Elevated Troponin Levels Research Articles

Pre-symptomatic scintigraphic and genetic cascade screening in cardiac transthyretin amyloidosis.

While early diagnosis is crucial, as new treatments can significantly slow the progression of the disease, there is growing evidence on the application of novel imaging techniques for detecting transthyretin amyloidosis (ATTR) in pre-symptomatic stages. This study aimed to evaluate the utility of pre-symptomatic scintigraphic imaging cascade screening for early detection of ATTR. During the period from 2020 to 2024, we conducted a prospective study that enrolled 100 consecutive adults. The study utilized a multimodal cascade screening approach to assess asymptomatic relatives of individuals with ATTR (ClinicalTrials.gov Identifier: NCT05814380). The analysis incorporated clinical data, genetic testing, echocardiography, scintigraphy and single-photon emission computed tomography/computed tomography (SPECT/CT) with [99mTc]Tc-DPD, regardless of the predicted age of disease onset. Overall, scintigraphy identified cardiac amyloidosis (CA) in 8.2% of relatives, while 20.5% carried a pathogenic transthyretin variant without radiotracer uptake, with Phe53Leu being predominant. Notably, no relatives of wild-type ATTR patients exhibited CA on scintigraphy or carried a transthyretin variant. Additionally, newly-diagnosed relatives with ATTR CA presented elevated high-sensitivity troponin levels and exhibited a higher incidence of pathological electrocardiographic Q waves, greater thickness of the intraventricular septum and left ventricular posterior wall, a notable decline in lateral wall and intraventricular septal E' tissue velocities measured by TDI, and the "5-5-5" sign (p < 0.05). The presented findings demonstrate that implementing a systematic screening protocol, which integrates genetic and scintigraphic testing, facilitates the early detection of ATTR. Crucially, a significant proportion of asymptomatic relatives of patients with hereditary ATTR may suffer from underlying CA. ClinicalTrials.gov Identifier: NCT05814380.

Abstract 4140198: Impact of Non-ST-segment elevation Myocardial Infarction on outcomes of Diabetic Ketoacidosis in Hospitalized Patients: A National Inpatient Sample Analysis

Introduction: Diabetes Mellitus (DM) has a broad spectrum of complications and is one of the leading 5 causes of hospital admissions in the US. Decompensated DM is associated with high mortality in hospitalized patients. Cardiac ischemia and related events are proposed to be increasingly prevalent in hospitalized patients with decompensated diabetes. Numerous studies and reports have suggested that elevation in troponin levels is associated with high mortality in such patients. Notably, there have only been a few studies that assessed the prevalence of NSTEMI (Non-ST segment elevation myocardial infarction) and its effect on outcomes in patients hospitalized with Diabetes ketoacidosis (DKA). Methods: We aimed to compare the outcomes of DKA in hospitalized adults (age &gt;18 years) with NSTMI with those without NSTEMI using the National Inpatient Sample (NIS) database from 2018 to 2020. NIS is the largest publicly available all-payer inpatient care database in the United States, containing data on more than seven million hospital stays. Results: There were a total of 1113295 hospitalizations identified with a diagnosis of DKA. Of these, 9860 (0.88%) patients had NSTEMI. The mean age of this subpopulation was 38.71 years. Among these patients, 48.59% were female, and 58.40% were male. We attempted to assess the impact of NSTEMI on the occurrence of complications such as cardiac arrest, acute renal failure (ARF), Acute liver failure (ALF), Acute heart failure (Acute HF), and acute respiratory failure in patients admitted with DKA. The results of this analysis are depicted in the table below. The cost of hospitalization for DKA with NSTEMI was $35878 higher and the length of stay was 50% longer compared to the patients with DKA without NSTEMI. The Odds ratio for mortality was 2.84 for patients with NSTEMI. Conclusions: Our analysis suggests that the occurrence of NSTEMI negatively impacts outcomes in DKA patients. The occurrence of primary outcomes assessed in this study (Cardiac arrest, ARF, ALF, Acute HF, and Acute respiratory failure) was significantly higher in DKA patients with concomitant diagnosis of NSTEMI. NSTEMI also increased the cost burden on hospitalizations for DKA.

