byrne D, Cournane S, O’Riordan D, Coveney S, Silke B

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.