Elevated Serum Troponin Levels Research Articles

The Role of Troponin Testing in Patients with Supraventricular Tachycardia, Systematic Review and Meta-Analysis

Background: Supraventricular tachycardia (SVT) is commonly evaluated in the emergency department (ED). While troponin has been shown to be elevated in SVT, its usefulness for predicting coronary artery disease and future adverse cardiovascular outcomes has not been shown. Objectives: We aimed to evaluate the prognostic utility of troponin measurement as part of SVT management in the ED. Methods: We performed a literature search in the PubMed and Scopus databases from inception to August 30, 2023, including all studies reporting troponin measurements in adult patients (age >18 years) presenting to the ED with supraventricular tachycardia. The primary outcome of interest for this study was the prevalence of elevated troponin in patients with SVT. Secondary outcomes included the prevalence of major adverse cardiac events (MACE) and additional cardiac testing with significant findings. Results: We included 7 studies (500 patients) in our analysis. Six studies reported the number of patients with SVT and elevated troponin, with a pooled prevalence of 46% (95% CI 27%-66%, I2 93%). The pooled prevalence of all MACE in our study was 6% (95% CI 1%-25%), while the prevalence for MACE among patients with elevated serum troponin levels was 11% (95% CI 4%-27%). Conclusions: Troponin levels are frequently ordered for ED patients with SVT and are often elevated. However, this review suggests that they have low prognostic value in predicting MACE.

Infarto com Supra-ST em Adulto Jovem: Rara Apresentação de Mixoma Atrial Gigante

Abstract Cardiac tumors are rare entities, among which atrial myxoma (AM) stands as the most frequent, accounting for approximately half of all reported cases. The incidence of AM is estimated to range from 0.001% to 0.3% within the general population, yet only about 0.06% of these cases present with coronary embolic events. We report on a 33-year-old male smoker who experienced acute, severe precordial pain radiating to the left upper limb, lasting for one hour. The electrocardiographic evaluation demonstrated ST-segment elevation in leads D2, D3, and aVF, alongside significantly elevated serum troponin levels, confirming a diagnosis of ST-segment elevation myocardial infarction (STEMI). Subsequent coronary angiography revealed proximal occlusion of the right coronary artery due to thrombus. An initial attempt of thrombus aspiration was unsuccessful, followed by primary angioplasty with balloon inflation without stent placement. Further diagnostic exploration through transthoracic echocardiography identified a homogenous, smooth-surfaced mass measuring 5.2 cm x 2.3 cm attached to the interatrial septum. This mass, characterized by lobulations, prolapsed into the mitral valve and left ventricle during diastole, consistent with AM. Surgical resection of the mass was successfully performed, with the patient being discharged asymptomatic. In the reported case, the patient's profile, notably his age, and gender, diverges from the typical epidemiological characteristics associated with AM. This case adds to the limited number of reports where the inferior wall is affected by the right coronary artery being occluded. This report emphasizes the significance of differential diagnoses in younger patients presenting with STEMI.

Risk and predictors of severity and mortality in patients with type 2 diabetes and COVID-19 in Dubai.

Globally, patients with diabetes suffer from increased disease severity and mortality due to coronavirus disease 2019 (COVID-19). Old age, high body mass index (BMI), comorbidities, and complications of diabetes are recognized as major risk factors for infection severity and mortality. To investigate the risk and predictors of higher severity and mortality among in-hospital patients with COVID-19 and type 2 diabetes (T2D) during the first wave of the pandemic in Dubai (March-September 2020). In this cross-sectional nested case-control study, a total of 1083 patients with COVID-19 were recruited. This study included 890 men and 193 women. Of these, 427 had T2D and 656 were non-diabetic. The clinical, radiographic, and laboratory data of the patients with and without T2D were compared. Independent predictors of mortality in COVID-19 non-survivors were identified in patients with and without T2D. T2D patients with COVID-19 were older and had higher BMI than those without T2D. They had higher rates of comorbidities such as hypertension, ischemic heart disease, heart failure, and more life-threatening complications. All laboratory parameters of disease severity were significantly higher than in those without T2D. Therefore, these patients had a longer hospital stay and a significantly higher mortality rate. They died from COVID-19 at a rate three times higher than patients without. Most laboratory and radiographic severity indices in non-survivors were high in patients with and without T2D. In the univariate analysis of the predictors of mortality among all COVID-19 non-survivors, significant associations were identified with old age, increased white blood cell count, lym-phopenia, and elevated serum troponin levels. In multivariate analysis, only lymphopenia was identified as an independent predictor of mortality among T2D non-survivors. Patients with COVID-19 and T2D were older with higher BMI, more comorbidities, higher disease severity indices, more severe proinflammatory state with cardiac involvement, and died from COVID-19 at three times the rate of patients without T2D. The identified mortality predictors will help healthcare workers prioritize the management of patients with COVID-19.