Abstract 4138376: A Machine Learning Approach to Predict Percutaneous Coronary Intervention in Patients with Critical Illness and Signs of Myocardial Injury

Background: Critically ill patients frequently experience multi-organ dysfunction and unstable vital signs, increasing their risk of myocardial injury and elevated serum troponin levels. Myocardial injury from oxygen supply-demand mismatch, whether due to systemic disease or obstructive coronary artery disease (CAD), often leads to patients undergoing an invasive coronary angiogram (ICA) and potentially percutaneous coronary intervention (PCI) if obstructive CAD is identified. However, this procedure carries significant risks for critically ill patients. To address this challenge, we aimed to develop a machine learning (ML) model to predict the need for PCI in critically ill patients with myocardial injury. Methods: The study cohort included critically ill patients with elevated serum troponin levels who underwent ICA during their hospitalization at a single institution from 2012 to 2022. We defined critical illness as a life-threatening condition requiring intensive support for vital sign instability. Patients with atherothrombosis identified during ICA were excluded from the study, focusing only on patients with type 2 MI. We utilized Matplotlib to analyze patient data, including demographics, lab results, vital signs, and comorbidities. We then used XGBoost, a supervised ML algorithm, for binary classification tasks. An ensemble of decision trees was employed, with gradient boosting to correct errors from previous trees. XGBoost iteratively adjusted predictions, creating a model to predict which patients required PCI. Results: Out of 765 patients, 173 (22.6%) underwent PCI. The cohort had a mean age of 60.5 ± 13.5 years, with 41.7% being female. The ML model accurately identified non-PCI candidates at 75% and PCI candidates at 64%, achieving an overall accuracy of 73%. The three most important features identified by the model were a history of diabetes, diastolic heart failure, and whether the patient received a blood transfusion during hospitalization. Conclusion: A ML approach using XGBoost demonstrated moderate accuracy in predicting the need for PCI in critically ill patients with signs of myocardial injury. This prediction holds clinical significance due to the heightened risks associated with ICA in these patients. Given that PCI occurred in only 22.6% of the cohort, future models should include a higher proportion of patients who underwent PCI to improve the robustness and true positive accuracy of the model.

Abstract 4122284: HEART Score Classification of Major Adverse Cardiovascular Events in Patients with Diabetes Mellitus

Introduction: Risk stratifying diabetes mellitus (DM) patients with chest pain in the emergency department (ED) can pose significant challenges because of atypical symptoms, non-specific ECG changes, and elevated baseline troponin levels. This study aims to evaluate HEART Score performance in DM versus non-DM patients. Methods: A prospective observational cohort study included chest pain patients transported by Emergency Medical Services to University of Pittsburgh Medical Center-affiliated hospitals. Data collection involved extracting data from electronic health records, including both DM and non-DM patients with chest pain. The HEART Score was retrospectively calculated by impartial assessors.The primary endpoint was major adverse cardiac events (MACE) within 30 days. This analysis included the classification performance of bivariate comparisons between the HEART Score and ACS outcomes using the area under the receiver-operator characteristic curve (AUC). Results: 4,058 patients were included. 52.7% were male, 42% were white, there was a mean age of 59.24 years (16.13 SD), 28.63% had DM, and 22.1% had MACE. MACE prevalence was 19.7% in non-DM patients and 28% in patients with DM. The AUC demonstrated more robust discriminatory ability of the HEART Score in non-DM (AUC = 0.81) (95% CI 0.79-0.83) versus DM patients (AUC = 0.74) (95% CI 0.71-0.78) (p 0.001). The performance of HEART Score components, including history, age, and risk factors, exhibited better significant predictive capability for MACE in non-DM patients compared to DM patients. Conversely, the HEART-ECG and troponin components were not different between the DM and non-DM groups. The HEART Score demonstrates better performance in White individuals and females when contrasted with males and Black individuals. Nevertheless, these disparities do not reach statistical significance. Conclusion: The HEART Score performs differently in DM versus non-DM patients, with stronger discrimination observed in non-DM individuals. The troponin and ECG components exhibit poorer performance in diabetes mellitus (DM) patients within the context of the HEART Score. This underscores the complexity of risk assessment in DM patients with chest pain and suggests the necessity for further exploration and refinement of risk stratification strategies in this population.

