Elevated High-sensitivity Troponin Research Articles

P1750 Association of high-sensitivity troponin elevation and LVEF decline in anthracycline-treated breast cancer patients

Abstract Introduction Cancer therapies have been linked to a wide variety of side effects, with cardiotoxicity being the most significant one. Early detection of subclinical cardiac dysfunction in cancer patients (pts) is necessary in order to prevent unfavorable outcomes. High-sensitivity troponin I (hsTI) levels have been proposed as predictors of cancer therapy related cardiotoxicity and may guide cardioprotective therapy initiation. Purpose To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer pts under chemotherapy in a single center cardio-oncology unit and to assess its relationship with hsTI levels. Methods We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018. CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to a value below 50%. Elevation of hsTI was defined as at least one measurement above the 99th percentile upper reference limit during follow-up (>34 ng/L). Pts had an organized follow-up in our cardio-oncology unit, consisting of a clinical, laboratorial (with dosing of cardiac biomarkers) and echocardiographic assessment at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases). Results A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 17 pts (20.5%) were considered at high risk of cardiac dysfunction due to hsTI elevation. During follow-up, the percent increase in the hsTI level (from basal level) correlated with CTRCD (p = 0.02). On the other hand, the absolute maximum value of hsTI did not (p = 0.159). In fact, pts who developed CTRCD had a significantly higher percent increase in the hsTI levels (142.9% +- 57.5%) vs those without CTRCD (14.29% +- 4.6%), p < 0.001. On ROC curve analysis, percent increase in troponin was a good identifier of CTRCD (AUC of 0.986; 95% CI 0.95-1.00; p = 0.022) and the best cut-off value was a 79.8% increase in hsTI (sensitivity: 100%; specificity: 97.2%). Conclusion In our population, the percent increase in the hsTI levels correlated with CTRCD. Larger studies are needed to prove this parameter as a predictor of CTRCD. Abstract P1750 Figure.

Risk Stratification of Older Adults Who Present to the Emergency Department With Syncope: The FAINT Score

Older adults with syncope are commonly treated in the emergency department (ED). We seek to derive a novel risk-stratification tool to predict 30-day serious cardiac outcomes. We performed a prospective, observational study of older adults (≥60 years) with unexplained syncope or near syncope who presented to 11 EDs in the United States. Patients with a serious diagnosis identified in the ED were excluded. We collected clinical and laboratory data on all patients. Our primary outcome was 30-day all-cause mortality or serious cardiac outcome. We enrolled 3,177 older adults with unexplained syncope or near syncope between April 2013 and September 2016. Mean age was 73 years (SD 9.0 years). The incidence of the primary outcome was 5.7% (95% confidence interval [CI] 4.9% to 6.5%). Using Bayesian logistic regression, we derived the FAINT score: history of heart failure, history of cardiac arrhythmia, initial abnormal ECG result, elevated pro B-type natriuretic peptide, and elevated high-sensitivity troponin T. A FAINT score of 0 versus greater than or equal to 1 had sensitivity of 96.7% (95% CI 92.9% to 98.8%) and specificity 22.2% (95% CI 20.7% to 23.8%), respectively. The FAINT score tended to be more accurate than unstructured physician judgment: area under the curve 0.704 (95% CI 0.669 to 0.739) versus 0.630 (95% CI 0.589 to 0.670). Among older adults with syncope or near syncope of potential cardiac cause, a FAINT score of zero had a reasonably high sensitivity for excluding death and serious cardiac outcomes at 30 days. If externally validated, this tool could improve resource use for this common condition.