Coronary calcium score in COVID-19 survivors: Association with cardiac injury and cardiac function after 6 weeks

AimsCardiac manifestations are common in COVID-19, often elevated serum troponin levels or myocardial dysfunction on trans-thoracic echocardiography (TTE) is observed. Both parameters are associated with increased in-hospital mortality. Possibly, subclinical coronary atherosclerosis plays a role, of which severity can be assessed by calculating the coronary artery calcium (CAC) score. This study aims to determine the relation between coronary atherosclerosis and cardiac manifestations in COVID-19 survivors. MethodsThis study was conducted at the Leiden University Medical Center. All patients admitted for COVID-19 were included and scheduled for a 6-week follow-up visit with trans-thoracic echocardiography (TTE). CAC was assessed according to an ordinal score on non-gated, non-contrast enhanced computed tomography of the chest. Patients with and without CAC were compared on cardiac injury as reflected by elevated serum troponin levels and impaired cardiac function assessed through TTE. ResultsIn total, 146 patients were included. Mean age was 62 years and 62 % of the patients were male. During admission, patients with CAC showed significantly higher levels of troponin (19 ng/L vs 10 ng/L; p < 0.01). Overall, mild echocardiographic abnormalities were seen; 12 % showed reduced left ventricular function (left ventricular ejection fraction of <50 %) and 14 % reduced right ventricular function (tricuspid annular planar systolic excursion ≤17 mm). Following multivariable adjustments, there was no significant relation between CAC and myocardial function at 6 weeks. ConclusionThe present study shows that coronary atherosclerosis is associated with cardiac injury in COVID-19 survivors. However, no significant relation with impaired cardiac function was demonstrated.

Plasma Troponins Identify Patients with Very Low-Risk Acute Pulmonary Embolism

Although in the non-vitamin K oral anticoagulants (NOAC) era majority of low-risk acute pulmonary embolism (APE) patients can be treated at home, identifying those at very low risk of clinical deterioration may be challenging. We aimed to propose the risk stratification algorithm in sPESI 0 point APE patients, allowing them to select candidates for safe outpatient treatment. Post hoc analysis of a prospective study of 1151 normotensive patients with at least segmental APE. In the final analysis, we included 409 sPESI 0 point patients. Cardiac troponin assessment and echocardiographic examination were performed immediately after admission. Right ventricular dysfunction was defined as the right ventricle/left ventricle ratio (RV/LV) > 1.0. The clinical endpoint (CE) included APE-related mortality and/or rescue thrombolysis and/or immediate surgical embolectomy in patients with clinical deterioration. CE occurred in four patients who had higher serum troponin levels than subjects with a favorable clinical course (troponin/ULN: 7.8 (6.4-9.4) vs. 0.2 (0-1.36) p = 0.000). Receiver operating characteristic (ROC) analysis showed that the area under the curve for troponin in the prediction of CE was 0.908 (95% CI 0.831-0.984; p < 0.001). We defined the cut-off value of troponin at >1.7 ULN with 100% PPV for CE. In univariate and multivariate analysis, elevated serum troponin level was associated with an increased risk of CE, whereas RV/LV > 1.0 was not. Solely clinical risk assessment in APE is insufficient, and patients with sPESI 0 points require further assessment based on myocardial damage biomarkers. Patients with troponin levels not exceeding 1.7 ULN constitute the group of "very low risk" with a good prognosis.