The Unusual Presentation of Non-ST Elevation Myocardial Infarction Following Acute Carbon Monoxide Poisoning in an Elderly Female: A Case Report

Carbon monoxide (CO) poisoning is a leading cause of poisoning-related deaths, particularly affecting organs with high oxygen demands such as the heart and brain. Cardiac complications, including non-ST elevation myocardial infarction (NSTEMI), can occur due to CO poisoning but are not frequently reported in the elderly. We present the case of an 82-year-old female with a medical history of diabetes, hypertension, dyslipidemia, and previous ischemic heart disease. She was brought to the emergency department after being found drowsy in a closed room with a burning charcoal heater. The initial assessment revealed a carboxyhemoglobin level of 33.5%, which decreased to 9.3% after high-flow oxygen therapy and hyperbaric oxygen therapy (HBOT). Laboratory tests indicated elevated troponin levels, and an ECG showed asymmetrical T-wave inversion and ST depression. Despite the improvement in carboxyhemoglobin, the patient experienced persistent chest pain and rising troponin levels. She was treated with dual antiplatelet therapy and low molecular weight heparin as per acute coronary syndrome protocol, leading to a gradual improvement and a subsequent discharge in a stable condition. This case highlights the potential for CO poisoning to induce NSTEMI in elderly patients. A prompt diagnosis and appropriate management, including the use of HBOT, were crucial for the patient’s recovery.

Prevalence of transthyretin cardiac amyloidosis in undifferentiated heart failure with preserved ejection fraction.

Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasinglyrecognized cause of heart failure with preserved ejection fraction (HFpEF), which may be diagnosed non-invasively using 99 mTc 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy-based diagnostic criteria. Our aim was to determine the prevalence of ATTR-CM in an undifferentiated HFpEF cohort with a DPD scintigraphy-based screening protocol. Patients with HFpEF [ejection fraction (EF) ≥50%] aged ≥60years and no prior evaluation for cardiac amyloidosis or known monoclonal gammopathy attending a regional cardiology network were screened with DPD scintigraphy. Patients with positive myocardial uptake (Perugini grade 2 or 3) were tested for a monoclonal protein and transthyretin gene variant. Eighty-six subjects were prospectively enrolled: 56% female, mean age 77±8years, 63% New York Heart Association (NYHA) Class III and median N-terminal pro-brain natriuretic peptide (NT-proBNP) 1766ng/L [inter-quartile range (IQR) 731-3703]. DPD scintigraphy was positive in seven patients (8%). Monoclonal gammopathy of undetermined significance was present in one out of seven patients, and no pathogenic TTR gene variant was identified. The prevalence of wild-type ATTR-CM was 8% of this cohort. Compared with the HFpEF DPD scintigraphy-negative cohort, DPD scintigraphy-positive patients were older (86±3 vs. 76±8years), more frequently male (16% vs. 2%, P=0.02), and had significantly greater left ventricular (LV) wall thickness (16 vs. 12mm; P=0.002) and higher high-sensitivity troponin levels at diagnosis [78ng/L (IQR 21-116) vs. 11ng/L (IQR 9-17); P<0.001]. In an undifferentiated HFpEF cohort, 8% were found to have wild-type ATTR-CM using a DPD scintigraphy-based screening protocol. Screening undifferentiated HFpEF patients is associated with a significant diagnostic yield, which can be further increased by targeting older males with increased LV wall thickness and elevated high-sensitivity troponin levels.