P5276A prospective pilot study to identify a myocarditis cohort who may safely resume sports activities 3 months after diagnosis

Abstract Background Sports activities may promote arrhythmias in the setting of acute myocarditis. International cardiovascular society recommendations to return to sports activities following acute myocarditis are based on expert consensus in the absence of prospective studies. Purpose We sought to identify patients who may safely resume sports activities 3 months after acute myocarditis. Methods We prospectively enrolled 27 patients with newly diagnosed myocarditis based on clinical parameters, elevated high sensitive troponin (TnT-hs) and cardiac magnetic resonance imaging (CMR) with mildly reduced or preserved LVEF. Follow-up examination included laboratory findings, electrocardiogram (ECG), 48-hour-Holter ECG, echocardiography, exercise stress testing and CMR. Cessation of physical activity was recommended for 3 months. All patients were followed for cardiac events for 12 months. Results Average age was 35 (19–80) years with 73% male patients. All patients performed 3- and 6-month follow-up with above mentioned diagnostic tests. Eight patients did not present for 12-month follow-up, but were contacted by phone. No cardiac events occurred within the interval of 12 months. After 3 months, participants achieved an average of 92% of predicted maximum power on stress test. One case of non-sustained ventricular tachycardia was recorded during 48-hour-Holter ECG. Except for this case, all patients were allowed to resume physical exercise after 3 months. At 6- (n=26) and 12-month (n=19) follow-up no arrhythmias, recurrent myocarditis, worsening left ventricular ejection fraction (LVEF) or physical performance were recorded. TnT-hs, creatine kinase (CK), myoglobin (Mb), and C-reactive protein (CRP) normalized. Conclusion The risk of cardiac events and decreasing LVEF appears to be low after early resumption of exercise in asymptomatic patients who recover from acute myocarditis. Acknowledgement/Funding Forschungskredit of the University of Zurich,the Holcim Foundation, the Hartmann Müller Foundation, and the Walter and Gertrud Siegenthaler Foundation

Postoperative Myocardial Injury in Middle-Aged and Elderly Patients Following Curative Resection of Esophageal Cancer With Aggressive or Standard Body Temperature Management: A Randomized Controlled Trial.

Risk of intraoperative hypothermia is relatively high in middle-aged and elderly patients undergoing curative resection of esophageal cancer, which may cause myocardial ischemia during the early postoperative period. The objective of this study was to compare aggressive or standard body temperature management for lowering the incidence of postoperative myocardial injury that was assessed by troponin levels collected at a priori defined set times in these patients. Seventy patients undergoing elective curative resection of esophageal cancer were randomly assigned to undergo aggressive body temperature management (nasopharyngeal temperature ≥36°C) or standard body temperature management (n = 35 in each arm). The primary outcome was myocardial injury, defined as the occurrence of elevated troponin I (>0.06 µg/L) or elevated high-sensitivity troponin T (≥0.065, or 0.02 µg/L≤ high-sensitivity troponin T <0.065 µg/L, but with an absolute change of at least 0.005 µg/L) or both during 2 days after surgery. Secondary outcomes included (1) severe arrhythmia, including atrial fibrillation, supraventricular tachycardia, frequent premature ventricular contractions intraoperatively or during 3 days postoperatively; (2) hypoxemia or metabolic acidosis during the first 12 h postoperatively; and (3) deep vein thrombosis or pulmonary embolism during 3 days postoperatively. Incidence of postoperative 2-day myocardial injury was 8.6% (3/35) among patients receiving aggressive body temperature management and 31.4% (11/35) among patients receiving standard body temperature management (P = .017, χ). Relative risk of myocardial injury in the aggressive body temperature management group was 0.27 (95% CI, 0.08-0.89). Incidence of intra- and postoperative 3-day severe cardiac arrhythmia was 2.9% (1/35) among patients receiving aggressive body temperature management and 28.6% (10/35) among patients receiving standard body temperature management. Incidence of postoperative 12-h hypoxia was 17.1% (6/35) with aggressive body temperature management and 40.0% (14/35) with standard body temperature management. Incidence of postoperative 12-h metabolic acidosis was 20% (7/35) among patients receiving aggressive body temperature management and 48.6% (17/35) among patients receiving standard body temperature management. Incidence of postoperative 3-day deep vein thrombosis or pulmonary embolism was 0% (0/35) with aggressive body temperature management and 2.9% (1/35) with standard body temperature management. Aggressive body temperature management may be associated with a lower incidence of postoperative myocardial injury.