Characterization of Immune Checkpoint Inhibitor-Induced Myasthenia Gravis Using the US Food and Drug Administration Adverse Event Reporting System.

Myasthenia gravis (MG) is a rare but fatal adverse event of immune checkpoint inhibitors (ICIs). We assessed whether patient characteristics differed between those with ICI-related myasthenia gravis and those with idiopathic myasthenia gravis. Reports from the US Food and Drug Administration Adverse Event Reporting System were analyzed. Multivariate analyses were conducted to evaluate the associations between age, sex, and ICI treatment and the reporting rate of myasthenia gravis. Among 5 464 099 cases between 2011 and 2019, 53 447 were treated with ICIs. Myasthenia gravis was reported more often in ICI users. Multiple logistic regression analyses showed that the reporting rate of ICI-related myasthenia gravis did not differ significantly between men and women; however, it was higher in older people than in younger people (adjusted odds ratio, 2.4 [95%CI, 1.84-3.13]). We also investigated useful signs for the early detection of myositis and myocarditis, which are fatal when overlapping with ICI-related myasthenia gravis. Patients with elevated serum creatine kinase or troponin levels were more likely to have concurrent myositis and myocarditis. Unlike idiopathic myasthenia gravis, there was no sex difference in the development of ICI-related myasthenia gravis, which may be more common in older people. Considering the physiological muscle weakness that occurs in the elderly, it may be necessary to monitor ICI-related myasthenia gravis more closely in older people.

COVID-19 vaccine-associated myocarditis.

Myocarditis is now recognized as a rare complication of coronavirus disease 2019 (COVID-19) mRNA vaccination, particularly in adolescent and young adult males. Since the authorization of the Pfizer-BioNTech™ and Moderna™ mRNA vaccines targeting the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) spike protein, the Centers for Disease Control and Prevention (CDC) has reported 1175 confirmed cases of myocarditis after COVID-19 vaccination in individuals ages 30 years and younger as of January 2022. According to CDC data in June 2021, the incidence of vaccine-mediated myocarditis in males ages 12-29 years old was estimated to be 40.6 cases per million second doses of COVID-19 mRNA vaccination administered. Individuals with cases of COVID-19 vaccine-mediated myocarditis typically present with acute chest pain and elevated serum troponin levels, often within one week of receiving the second dose of mRNA COVID-19 vaccination. Most cases follow a benign clinical course with prompt resolution of symptoms. Proposed mechanisms of COVID-19 vaccine myocarditis include molecular mimicry between SARS-CoV-2 spike protein and self-antigens and the triggering of preexisting dysregulated immune pathways in predisposed individuals. The higher incidence of COVID-19 vaccine myocarditis in young males may be explained by testosterone and its role in modulating the immune response in myocarditis. There is limited data on long-term outcomes in these cases given the recency of their occurrence. The CDC continues to recommend COVID-19 vaccination for everyone 5 years of age and older given the greater risk of serious complications related to natural COVID-19 infection including hospitalization, multisystem organ dysfunction, and death. Further study is needed to better understand the immunopathology and long-term outcomes behind COVID-19 mRNA vaccine-mediated myocarditis.

COVID-19 review shows that benefits of vaccinating children and adolescents appear to outweigh risks of post-vaccination myopericarditis.

AimMyopericarditis after COVID‐19 vaccination were the most serious adverse events reported in children over 5 years of age. We want to summarise these cases, describing their incidence, clinical features, diagnostic pathways, therapeutic strategies and outcome.MethodsA systematic review of the literature was conducted until 20 March 2022 by bibliographic electronic databases. We included all reports of post‐vaccination myopericarditis in children aged between 5 and 18 years.ResultsAll reported cases had elevated serum Troponin levels, associated with electrocardiogram changes, but often with normal echocardiogram. Cardiac magnetic resonance images always showed typical alterations. The pathogenetic mechanism is still unknown. Myocarditis following post‐COVID vaccination is more frequent in boys with an average age of about 15 years. Treatment involves the usage of non‐steroidal anti‐inflammatory drugs, and the average hospitalisation is about 3 days. The long‐term consequences are not yet known, so these patients should be studied in a cardiological follow‐up and abstention from physical activity should be recommended.ConclusionThe benefits of COVID‐19 vaccination in children and adolescents appear to outweigh the risk of developing post‐vaccination myopericarditis. We can also speculate a possible approval of vaccination in children under 5 years for the coming winter.

