BackgroundThe relationship between troponin level and outcomes among patients with non‐ST‐segment elevation ACS is established, but the relationship of troponin level with long‐term outcomes among medically managed non‐ST‐segment elevation ACS patients receiving contemporary antiplatelet therapy is inadequately defined.Methods and ResultsIn 6763 medically managed non‐ST‐segment elevation ACS patients randomized in TRILOGY ACS (Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes) (prasugrel versus clopidogrel), we examined relationships between categories of peak troponin/upper limit of normal (ULN) ratio within 48 hours of the index ACS event (≈4.5 days before randomization) and 30‐month outcomes (cardiovascular death, myocardial infarction, or stroke; cardiovascular death or myocardial infarction; and all‐cause death). Patients with peak troponin levels <1×ULN were younger, were more often women, and had lower GRACE risk scores than those in other troponin groups. Those with ratios ≥5×ULN were more frequently smokers but less often had prior myocardial infarction or percutaneous coronary intervention. Diabetes mellitus prevalence, body mass index, serum creatinine, and hemoglobin were similar across groups. For all end points, statistically significant differences in 30‐month event rates were observed between peak troponin categories. The relationship was linear for 30‐month mortality (<1×ULN, n=1849 [6.2%]; 1 to <3×ULN, n=1203 [9.6%]; 3 to <5×ULN, n=581 [10.8%]; and ≥5×ULN, n=3405 [12.8%]) but plateaued for composite end points beyond peak troponin values ≥3×ULN. There was no statistically significant heterogeneity in treatment effect by peak troponin ratio for any end point.ConclusionsAmong medically managed non‐ST‐segment elevation ACS patients selected for medical management, there was a graded relationship between increasing peak troponin and long‐term ischemic events but no heterogeneity of treatment effect for prasugrel versus clopidogrel according to peak troponin.Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT00699998.