Sex-specific non-linear association between post-procedural high-sensitivity troponin t and 12-month mortality after PCI: insights from a prospective large-scale registry

Post-procedural high-sensitivity cardiac troponin T (hs-TnT) is an established prognostic marker in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Current practice applies uniform troponin thresholds regardless of sex, potentially overlooking biological differences in cardiac mass and injury patterns. This study aimed to investigate whether the association between elevated hs-TnT and clinical outcomes differs by sex, and to characterize sex-specific dose–response relationships.

This retrospective analysis utilized data from a prospective PCI registry enrolling consecutive ACS patients between March 2016 and March 2019. Patients were stratified by post-procedural hs-TnT concentrations measured within 48 h after PCI (< 0.5 vs. ≥ 0.5 ng/mL). The primary outcome was all-cause mortality at 12 months after PCI. The main secondary outcomes included ischemic events (composite of cardiac death, myocardial infarction, or stroke) at 12 months. Multivariable Cox regression models with sex-by-hs-TnT interaction terms and restricted cubic spline (RCS) analyses were performed.

Among 14,214 patients (10,416 males, 3,798 females), elevated hs-TnT (≥ 0.5 ng/mL) was associated with increased 12-month mortality in both sexes, with a stronger association in females (aHR 2.83; 95% CI 1.56–5.13) than in males (aHR 1.63; 95% CI 1.03–2.58; P for interaction = 0.019). For cardiac death, similar differences were observed (P for interaction = 0.023). RCS analysis revealed a nonlinear relationship between hs-TnT and mortality in females (P for nonlinearity = 0.01), whereas the relationship was linear in males (P for nonlinearity = 0.12). The formal test of interaction between continuous hs-TnT and sex confirmed this divergence (P = 0.0042).

The prognostic impact of elevated post-procedural hs-TnT on mortality was substantially greater in female than in male ACS patients. These hypothesis-generating findings suggest that sex-specific approaches to troponin-based risk stratification after PCI warrant further investigation.