Systematic use of cardiac magnetic resonance imaging in MINOCA led to a five-fold increase in the detection rate of myocarditis: a retrospective study.

Systematic work-up of patients with myocardial infarction and non-obstructive coronary artery disease (MINOCA) using cardiac magnetic resonance imaging (CMR) led to a more than six-fold increase in the detection rate of myocarditis. In this study, we expanded on our prior two-year analysis by including preceding and subsequent years. We performed a retrospective chart review of patients with angina-like symptoms and elevated high-sensitivity troponin T (TnT-hs &ge;14 ng/l) but without significant coronary artery disease, from 2011 to 2017. Patients underwent CMR to test for myocarditis. From 2011 to 2015, only patients with elevated TnT-hs, no significant coronary artery disease and moderate to high clinical likelihood of suffering from myocarditis, underwent CMR. In 2016 and 2017, CMR images were obtained from all patients with MINOCA, independent of the clinical likelihood that patients were suffering from myocarditis. A total of 556 patients who underwent CMR (70.5% male, 57 &plusmn; 17 years, with an average left ventricular ejection fraction of 51 &plusmn; 15%) qualified for inclusion in this study&rsquo;s analysis. From 2011 to 2015, 240 CMR examinations were performed, with the number increasing to 316 between 2016 and 2017. In total, myocarditis was diagnosed in 76 out of the 556 patients (13.7%). Between 2011 and 2015, the detection rate of myocarditis was 12.7 per 100,000 hospitalisations and increased 4.9-fold (p &lt;0.0001), to 62.5 per 100,000 hospitalisations, between 2016 and 2017. A novel diagnostic algorithm led to an average 4.9-fold increase in the rate of myocarditis detection in our hospital over the two subsequent years. This highlights that myocarditis continues to be underdiagnosed when CMR is not systematically used in patients with MINOCA. &nbsp.

Rationale and design of perioperative myocardial ischemia: a protocol for troponin monitoring, prognostic thresholds, economic analysis and further insights into pathophysiology for non-cardiac surgery patients

Introduction: Worldwide, near 200 million adults undergo major non cardiac surgery each year, and 10 million of them are estimated to suffer a myocardial injury after non-cardiac surgery (MINS), defined as an elevated high sensitive troponin T (hs-cTnT) in the first 3 days after surgery. Troponin levels need to be monitored in order to diagnose MINS, high sensitive cardiac Troponin T (hs-cTnT) assays being currently the most frequently used. Perioperative hs-cTnT screening could lead to care decisions that can potentially improve clinical outcomes. However, many of the clinical and economic implications of perioperative hs-cTnT monitoring remain unclear, and need to be elucidated. Methods and analysis: Prospective cohort that will include patients with high cardiovascular risk undergoing major non-cardiac surgery, expected to require at least an overnight hospital admission. Three determinations of hs-cTnT in each patient (before surgery, at 48, and 72 hours after surgery) will be obtained. We will determine the incidence and prognosis of MINS, and calculate prognostically relevant thresholds for pre- and post-operative hs-cTnT. We will also conduct a cost-effectiveness analysis of hs-cTnT screening, compared with usual care. Finally, using computed tomography angiography (CTA) and cardiac magnetic resonance imaging (MRI), we aim to elucidate further the pathophysiology of MINS. Ethics and dissemination: Our center had Ethics approval before including patients. Written informed consent is required for all patients before inclusion. The study will evaluate the feasibility and impact of implementing an hs-cTnT monitoring program at a tertiary hospital, as well as its cost-effectiveness, determine pre and postoperative thresholds of hs-cTnT and finally, evaluate potential mechanisms involved in perioperative ischemic events. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organizations, and taking published results to real practice.

