From numbers to trajectories: a pragmatic hs-cTnT/NT-proBNP delta-check for 12-month risk stratification in chronic heart failure

High-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro–B-type natriuretic peptide (NT-proBNP) are widely used in heart failure (HF), but outpatient interpretation often depends on isolated values rather than within-person change. We evaluated a pragmatic dual-biomarker delta-check framework for 12-month risk stratification in chronic HF. We performed a retrospective cohort study of adults with chronic HF who had paired hs-cTnT and NT-proBNP measurements obtained during a clinically stable anchor visit and repeated within 3–6 months. The second paired measurement served as the index date. Patients were classified a priori into Green, Yellow, or Red trajectory tiers using combined relative and absolute biomarker changes, interpreted with a minimum clinical context bundle including rhythm, renal function, and clinical state. Meaningful adverse change was defined as hs-cTnT rise ≥ 20% and ≥ 5 ng/L, and NT-proBNP rise ≥ 30% and ≥ 500 pg/mL, or ≥ 300 pg/mL when anchor NT-proBNP was < 1,000 pg/mL. The primary endpoint was HF hospitalization or all-cause death within 12 months. Among 520 patients, 229 (44%) were Green, 187 (36%) Yellow, and 104 (20%) Red. Anchor median NT-proBNP was 1,850 pg/mL [780–4,400], and hs-cTnT was 21 ng/L [13–36]. The primary endpoint occurred in 140 patients (26.9%). Event rates increased stepwise across tiers: Green 17.9%, Yellow 27.8%, and Red 45.2% (log-rank p < 0.001). In adjusted Cox models, Yellow showed an intermediate signal (HR 1.4, 95% CI 1.0–2.0; p = 0.06), whereas Red remained independently associated with higher risk (HR 2.1, 95% CI 1.4–3.2; p < 0.001). In a sensitivity model excluding anchor hs-cTnT and anchor NT-proBNP, the associations were preserved: Yellow HR 1.5 (95% CI 1.1–2.2; p = 0.03) and Red HR 2.5 (95% CI 1.7–3.6; p < 0.001). A pragmatic hs-cTnT/NT-proBNP delta-check stratified 12-month risk in chronic HF. Concordant worsening across both biomarkers identified a high-risk trajectory, while isolated or borderline change was best interpreted as a lower-intensity review signal. Prospective testing is needed before this framework is used to guide outcome-modifying interventions.