Troponin Test, Not Only a Number: An Unusual Case of False Positive

Heterophile antibodies, which can arise from infections, autoimmune disorders, or exposure to animal antigens, can interfere with immunoassays. These antibodies can cross-react with the test reagents used in troponin assays, causing a false elevation in troponin levels. The paper describes a case of a 37-year-old male drug abuser admitted to the emergency room with chest pain. A series of troponin measurements performed using different assays gave discrepant results. Only thanks to the use of Scantibodies HBT tubes, which remove heterophile antibodies, was it possible to make a correct diagnosis of troponin negativity. In conclusion, a correct laboratory/clinical approach to the identification of heterophile antibody interference is essential for accurate troponin testing in order to avoid false positive results. Implementing neutralizing tests can significantly improve the reliability of these diagnostic assays, ensuring better patient outcome.

Taurine and enzymatically modified isoquercitrin synergistically protect against the methotrexate-induced cardiotoxicity in rats: antioxidant and antiapoptotic effects

This study aimed to evaluate the protective potential of taurine (Tau) and enzymatically modified isoquercitrin (EMIQ), both individually and in combination, against MTX-induced cardiotoxicity in male rats. A total of 36 rats were randomly divided into six groups (six animals each): control (vehicle), MTX alone (20 mg/kg, single dose), EMIQ+MTX (EMIQ at 26 mg/kg, p.o. for 16 days, with a single dose of MTX on the 13th day), Tau + MTX (Tau at 500 mg/kg, p.o. for 16 days, with a single dose of MTX on the 13th day), (EMIQ+Tau)+MTX, and (EMIQ+Tau)½+MTX. MTX treatment resulted in elevated levels of cardiac creatine phosphokinase-myocardial band, troponin I, nitric oxide, malondialdehyde, and serum IL-6, while decreasing levels of cardiac myeloperoxidase, catalase, and superoxide dismutase. MTX also reduced expression of BMI-1, induced DNA laddering and fragmentation, and increased cleaved caspase-3 protein expression in cardiac tissue. Both Tau and EMIQ showed equivalent effectiveness in protecting the heart against MTX-induced damage due to their antioxidant, anti-inflammatory, and antiapoptotic properties. Notably, combined treatment with half-doses of Tau and EMIQ offered superior protection compared to full doses of each agent alone. The full-dose combination showed similar efficacy to the half-dose combination, with a few exceptions. Overall, these results suggest a synergistic effect of Tau and EMIQ in mitigating MTX-induced cardiotoxicity, warranting further investigation into the underlying mechanisms.

Atypical Presentation of Viral Myocarditis with Isolated Fatigue

Viral myocarditis is an inflammatory condition of the myocardium, often caused by viral infections. While the typical presentation includes chest pain, shortness of breath, and palpitations, fatigue as the primary symptom is unusual and presents diagnostic challenges. This report presents the case of a 39-year-old healthy male who complained of isolated fatigue and mild chest discomfort after experiencing flu-like symptoms. Initial workup revealed elevated troponin levels with abnormal ECG findings, raising concerns for myocardial involvement. Coronary angiography ruled out obstructive coronary artery disease, confirming the diagnosis of viral myocarditis. The patient responded well to anti-inflammatory and antithrombotic treatment, and no complications were observed during follow-up. This case highlights the importance of considering viral myocarditis in patients with vague symptoms, especially those with recent viral infections, to prevent delayed diagnosis and potential complications. Early identification and treatment are critical to ensure a favorable outcome.