Non-steroidal anti-inflammatory drug use in acute myopericarditis: 12-month clinical follow-up

ObjectiveClinical data on the effect of non-steroidal anti-inflammatory drugs (NSAIDs) in myopericarditis are limited. Since NSAIDs are standard therapy in pericarditis, we retrospectively investigated their safety in myopericarditis.MethodsIn a retrospective...

Cabozantinib-related cardiotoxicity: a prospective analysis in a real-world cohort of metastatic renal cell carcinoma patients.

Data regarding the cardiac toxicity of cabozantinib lacks. The aim of our study was to assess the risk of cabozantinib-related cardiotoxicity in mRCC patients. We performed a multicentre prospective study on mRCC patients treated with cabozantinib between October 2016 and November 2017. Transthoracic echocardiogram and plasma biomarkers assay were assessed at baseline, 3 and 6months after cabozantinib initiation. The study population included 22 mRCC patients. At baseline, 9.1% had a reduced left ventricular ejection fraction (LVEF), but none had a left ventricular systolic dysfunction. Patients with baseline reduced LVEF did not show further significant LVEF modification after 3months. After 6months, only 1 had an LVEF decline >10% compared to baseline, resulting in LV systolic dysfunction. At baseline, 64.7% and 27.3% of patients had elevated precursor brain natriuretic peptide (proBNP) and high-sensitivity troponin I (hsTnI), respectively. Among patients with basal normal proBNP and hsTnI, none had elevated values at 3 and 6months. No correlation was found between basal elevated proBNP and basal reduced LVEF (P=.29), and between elevated proBNP and reduced LVEF after 6months (P=.37). Similarly, we found no correlations between elevated hsTnI and reduced LVEF or elevated proBNP at baseline (P=.47; P=.38), at 3 (P=.059; P=.45) and after 6months (P=.72; P=1.0). This prospective study revealed a modest risk of developing left ventricular systolic dysfunction related to cabozantinib. A lack of correlation between elevated cardiac biomarkers and reduced LVEF at different time-points was detected. Assessments of the cardiac function should be reserved at the occurrence of clinical symptoms.

CAUSES OF ELEVATED HIGH SENSITIVITY TROPONIN T IN CONSECUTIVE EMERGENCY DEPARTMENT PATIENTS

There is a need to understand when elevations in high sensitivity troponin (hs-cTn) can be expected. We prospectively measured 1,160 consecutive serial (0, 3 and 6 hour) samples from the ED with 4th and 5th generation cTnT. An elevated hs-cTnT was ≥10 ng/L in women, >15 ng/L in men and

PATIENT WITH MYELODYSPLASTIC SYNDROME IN EMERGENCY DEPARTMENT

Myelodysplastic syndromes (MDS) are a group of clonal disorders arising from hematopoietic stem cells and are generally characterized by inefficient hematopoiesis and dysplasia. The International Prognostic Scoring Sytem (IPSS) is an important standard for assessing prognosis of primary untreated adult patients with myelodysplastic syndromes (MDS). Ineffective hematopoiesis leading to anemia is the most common cause of the arrival of patients with MDS in the emergency room . Patients with MDS have a number of associated conditions such as chronic kidney disease and hypertension, and may be present as acute coronary syndrome. We report a case of a 83-year-old female with MDS that was diagnosed in 2014 and had no specific treatment. She presented to the emergency department at the beginning of 2016 because of epigastric and chest pain that began in the morning. Diagnosis of subacute STEMI with a scar formed on front wall and elevated high-sensitivity troponin (hsTnI) which amounted to 1,369 ng / L (reference value &lt; 15.6 ng / L) was made, and the patient was hospitalized in the Coronary Care Unit . The care for this population of patients, mainly elderly, in the emergency department requires a comprehensive approach due to the presence of associated conditions such as hypertension, chronic kidney disease and ischemic heart disease. Cardiovascular diseases (CVD) are the leading cause of death in all countries worldwide.

Baseline Troponin T level in stroke and its association with stress cardiomyopathy.