P415 NEUROGENIC STRESS CARDIOMYOPATHY

Abstract Case Report Caucasian 84–years–old woman was found on the floor at her house and was brought to the ED of Policlinico Umberto I with the diagnosis of cranial trauma following a syncope. A head CT showed right paramedian fracture of the occipital bone, left frontal subarachnoid hemorrhage and left frontal subdural hemorrhage. The neurosurgeon gave no indication to urgent evacuation of the hemorrhage. Then elevation of cardiac enzymes and ST–segment elevation at the EKG were found but due to the state of the patient a coronary angiography was not performed and the patient was transferred to the CCU. The patient was hemodynamically stable with right hemiplegia. The EKG showed rapid ventricular rate atrial fibrillation with ST segment elevation in inferior and lateral leads with T wave inversion in the same leads and elevated serum troponin levels. ETT showed: EF 30% with a global reduction of left ventricular systolic function with diffuse akinesis. Intravenous therapy with mannitol and corticosteroids for perilesional oedema was started. Beta blockers and a class III antiarrhythmic drug were also started, but hemodynamic conditions declined and acute kidney failure occurred with progressive hypotension followed by cardiogenic shock. The patient had an episode of nonsustained ventricular tachycardia treated with antiarrhythmic drugs and magnesium sulfate. The EKG started to show a normalization of the repolarization phase with regression of ST segment elevation and persistent T wave inversion.The patient’s neurological conditions were complicated with epileptic seizures.On the fifth day of hospitalization the TTE revealed a slight improvement of global systolic function and the presence of an apical thrombotic apposition.The patient’s clinical conditions worsened and led to exitus. Discussion The interpretation of this patient’s history was made more difficult by the lack of witnesses of the trauma.The patient’s age, her history of hypertension and the presence of regional wall motion abnormalities at the TTE suggested the presence of CAD. On the other side the atrial fibrillation could hint a primitive cerebral event. This case report shows the potentially severe cardiac manifestations of cerebral hemorrhage and the necessity to consider cerebrovascular events as the cause of EKG changes mimicking a myocardial infarction, cardiac enzymes elevation and ventricular wall motion abnormalities, in order to avoid inappropriate or delated therapies.

Idiopathic posterior papillary muscle rupture; a case report

BackgroundPapillary muscle rupture is a rare condition. Its clinical presentation, diagnosis and management can be very challenging for the clinician.Case presentationA 73-year-old woman with hypertension presented with chest pain, ST-segment changes, and elevated serum troponin levels. Coronary angiography was normal. Echocardiography revealed normal ventricular function, flail posterior mitral leaflet, and severe mitral regurgitation. She underwent emergent mitral valve replacement.ConclusionThe diagnostic and management strategies of this uncommon presentation are discussed.

COVID-19 vaccine-associated myocarditis (Russian translation)

