Among 8,394 STEMI patients treated with PCI across four Israeli academic centers (2016–2023), those presenting with high-sensitivity cardiac troponin below the ESC rule-in threshold — 36.5% of the cohort — showed dramatically better survival: 92.9% vs. 84.0% at one year and 85.7% vs. 75.0% at five years. After adjusting for age, sex, heart failure, and chronic kidney disease, elevated admission troponin remained an independent predictor of 5-year all-cause mortality (HR 1.15, 95% CI 1.14–1.16). Age over 75, female sex, and CKD were co-predictors.
The finding reframes admission troponin not merely as a diagnostic binary — rule-in versus rule-out — but as a continuous prognostic signal with meaningful long-term mortality separation. This aligns with established pathophysiology: low admission troponin likely reflects earlier presentation before significant myocardial necrosis accumulates, or smaller infarct territory, both of which favor preserved left ventricular function. Clinically, this suggests risk stratification protocols could incorporate admission troponin magnitude to guide post-STEMI surveillance intensity and resource allocation.
Limitations deserve attention: the retrospective design precludes causal inference, and the notably tight confidence interval (1.14–1.16) for an HR of 1.15 suggests possible modeling constraints or reporting artifacts that peer review should scrutinize. The cohort is also geographically limited to Israel. As a preprint not yet peer-reviewed, these results — while generated from a substantial real-world dataset — require independent validation before influencing clinical guidelines. Nonetheless, the scale and effect consistency make this an incrementally important confirmatory contribution to STEMI risk stratification.