BackgroundDifferential diagnosis of elevated high sensitive Troponin T (hsTnT) in acute ischemic stroke includes myocardial infarction (MI) and neurogenic stunned myocardium (NSM). The aim of this study was to identify factors associated with baseline hsTnT levels and MI or NSM in acute ischemic stroke.MethodsWe studied 204 consecutive patients of the prospective acquired Bern Stroke Database with acute ischemic stroke diagnosed by brain MR. All patient histories and cardiac examinations were reviewed retrospectively. Volumetry of lesions on diffusion and perfusion weighted brain imaging (circular singular value decomposition, Tmax >6sec) was performed. Voxel based analysis was performed to identify brain areas associated with hsTnT elevation. Linear regression analysis was used to identify predictors of baseline hsTnT levels and myocardial infarction.ResultsElevated hsTnT was observed in 58 of the 204 patients (28.4%). The mean age was 68.3 years in the normal hsTnT group and 69.7 years in the elevated hsTnT group. Creatinine (p<0.001, OR 6.735, 95% CI 58.734–107.423), baseline NIHSS score (p = 0.029, OR 2.207, 95% CI 0.675–12.096), ST segment depression (p = 0.025, OR 2.259, 95% CI 2.419–35.838), and negative T waves in baseline ECG (p = 0.002, OR 3.209, 95% CI 13.007–54.564) were associated with hsTnT elevation, while infarct location and size were not. Coronary angiography was performed in 30 of the 204 patients (14.7%) and myocardial infarction was diagnosed in 7 of them (23.3%). Predictive factors for myocardial infarction could not be identified.ConclusionElevated baseline baseline hsTnT was associated with NIHSS, creatinine, ST segment depression and inverted T waves, but not with stroke location or size. None of the factors was helpful to differentiate MI and NSM. Therefore, ancillary investigations such as coronary angiography, cardiac MRI or both may be needed to solve the differential diagnosis.

Early Prognostic Value of High-Sensitivity Troponin T after Coronary Artery Bypass Grafting.

Periprocedural myocardial injury after coronary artery bypass grafting (CABG) may affect the patient's prognosis and may be due to a different set of factors beyond the atherosclerotic plaque instability. Considering the challenges in the diagnosis of myocardial injury after CABG, the aim of this study was to determine the association between postoperative early elevation of high-sensitivity troponin T (hsTnT) and all-cause 30-day mortality after CABG. We enrolled 600 consecutive patients who underwent CABG. The hsTnT value was measured immediately before surgery and in the morning of the first postoperative day. The baseline hsTnT was 13 ng/L (7-26 ng/L) and 273 patients (45.7%) had baseline hsTnT above the 99th percentile/upper reference limit (URL) (14 ng/L). The median for hsTnT at first postoperative day was 235 ng/L (152-425 ng/L). We calculated the postoperative hsTnT ratio to URL for each patient, representing the number of times exceeding the URL (hsTnT value divided by 14 ng/L). The multivariate analysis by Cox proportional hazard model revealed that age (years) (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 1.07-1.20; p < 0.001) and postoperative hsTnT ratio to URL (per 10-fold increase) (HR = 1.06, 95% CI: 1.04-1.08; p < 0.001) were independent predictors of all-cause 30-day mortality after CABG. In our series, age and higher postoperative hsTnT levels were independent and reliable predictors of all-cause 30-day mortality after CABG.

Web Exclusive. Annals for Hospitalists Inpatient Notes - Clinical Pearls-A Middle-Aged Man With Pneumonia and Elevated High-Sensitivity Troponin Levels.

Although high-sensitivity assays for cardiac troponin testing can help rapidly rule out suspected acute coronary syndrome, a single measurement is generally not clinically meaningful. This commenta...