Myocarditis is now recognized as a rare complication of coronavirus disease 2019 (COVID-19) mRNA vaccination, particularly in adolescent and young adult males. Since the authorization of the Pfizer-BioNTech™ and Moderna™ mRNA vaccines targeting the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) spike protein, the Centers for Disease Control and Prevention (CDC) has reported 1175 confirmed cases of myocarditis after COVID-19 vaccination in individuals ages 30 years and younger as of January 2022. According to CDC data in June 2021, the incidence of vaccine-mediated myocarditis in males ages 12-29 years old was estimated to be 40.6 cases per million second doses of COVID-19 mRNA vaccination administered. Individuals with cases of COVID-19 vaccine-mediated myocarditis typically present with acute chest pain and elevated serum troponin levels, often within one week of receiving the second dose of mRNA COVID-19 vaccination. Most cases follow a benign clinical course with prompt resolution of symptoms. Proposed mechanisms of COVID-19 vaccine myocarditis include molecular mimicry between SARS-CoV-2 spike protein and self-antigens and the triggering of preexisting dysregulated immune pathways in predisposed individuals. The higher incidence of COVID-19 vaccine myocarditis in young males may be explained by testosterone and its role in modulating the immune response in myocarditis. There is limited data on long-term outcomes in these cases given the recency of their occurrence. The CDC continues to recommend COVID-19 vaccination for everyone 5 years of age and older given the greater risk of serious complications related to natural COVID-19 infection including hospitalization, multisystem organ dysfunction, and death. Further study is needed to better understand the immunopathology and long-term outcomes behind COVID-19 mRNA vaccine-mediated myocarditis. &lt;br&gt;&lt;b&gt;Original article:&lt;/b&gt; Morgan MC, Atri L, Harrell S, Al-Jaroudi W, Berman A. COVID-19 vaccine-associated myocarditis. World J Cardiol. 2022;14(7):382-391. DOI: 10.4330/wjc.v14.i7.382. &lt;br&gt;&lt;i&gt;The article was translated into Russian and published under the terms of the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license.&lt;/i&gt;

Echocardiogram in critically ill patients with COVID-19

BackgroundDescribe echocardiographic characteristics in patients admitted to an intensive care unit by COVID-19 and identify clinical and laboratory findings associated with an abnormal echocardiogram and its association with in-hospital mortality.MethodsIncluded all patients with RT-PCR-confirmed COVID-19 who underwent echocardiography during hospitalization. Echocardiographic characteristics were assessed in the entire population and subgroups. We also analyzed clinical characteristics associated with an abnormal echocardiogram. An echocardiogram was defined as abnormal when it demonstrates systolic ventricular dysfunction of any degree (left and/or right ventricle) and/or high filling pressures (E/E' ratio>16; SPAP>40mmHg, RAP>15mmHg or diastolic dysfunction ≥ grade 2) and/or moderate to severe pericardial effusion. Clinical variables were also assessed using a classification tree and binary logistic regression was performed with characteristics that showed a statistical significance in univariate analysis. Finally, echocardiographic variables were assessed for in-hospital mortality outcome using the chi-square test.Results272 admissions to ICU by COVID-19 were identified. Of these, 159 underwent echocardiography (58.5%). 39 were excluded by incomplete demographic data. 72 echocardiograms (60%) were abnormal according to pre-established criteria. Low occurrence of left and right ventricular systolic dysfunction was observed, as well as 30.8% of the population had a normal diastolic function. In univariate analysis, characteristics associated with abnormal echocardiogram were age, elevated troponin, previous heart failure, and SAPS3 score. In the regression model, troponin was the independent marker of abnormal echocardiography in patients admitted to the intensive care unit by COVID19. This finding was corroborated by the classification tree. The abnormal echocardiogram was not associated with in-hospital mortality (OR 1.60; CI95% 0.75–3.41), but the presence of systolic ventricular dysfunction of any degree was associated with a higher occurrence of this outcome (OR 3.52; CI95% 1.12–11.1).ConclusionsIn intensive care COVID-19 patients, many manifested elevated ventricular filling pressures, but the occurrence of ventricular dysfunction was low. Elevated serum troponin level was the independent marker associated with an abnormal echocardiogram. Systolic ventricular dysfunction was the only echocardiographic variable associated with in-hospital mortality.FUNDunding AcknowledgementType of funding sources: None.

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Differences in Cardiac Magnetic Resonance Imaging Markers Between Patients With COVID-19-associated Myocardial Injury and Patients With Clinically Suspected Myocarditis.