Increased index of microcirculatory resistance, capillary rarefaction, elevated troponin levels, and their association with transthyretin amyloidosis cardiomyopathy

Abstract Background The pathophysiology of coronary microvascular disease (CMD) in patients with transthyretin amyloidosis cardiomyopathy (ATTR-CM) remains unclear. Objective This study aims to functionally and pathologically assess coronary microvasculature to elucidate the underlying mechanisms of myocardial injury in patients with ATTR-CM. Methods Fifty patients (median age, 74 years; men, n=46, 92%) with echocardiographic evidence of left ventricular hypertrophy (≥12 mm) who underwent endomyocardial biopsy (EMB) and invasive coronary physiological assessments following coronary angiography were enrolled between October 2021 and September 2023 and divided into ATTR-CM (n=30) and non-cardiac amyloidosis (CA) (n=20) groups according to EMB results. All patients with ATTR-CM exhibited positive heart-to-contralateral (H/CL) ratios (&amp;gt;1.5) on technetium 99m pyrophosphate scintigraphy. Fractional flow reserve (FFR), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR) were measured using the PressureWire X guidewire in the left anterior descending artery. Capillary density (/mm2) was determined with EMB tissues by counting the number of CD31 immunopositive luminal structures, whereas the amyloid deposition burden was assessed by measuring the transthyretin immunopositive areas. Circulating cardiac troponin T (hs-cTnT) and brain natriuretic peptide (BNP) were measured. Results Compared to the non-CA group, the ATTR-CM group exhibited lower CFR (2.4±0.3 vs. 3.6±0.4, p=0.01), higher IMR (35.4±3.0 vs. 18.7±3.7, p=0.0009), lower capillary density (255.3±24.9 /mm2 vs. 408.6±29.5 /mm2 , p=0.0002), and elevated hs-cTnT levels (0.056±0.006 ng/mL vs. 0.036±0.004 ng/mL, p=0.01), with similar FFR (0.87±0.015 vs. 0.84±0.013, p=0.1) and BNP levels (229.6±38.1 pg/mL vs. 210.2±46.7 pg/mL, p=0.75). In the overall and ATTR-CM groups, capillary density had no significant correlation with IMR (r=0.16, p=0.41 and r=0.04, p=0.84, respectively) and a significant inverse correlation with hs-cTnT (r=-0.47, p=0.001, and r=-0.48, p=0.009, respectively). In the ATTR-CM group, capillary density was not significantly correlated with the H/CL ratio (r=-0.23, p=0.09); nevertheless, transthyretin immunopositive areas were positively correlated with the H/CL ratio (r=0.47, p=0.01). Conclusion Capillary rarefaction correlates with elevated hs-cTnT levels but not with elevated IMR, and H/CL ratios, suggesting that CMD is involved at the capillary level in ATTR-CM-related myocardial injury independent of the amyloid deposition burden.

Ischemic Stroke Unveiling Takayasu Arteritis Complicated by Coronary Arteritis: A Case Study

Context: We present the case of a 38-year-old woman admitted for ischemic stroke. Etiological evaluation revealed halo signs on transesophageal echocardiography (TEE), suggestive of Takayasu arteritis. Case Presentation: During hospitalization, the patient developed chest pain, elevated troponin levels (300 ng/L), left ventricular hypokinesia on echocardiography, and T-wave inversions on electrocardiogram (ECG), indicating coronary arteritis. High-dose corticosteroid therapy led to rapid improvement in inflammatory markers. The diagnosis of Takayasu arteritis was confirmed based on the American College of Rheumatology (ACR) criteria. This case highlights the variable clinical presentation of Takayasu arteritis, including coronary involvement, and underscores the effectiveness of corticosteroid therapy in controlling inflammation. Conclusion: Takayasu arteritis, though rare, can manifest with ischemic stroke and coronary arteritis. Prompt recognition and corticosteroid treatment are essential in managing this potentially life-threatening condition.