HIGH SENSITIVITY TROPONIN AND BRAIN-TYPE NATRIURETIC PEPTIDE FLUCTUATION DURING HEMODIALYSIS AND THEIR POTENTIAL CLINICAL APPLICATION ON CARDIOVASCULAR PROGNOSIS

Chronic elevation of high sensitivity troponin (hs-cTnT) and Brain-type natriuretic peptide (Nt-pro-BNP) in end-stage renal disease is associated with worse cardiovascular outcomes, including in hemodialysis (HD) setting. Studies have attempted to correlate variation of those biomarkers over time to cardiovascular prognosis but little is known about how HD parameters acutely influence those biomarkers. To determine the relationship between Nt-pro-BNP and hs-cTnT with HD parameters, 50 participants that were on HD for at least a month were enrolled on the HD ward at our institution. Exclusion criteria were designed to exclude any potential alternative source of hs-cTnT and Nt-pro-BNP elevation (eg. recent myocardial infarction or heart failure, Ejection fraction < 40% (…) ). Among those approached, eight patients were excluded. Six consecutive serum samples were analysed for hs-cTnT and Nt-pro-BNP before and after HD. Hs-cTnT and Nt-pro-BNP percentage decrease after HD were individually analysed in respect with HD weight reduction percentage, ultrafiltration rate, Kt/V (HD adequacy parameter) presence of diastolic dysfunction, indexed left ventricular mass, peri-dialysis hypotension, blood filtration rate and with the other biomarker. Linear regression analysis was used in a fixed-effect model for multivariate assessment and pearson coefficient was calculated for association between the variation of the two biomarkers. Mean decrease after dialysis for hs-cTnT was 38,3% ± 3,9% and for Nt-pro-BNP was 56,1% ± 3,5%. Pearson’s correlation coefficient was of 0,646 (p<0.001) between the decrease of Hs-cTnT and Nt-pro-BNP. Nt-pro-BNP percentage fluctuated with a R2 coefficient of 0,53 with our model. Standardised significant β coefficient were the following: troponin percentage decrease: 0,570 (p<0,001), ultrafiltration rate: -0,558 (p=0,001), weight decrease percentage: 0,399 (p=0,020). Mean absolute and average changes of the two biomarkers following each HD session is shown in table 1. Hs-cTnT and Nt-pro-BNP are diminished after HD in a manner that is reproducible for the same patient and their change is interrelated. Factors that decrease Nt-pro-BNP are higher quantity of fluid removal during HD and lower ultrafiltration rates. Since elevated levels of those biomarkers correlate with increased mortality, strategies to decrease their level by adjusting hemodialysis parameters (increasing fluid removal and lowering ultrafiltration rate) could be evaluated in further studies to improve cardiovascular prognosis in patients undergoing HD.

High-sensitivity troponin T in preterm infants with a hemodynamically significant patent ductus arteriosus.

To investigate if a hemodynamically significant patent ductus arteriosus (hsPDA) leads to elevated high-sensitivity troponin T (hsTnT) and NTproBNP levels in serum. Infants <34 weeks and <1500 g were prospectively enrolled, except those with major congenital or chromosomal anomalies. An echocardiogram (ECHO) was performed and hsTnT and NTproBNP were measured within 5 days of life and repeated after treatment of hsPDA. Clinical, ECHO, and hsTnT data were analyzed using Student t-test, two proportion z-test, and regression analysis. Seventy infants were enrolled. Infants in the hsPDA group had lower gestation and birth weight. Mean hsTnT and NTproBNP levels in the hsPDA group were higher compared to the group without an hsPDA, with levels being 251.54 vs 161.6 pg/ml, p < 0.01 for hsTnT and 18181.02 vs 3149.23 pg/ml, p < 0.001 for NTproBNP. HsPDA leads to increased hsTnT and NTproBNP levels in preterm infants without affecting cardiac function.

Prevalence and outcome of patients referred for chest pain with high-sensitivity troponin elevation and no diagnosis at discharge.