Coronavirus 2019 disease (COVID-19) has been shown to affect the myocardium, resulting in a worse clinical outcome. In this registry study, we aimed to identify differences in cardiac magnetic resonance imaging (CMRI) between COVID-19 and all-cause myocarditis. We examined CMRI of patients with COVID-19 and elevated high-sensitivity serum troponin levels performed between March 31st and May 5th and compared them to CMRI of patients without SARS-CoV-2 infection with suspected myocarditis in the same time period. For this purpose, we evaluated Lake-Louise Criteria for myocarditis by determining nonischemic myocardial injury via T1-mapping, extracellular volume, late gadolinium enhancement, and myocardial edema (ME) by T2-mapping and fat-saturated T2w imaging (T2Q). A total of 15 of 18 (89%) patients with COVID-19 had abnormal findings. The control group consisted of 18 individuals. There were significantly fewer individuals with COVID-19 who had increased T2 (5 vs. 10; P=0.038) and all-cause ME (7 vs. 15; P=0.015); thus, significantly fewer patients with COVID-19 fulfilled Lake-Louise Criteria (6 vs. 17; P<0.001). In contrast, nonischemic myocardial injury was not significantly different. In the COVID-19 group, indexed end-diastolic volume of the left ventricle showed a significant correlation to the extent of abnormal T1 (R2=0.571; P=0.017) and extracellular volume (R2=0.605; P=0.013) and absolute T1, T2, and T2Q (R2=0.644; P=0.005, R2=0.513; P=0.035 and R2=0.629; P=0.038, respectively); in the control group, only extracellular volume showed a weak correlation (R2=0.490; P=0.046). Cardiac involvement in COVID-19 seems to show less ME than all-cause myocarditis. Abnormal CMRI markers correlated to left ventricle dilation only in the COVID-19 group. Larger comparative studies are needed to verify our findings.

Association between Troponin I Levels during Sepsis and Postsepsis Cardiovascular Complications.

Rationale: Sepsis commonly results in elevated serum troponin levels and increased risk for postsepsis cardiovascular complications; however, the association between troponin levels during sepsis and cardiovascular complications after sepsis is unclear.Objectives: To evaluate the association between serum troponin levels during sepsis and 1 year after sepsis cardiovascular events.Methods: We analyzed adults aged ⩾40 years without preexisting cardiovascular disease within 5 years, admitted with sepsis across 21 hospitals from 2011 to 2017. Peak serum troponin I levels during sepsis were grouped as normal (⩽0.04 ng/ml) or tertiles of abnormal (>0.04 to ⩽0.09 ng/ml, >0.09 to ⩽0.42 ng/ml, or >0.42 ng/ml). Multivariable adjusted cause-specific Cox proportional hazards models with death as a competing risk were used to assess associations between peak troponin I levels and a composite cardiovascular outcome (atherosclerotic cardiovascular disease, atrial fibrillation, and heart failure) in the year following sepsis. Models were adjusted for presepsis and intrasepsis factors considered potential confounders.Measurements and Main Results: Among 14,046 eligible adults with troponin I measured, 2,012 (14.3%) experienced the composite cardiovascular outcome, including 832 (10.9%) patients with normal troponin levels, as compared with 370 (17.3%), 376 (17.6%), and 434 (20.3%) patients within each sequential abnormal troponin tertile, respectively (P < 0.001). Patients within the elevated troponin tertiles had increased risks of adverse cardiovascular events (adjusted hazard ratio [aHR]troponin0.04-0.09 = 1.37; 95% confidence interval [CI], 1.20-1.55; aHRtroponin0.09-0.42 = 1.44; 95% CI, 1.27-1.63; and aHRtroponin>0.42 = 1.77; 95% CI, 1.56-2.00).Conclusions: Among patients without preexisting cardiovascular disease, troponin elevation during sepsis identified patients at increased risk for postsepsis cardiovascular complications. Strategies to mitigate cardiovascular complications among this high-risk subset of patients are warranted.

Role of troponin as a biomarker for predicting outcome after ischemic stroke.

