Cardiovascular

Association of Hypertension Severity with 30-Day Major Adverse Cardiovascular Events in Patients with Intermediate High-Sensitivity Cardiac Troponin I.

Hawatian K, Emakhu J, et al. • The western journal of emergency medicine • 2026

PubMed 42258862 DOI 10.5811/westjem.48347

TL;DR

Among ED patients with intermediate hscTnI, blood pressure ≥ 140/90 mm Hg confers modestly higher short-term risk of major adverse cardiovascular events, but incremental severity beyond this threshold does not add prognostic value.

Key Findings

Results

Severe hypertension was associated with significantly higher mean high-sensitivity cardiac troponin I (hscTnI) levels after adjustment.

Severe blood pressure (≥ 180/≥ 110 mm Hg) was associated with a 16% higher mean hscTnI compared to normotension after adjustment
Statistical result: β = 0.064, 95% CI 0.047–0.082
Percent change was calculated as 10^β - 1
This elevation likely reflects myocardial stress rather than additional ischemic risk according to the authors

Results

Moderate hypertension independently increased the risk of 30-day major adverse cardiovascular events (MACE) compared to normotension.

Adjusted odds ratio (AOR) for moderate hypertension (140–179/90–109 mm Hg) vs. normotension: 1.47, 95% CI 1.02–2.13
Absolute risk difference: +0.25%, 95% CI 0.01–0.49
MACE occurred in 77 of 10,972 patients with moderate hypertension (0.7%) vs. 47 of 9,740 normotensive patients (0.5%)
30-day MACE included all-cause death, myocardial infarction, or urgent revascularization

Results

Severe hypertension showed no statistically significant association with 30-day MACE compared to normotension.

AOR for severe hypertension vs. normotension: 1.32, 95% CI 0.80–2.18
Absolute risk difference: +0.17%, 95% CI -0.09 to 0.43
MACE occurred in 24 of 2,999 patients with severe hypertension (0.8%)
Confidence intervals crossed 1.0, indicating no clear independent association

Results

The overall 30-day MACE rate among ED patients with intermediate hscTnI values was low at 0.6%.

148 of 23,803 patients with intermediate hscTnI (4–18 ng/L) experienced 30-day MACE
MACE rates by blood pressure category: normotensive 0.5% (47 events), moderate hypertension 0.7% (77 events), severe hypertension 0.8% (24 events)
The study population was drawn from a stepped-wedge randomized trial across nine Michigan emergency departments (July 2020–April 2021)
Of 32,609 patients in the primary trial, 23,803 had hscTnI values in the intermediate range and were included in this analysis

Results

The study population with intermediate hscTnI values was predominantly female, middle-aged, and included a substantial proportion of Black patients.

Mean age was 57.5 ± 17.9 years
57.5% were women
32.7% were Black
Blood pressure distribution: normotensive 40.9%, moderate hypertension 46.5%, severe hypertension 12.6%

Results

Sensitivity analyses limited to patients without coronary artery disease yielded similar estimates to the primary analysis.

Sensitivity analyses were performed restricting the sample to patients without known coronary artery disease
Results were described as 'similar' to the primary adjusted estimates
This supports the robustness of the main findings regarding blood pressure category and MACE risk

Methods

The study used a secondary analysis design of the Rapid Acute Coronary Syndrome Evaluation-Implementation Trial (RACE-IT), a stepped-wedge randomized trial.

Data source: RACE-IT trial across nine Michigan emergency departments
Study period: July 2020–April 2021
First recorded ED blood pressure was used to determine hypertension category
Generalized linear models examined associations with hscTnI levels; penalized logistic regression examined associations with 30-day MACE, adjusting for confounders

What This Means

This research suggests that among emergency department patients with mildly elevated ("intermediate") cardiac troponin levels — a protein released into the blood when the heart is under stress — having elevated blood pressure is linked to a modestly higher risk of serious heart events within 30 days. However, having extremely high blood pressure (≥ 180/110 mmHg) did not confer meaningfully greater risk than having moderately elevated blood pressure (140–179/90–109 mmHg). In fact, very high blood pressure was associated with higher troponin levels overall, suggesting the troponin rise in these patients may reflect the heart working harder under pressure rather than a heart attack occurring. The study analyzed over 23,000 emergency patients whose troponin levels fell in a gray zone (4–18 ng/L) — not clearly normal, but not clearly abnormal either — making clinical decision-making more challenging. The overall rate of serious cardiac events (death, heart attack, or emergency heart procedure) within 30 days was low at 0.6%, but patients with moderate hypertension had about a 47% higher adjusted odds of experiencing such events compared to patients with normal blood pressure. This association was not statistically significant for the severely hypertensive group, and the absolute differences in risk were small (less than 0.3% in all groups). This research suggests that clinicians in emergency settings should be cautious when interpreting borderline troponin results in patients with high blood pressure, since elevated blood pressure can artificially inflate troponin readings through cardiac stress rather than injury. The findings support integrating blood pressure status, clinical presentation, and known risk factors together rather than relying on troponin values alone to guide decisions about intermediate-range results.

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Citation

Hawatian K, Emakhu J, Morton T, Husain A, Nassereddine H, Sidani M, et al.. (2026). Association of Hypertension Severity with 30-Day Major Adverse Cardiovascular Events in Patients with Intermediate High-Sensitivity Cardiac Troponin I.. The western journal of emergency medicine. https://doi.org/10.5811/westjem.48347

Key Findings

What This Means

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