Specialized chest pain units appear to increase the proportion of patients with acute chest pain who are properly evaluated, but some of them remain doubtful. The aim of this study was to evaluate the survival and occurrence of cardiovascular events in patients without diagnosis at the end of management of chest pain with high-sensitivity troponin (Tn) elevation. All consecutive patients who came to the cardiac emergency room of Poitiers University Hospital between January 1, 2014, and August 7, 2015, for chest pain and Tn elevation were included. The primary endpoint was the number of undiagnosed patients; secondary endpoints included survival and major adverse cardiac events. A total of 1001 patients (695 male; mean age, 68 ±16 years) who had chest pain and Tn elevation were included. Median follow-up was 24.5 (IQR, 14.7-29.5) months. Forty-seven (4.7%) patients remained without diagnosis. Compared with patients with diagnosis, these patients were younger (53.6 ±19.7 years; P < 0.0001) and had less hypertension (29.8%; P < 0.0001), diabetes (4.3%; P = 0.0016), and history of coronary artery disease (6.4%; P < 0.0001). No patients died or experienced MACE in 6-month follow-up. Survival curves showed the probability of survival was excellent, not only at 6 months, but also at 36 months (P = 0.0025). Less than 5% of patients referred for chest pain and with high-sensitivity Tn elevation remained without diagnosis after adapted care in the chest pain unit. Their 6-month prognosis was excellent.

Approximation of the Incidence of Myocarditis by Systematic Screening With Cardiac Magnetic Resonance Imaging

ObjectivesThis study sought to obtain an approximation of the true incidence of myocarditis by systematic screening of patients at risk using cardiac magnetic resonance imaging (CMR) in a tertiary care center. BackgroundUnderdiagnosis of myocarditis and resulting uncertainty about its incidence remain a clinical dilemma. The authors hypothesized that systematic screening of patients presenting with angina-like symptoms, elevated troponin T, and no significant coronary artery disease using CMR will provide an approximation of the true incidence of myocarditis. MethodsThe authors performed a retrospective chart review of patients presenting with angina-like symptoms and elevated high-sensitivity troponin T (TnT-hs ≥14 ng/l) in 2015 and 2016. During the year 2015, only patients with elevated TnT-hs, no significant coronary artery disease, and moderate-to-high clinical likelihood of myocarditis underwent CMR. Starting in 2016, CMR was obtained in patients with similar presentation, but independent of clinical likelihood of myocarditis. ResultsA total of 1,788 patients (74% male, age 69 ± 14 years) qualified for our analysis. In 2015, 521 patients presented with angina-like symptoms and TnT-hs elevation. In 2016, the number increased to 1,267 patients. Although in the year 2015, a total of 4 of 88 (5%) CMRs were positive for myocarditis, the percentage of positive CMRs doubled (26 of 199; 13%; p = 0.03) in 2016. ConclusionsA novel diagnostic screening algorithm led to a 6.3-fold increase of the incidence of myocarditis in our hospital. Furthermore, the percentage of CMRs positive for myocarditis doubled, supporting the diagnostic value of this method. Considering the potentially lethal adverse events of myocarditis if left untreated, we recommend a low threshold for the use of CMR in patients with angina-like symptoms and elevated TnT-hs after exclusion of coronary artery disease.

Elevated High-Sensitivity Troponin I During Living Donor Liver Transplantation Is Associated With Postoperative Adverse Outcomes.

This study aimed to evaluate risk factors and postoperative clinical outcome associated with myocardial injury detected by an elevated high-sensitivity cardiac troponin I (hs-cTnI) immediately after living donor liver transplantation (LDLT). Between January 2011 and December 2016, 313 adult recipients undergoing LDLT, with normal preoperative hs-cTnI were selected. Hs-cTnI level above 0.04 ng/mL according to 99th percentile reference limit was defined as myocardial injury. The recipients were divided into 2 groups according to postoperative hs-cTnI measured immediately after LDLT and postoperative clinical outcome was compared. The primary outcome was composite of death or graft failure during hospital stay. Risk factors associated with myocardial injury during LDLT was also evaluated. Of the 313 recipients with normal preoperative hs-cTnI level, 159 (50.8%) had elevated hs-cTnI level and 154 (49.2%) had normal level after LDLT. The incidence of all-cause death or graft failure during hospital stay was significantly higher in recipients with myocardial injury (1.9% vs 7.6%; hazard ratio, 4.15; 95% confidence interval, 1.01-17.14; P = 0.049). The same result was shown in propensity-matched population (0.9% vs 9.0%; hazard ratio, 9.08; 95% confidence interval, 1.16-71.01; P = 0.04). The results during 1-year follow-up were not consistent. Female sex, ischemia time, and presence of postreperfusion syndrome were independent predictors of myocardial injury during LDLT. Myocardial injury detected by elevation of hs-cTnI level immediately after LDLT was independently associated with adverse outcome during hospital stay.