BACKGROUND:After acute ischemic stroke, a higher level of troponin has been considered as an important biomarker for predicting mortality.AIM AND OBJECTIVES:The study aimed to quantitatively assess the prognostic significance of the effect of baseline troponin levels on all-cause mortality in patients with acute ischemic stroke using a meta-analysis approach.MATERIALS AND METHODS:The following electronic databases such as PubMed, Web of Science, Cochrane Central Register of Controlled Trials, TRIP Database, and ClinicalTrialsgov were used for obtaining the relevant articles from literature. Data were extracted in standardized data collection form by two independent investigators. Any disagreements were resolved by consensus. All the statistical analyses were performed in STATA software (Version 13.1).RESULTS:A total of 19 studies were included in the present meta-analysis involving a total of 10,519 patients. The pooled analysis suggested that elevated serum troponin level was associated with inhospital mortality (rate ratios [RR] 2.34, 95% confidence interval [CI] 1.30–3.38) and at the end of last follow-up mortality (RR 2.01; 95% CI 1.62–2.40). Sensitivity analysis by removing a single study by turns indicated that there was no obvious impact of any individual study on the pooled risk estimate. No significant publication bias was observed in the beg test (P = 0.39); however, significant publication bias was observed in the egger test (P = 0.046).CONCLUSION:Our findings indicated that a higher level of troponin might be an important prognostic biomarker for all cause in hospital and follow-up mortalities in patients with acute ischemic stroke. These study findings offer insight into further investigation in prospective studies to validate this particular association. The study was registered in OSF registries DOI's 10.17605/OSF. IO/D95GN

Risk Factors Associated with Post Heart Transplantation Left Ventricular versus Right Ventricular Primary Graft Dysfunction

PurposeVarious donor, recipient and procedure related risk factors have been associated with post-heart transplantation primary graft dysfunction (PGD). Little is known about whether there are differences in risk factors for left ventricular (PGDLV) versus right ventricular graft dysfunction (PGDRV).MethodsWe retrospectively reviewed records of consecutive heart transplantation procedures performed at our institution between 2010 and 2017. Donor, recipient and procedure related factors were evaluated for the association with severe PGDLV and PGDRV.ResultsWe observed severe PGDLV in 15 (6.8%) and PGDRV (6.3%) in 14 of 222 consecutive first-time heart-alone adult procedures. Univariate analysis of pre-transplant characteristics with severe PGDLV and PGDRV is summarized in Table 1. Factors associated with severe PDGLV in multivariable logistic regression analysis were greater recipient age (odds ratio [OR] 1.045, P = .024), elevated donor serum troponin level (OR 1.089, P =.050, and number of donor pre-recovery blood transfusions (OR 2.704, P =.025). Factors associated with PGDRV were lower recipient BMI (OR 1.234, P = .001), elevated recipient pre-transplantation creatinine level (OR 15.923, P = .001), and transplantation procedure with LVAD explantation (OR 15.747, P = .002).ConclusionVariables predictive of post-heart transplantation primary graft dysfunction are different for left and right ventricle. PGDLV is primarily determined by the quality of the graft, whereas right ventricular dysfunction is predominantly caused by recipient characteristics. Various donor, recipient and procedure related risk factors have been associated with post-heart transplantation primary graft dysfunction (PGD). Little is known about whether there are differences in risk factors for left ventricular (PGDLV) versus right ventricular graft dysfunction (PGDRV). We retrospectively reviewed records of consecutive heart transplantation procedures performed at our institution between 2010 and 2017. Donor, recipient and procedure related factors were evaluated for the association with severe PGDLV and PGDRV. We observed severe PGDLV in 15 (6.8%) and PGDRV (6.3%) in 14 of 222 consecutive first-time heart-alone adult procedures. Univariate analysis of pre-transplant characteristics with severe PGDLV and PGDRV is summarized in Table 1. Factors associated with severe PDGLV in multivariable logistic regression analysis were greater recipient age (odds ratio [OR] 1.045, P = .024), elevated donor serum troponin level (OR 1.089, P =.050, and number of donor pre-recovery blood transfusions (OR 2.704, P =.025). Factors associated with PGDRV were lower recipient BMI (OR 1.234, P = .001), elevated recipient pre-transplantation creatinine level (OR 15.923, P = .001), and transplantation procedure with LVAD explantation (OR 15.747, P = .002). Variables predictive of post-heart transplantation primary graft dysfunction are different for left and right ventricle. PGDLV is primarily determined by the quality of the graft, whereas right ventricular dysfunction is predominantly caused by recipient characteristics.