A systematic assessment of myocardial involvement and cardiovascular events up to six months in patients hospitalised with COVID-19

Abstract Background Retrospective cohort studies indicate that myocardial injury occurs in approximately 25% of patients hospitalised with COVID-19. However, prospective studies with a systematic assessment of myocardial involvement and major adverse cardiovascular events (MACE) after COVID-19 are scarce. Purpose The primary objective was to determine the incidence of MACE within six months of hospitalisation. MACE was defined as a composite of cardiac death, sudden death, life-threatening ventricular arrhythmia's, heart failure, non-fatal myocardial infarction, and/or non-fatal stroke. The main secondary objective was to determine the frequency of other cardiac complications not covered by this definition. Methods We conducted a prospective multicenter cohort study in 13 Dutch medical centers. Adult patients hospitalised with COVID-19 were consecutively recruited (May 2021-April 2023). Exclusion criteria were age ≥70 years, a history of new cardiac disease in the past six months, or dependency in the activities of daily living. Cardiac involvement was evaluated by a standardised healthcare pathway that was implemented in participating hospitals. All patients received an electrocardiogram, transthoracic echocardiogram, and troponin measurement at admission and at six months follow-up. Furthermore, a questionnaire was distributed at three and six months after admission to collect information on post-COVID symptomatology. Results In total 190 patients were included, median age of 57 years [IQR 48; 64], mostly male (n=110, 60%) and white (n=136, 72%). Cardiovascular risk factors were present in 116 (61.1%) patients and 33 (17.4%) had a history of cardiac disease. At admission, troponin was above the upper limit of normal in 68 (35.8%) patients. Seven (3.7%) patients died during follow-up. The cumulative incidence of MACE was 2.6% at discharge with no additional events during follow-up. Other cardiac complications were detected in 18 (9.5%) patients during admission with 3 (1.6%) additional events at six months follow-up. Supraventricular tachycardias (n=8, 4.2%) were the most common cardiac complication. Other complications were myocarditis (n=2, 1.1%), pericarditis (n=1, 0.5%), non-sustained ventricular tachycardia (n=1, 0.5%), and other arrhythmias or conduction disorders (n=5, 2.6%). At six months follow-up, three (2.3%) patients reported chest pain, with one requiring a percutaneous coronary intervention. Palpitations and dizziness were experienced by 88.9% and 83.3% of patients three months after admission but the prevalence of these symptoms decreased to 9.8% and 11.8% at six months. Conclusion With a systematic assessment, one in three patients hospitalized with COVID-19 have elevated troponin levels at admission. However, the overall incidence of MACE within six months is low. Palpitations and dizziness are commonly reported after discharge but these symptoms disappeared for most participants within six months.

Comparison of ultrasound-assisted thrombolysis and mechanical thrombectomy in patients with intermediate-high-risk pulmonary embolism

Abstract Background Pulmonary embolism (PE) can cause right heart failure and is associated with a high mortality. Early risk stratification is critical for individualized management. In patients with intermediate-high-risk PE, guidelines recommend to consider a percutaneous catheter-directed treatment (CDT). While different techniques are available, comparisons between treatments regarding right heart function and outcome are still scarce. Purpose To compare changes in right heart function as well as outcome in patients with intermediate-high-risk PE after catheter-directed treatment with ultrasound-assisted thrombolysis as compared to mechanical thrombectomy. Methods This is a retrospective, single-center study in intermediate-high-risk PE. According to the ESC guidelines, all patients had PESI class III-V, RV dysfunction and elevated cardiac troponin levels, but were hemodynamically stable. PE was confirmed by CT angiography. All patients underwent a catheter-directed treatment. One group received an ultrasound-assisted thrombolysis (USAT), while the other had a large-bore mechanical thrombectomy (MT). Right heart function (RV-Diameter, RV-/LV-Ratio, TAPSE) assessed via transthoracic echocardiography before and after CDT as well as interventional characteristics and postinterventional hospital stay were compared. Results From June 2022 to January 2024, 27 patients (43% female; aged 62 ± 14 years) were diagnosed with pulmonary embolism with intermediate-high-risk and underwent a catheter-directed treatment. Most patients (89%) had bilateral pulmonary embolisms. 15 patients (55%) received an ultrasound-assisted thrombolysis. 12 patients (45%) had a mechanical thrombectomy via a large-bore aspiration system. The mean procedural time was 41 ± 19 minutes for USAT and 106 ± 33 minutes for MT (p &amp;lt; 0.001). Right ventricular / left ventricular ratio reduction was -0.48 ± 0.25 in the USAT group (p &amp;lt; 0.001) and -0.34 ± 0.14 in the MT group (p &amp;lt; 0.001) (between group difference p = 0.2). TAPSE increased by 8 mm ± 4.4 mm in the USAT group (p &amp;lt; 0.001) and by 8.7mm ± 3.8 mm in the MT group (p &amp;lt; 0.001) (between group difference p = 0.7). The median postinterventional hospital stay was 7 days for the USAT patients and 7 days for the MT patients (between group difference p = 1). Conclusions In patients with intermediate-high-risk PE both ultrasound-assisted thrombolysis and large-bore mechanical thrombectomy lead to an improved right heart function with both interventions leading to a similar length of postprocedural hospital stay. Further randomized data have to discriminate differential impact of novel tools for the treatment of intermediate risk PE.