Myocardial injury after non-cardiac surgery: a perioperative affair?

Myocardial injury after non-cardiac surgery (MINS) is a rather new nosological entity and an unfortunately common perioperative complication. The diagnostic criteria for MINS, also indicated as isolated myocardial injury (IMI), are an elevated postoperative high sensitivity troponin T (hsTnT level ranging between 20 and 65 ng/L with an absolute change of at least 5 ng/L or hsTnT level >65 ng/L), in absence of symptoms and/or EKG findings suggestive of ischemia and without a non-ischemic etiology causing troponin elevation. MINS does not fulfill the universal definition of myocardial infarction even if it is related to ischemic causes and it is independently associated with 30-day postoperative mortality and complications. Nevertheless, mortality at 30 days in MINS patients has been calculated up to 10% and it increases exponentially as a function of peak postoperative troponin concentration. Physician and researchers should discriminate MINS from perioperative myocardial infarction and from not ischemic troponin increases. In the postoperative period, the possibility of missing the diagnosis of an acute coronary syndrome for the paucity of clinical symptoms or because physician failed to evaluate a postoperative EKG recording should always be considered. Physiopathology of MINS is not yet well defined: current hypotheses are surrogated from perioperative myocardial infarction studies. Up to now there are not specific treatments for MINS, even if antithrombotic therapy is under evaluation. Treatment decisions should be tailored to the individual case; potential benefits of troponin screening include a cardiology consultation and consequently, improved patients' information to promote lifestyle changes and enhanced therapy.

Elevated High-Sensitivity Troponin I in the Stabilized Phase after an Acute Coronary Syndrome Predicts All-Cause and Cardiovascular Mortality in a Highly Admixed Population: A 7-Year Cohort.

BackgroundHigh-sensitivity cardiac troponin I (hs-cTnI) has played an important role in the risk stratification of patients during the in-hospital phase of acute coronary syndrome (ACS), but few studies have determined its role as a long-term prognostic marker in the outpatient setting.ObjectiveTo investigate the association between levels of hs-cTnI measured in the subacute phase after an ACS event and long-term prognosis in a highly admixed population.MethodsWe measured levels of hs-cTnI in 525 patients 25 to 90 days after admission for an ACS event; these patients were then divided into tertiles according to hs-cTnI levels and followed for up to 7 years. We compared all-cause and cardiovascular mortality using Cox proportional hazards models and adopting a significance level of 5%.ResultsAfter a median follow-up of 51 months, patients in the highest tertile had a greater hazard ratio (HR) for all-cause mortality after adjustment for age, sex, known cardiovascular risk factors, medication use, and demographic factors (HR: 3.84, 95% CI: 1.92-8.12). These findings persisted after further adjustment for estimated glomerular filtration rate < 60 ml/min/1.73 m2 and left ventricular ejection fraction < 0.40 (HR: 6.53, 95% CI: 2.12-20.14). Cardiovascular mortality was significantly higher in the highest tertile after adjustment for age and sex (HR: 5.65, 95% CI: 1.94-16.47) and both in the first (HR: 4.90, 95% CI: 1.35-17.82) and second models of multivariate adjustment (HR: 5.89, 95% CI: 1.08-32.27).ConclusionsElevated hs-cTnI levels measured in the stabilized phase after an ACS event are independent predictors of all-cause and cardiovascular mortality in a highly admixed population.