Chest Pain Radiating to the Jaw with Elevated Troponin: Aortic Dissection Masquerading as Myocardial Infarction

Introduction: Chest pain radiating to the jaw, is a classic symptom of acute myocardial infarction (AMI). Electrocardiogram (EKG) changes consistent with ischemia and elevated serum troponin I levels are used to confirm the diagnosis. Prompt management including medical or procedural intervention is required to help reduce mortality in patients with AMI. However, additional conditions may mimic those of classic primary coronary pathology. Case Report: We present the case of a 43-year-old male who came to the emergency department (ED) complaining of acute onset of chest pain radiating to the left jaw. His EKG revealed mild ST changes and T-wave inversion in the antero-lateral leads. Laboratory testing revealed an elevated serum troponin level of 0.18 ng/mL (normal: < 0.04 ng/mL). He was taken for a coronary angiogram and during the procedure, an aortogram was performed revealing a type A aortic dissection. Findings were confirmed by Computed Tomography Angiogram (CTA) showing a dissection extending from the aortic root to the iliac bifurcation. He was promptly taken to the operating room (OR) for surgical repair. Conclusion: Aortic dissection (AD) is included in the differential diagnosis in patients presenting with symptoms and signs consistent with AMI. However, in patients presenting with AD, there are some clues in history and physical exam, such as high blood pressure, history of noncompliance with antihypertensive medications, or location of pain that may provide a clue towards an underlying AD. Our case demonstrates that even if all evidence points towards an AMI, AD should still be on the differential until successfully ruled out by imaging.

Aneurysmal subarachnoid hemorrhage as a trigger for Takotsubo syndrome: a comprehensive review.

Takotsubo syndrome (TTS) can result in acute heart failure and lead to a potentially life-threatening complication of aneurysmal subarachnoid hemorrhage (aSAH). The incidence of TTS in aSAH is less than 10% of all patients with aSAH, with a preponderance of postmenopausal women. Early indicators of TTS include elevated serum troponin levels and electrocardiographic abnormalities. The key finding is left ventricular wall motion abnormality. Echocardiography and coronary angiography help to establish the diagnosis. Vasopressors, milrinone, levosimendan, insulin, and anticoagulation may be required. The value of beta-blockers is a matter of controversy. TTS must not delay the treatment of a ruptured aneurysm. The clinical outcome in patients with aSAH and TTS is mostly determined by the aSAH and not the TTS.

Pathological features of COVID-19-associated myocardial injury: a multicentre cardiovascular pathology study.

AimsCoronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been associated with cardiovascular features of myocardial involvement including elevated serum troponin levels and acute heart failure with reduced ejection fraction. The cardiac pathological changes in these patients with COVID-19 have yet to be well described.Methods and resultsIn an international multicentre study, cardiac tissue from the autopsies of 21 consecutive COVID-19 patients was assessed by cardiovascular pathologists. The presence of myocarditis, as defined by the presence of multiple foci of inflammation with associated myocyte injury, was determined, and the inflammatory cell composition analysed by immunohistochemistry. Other forms of acute myocyte injury and inflammation were also described, as well as coronary artery, endocardium, and pericardium involvement. Lymphocytic myocarditis was present in 3 (14%) of the cases. In two of these cases, the T lymphocytes were CD4 predominant and in one case the T lymphocytes were CD8 predominant. Increased interstitial macrophage infiltration was present in 18 (86%) of the cases. A mild pericarditis was present in four cases. Acute myocyte injury in the right ventricle, most probably due to strain/overload, was present in four cases. There was a non-significant trend toward higher serum troponin levels in the patients with myocarditis compared with those without myocarditis. Disrupted coronary artery plaques, coronary artery aneurysms, and large pulmonary emboli were not identified.ConclusionsIn SARS-CoV-2 there are increased interstitial macrophages in a majority of the cases and multifocal lymphocytic myocarditis in a small fraction of the cases. Other forms of myocardial injury are also present in these patients. The macrophage infiltration may reflect underlying diseases rather than COVID-19.