ELEVATED TROPONIN OF NON-CORONARY ETIOLOGY A REVIEW

Elevated troponin levels are traditionally associated with acute myocardial infarction (AMI) and are widely used as a specific marker for the diagnosis of ischemic myocardial injury. However, recent studies have shown that elevated troponin levels can occur in several non-coronary conditions, requiring a more careful diagnostic approach to avoid misinterpretations and inadequate management. This study aimed to perform a systematic review of the literature on the non-coronary causes of elevated troponin levels, seeking to identify the main associated clinical conditions and discuss their prognostic value in different contexts. To this end, a systematic review of articles published between 2014 and 2024 was conducted using the PubMed, Scopus and Web of Science databases. The results revealed that conditions such as sepsis, pulmonary embolism (PE), chronic renal failure (CRF), chronic obstructive pulmonary disease (COPD) and tachyarrhythmias are the main non-coronary causes of elevated troponin levels. It is concluded that elevated troponin levels of non-coronary etiology are an important marker of severity and poor prognosis in several systemic conditions. Troponin levels should be interpreted carefully, taking into account the clinical context and underlying conditions of each patient.

Cardiac Troponin Levels in Patients with Chronic Kidney Disease: "Markers of High Risk or Just Noise''?

Kidney disease is linked to the development of cardiovascular disorders, further increasing morbidity and mortality in this high-risk population. Thus, early detection of myocardial damage is imperative in order to prevent devastating cardiovascular complications within this patient group. Over the years, cardiac biomarkers have been identified and are now widely used in everyday clinical practice. More specifically, available data suggest that cardiac troponin and its regulatory subunits (TnT, TnI, and TnC) reflect the injury and necrosis of myocardial tissue. While cTnC is identical in cardiac and skeletal muscle, TnT and TnI constitute cardiac-specific forms of troponin, and, as such, they have been established by international societies as biomarkers of cardiac damage and diagnostic indicators for acute myocardial infarction. Elevations in the levels of both cardiac troponins (cTnT and cTnI) have been also reported in asymptomatic patients suffering from chronic kidney disease. Therefore, if abnormal, they often generate confusion among clinicians regarding the interpretation and clinical significance of their numerical values in emergency settings. The aim of this review is to explore the reasons behind elevated troponin levels in patients with chronic kidney disease and identify when these elevated levels of biomarkers indicate the need for urgent intervention, considering the high cardiovascular risk in this patient group.

The Hidden Heart: Exploring Cardiac Damage Post-Stroke: A Narrative Review

Stroke–heart syndrome (SHS), a critical yet underrecognized condition, encompasses a range of cardiac complications that arise following an ischemic stroke. This narrative review explores the pathophysiology, clinical manifestations, and implications of SHS, focusing on the complex interplay between the brain and the heart. Acute ischemic stroke (AIS) triggers autonomic dysfunction, leading to a surge in catecholamines and subsequent myocardial injury. Our review highlights the five cardinal manifestations of SHS: elevated cardiac troponin (cTn) levels, acute myocardial infarction, left ventricular dysfunction, arrhythmias, and sudden cardiac death. Despite the significant impact of these complications on patient outcomes, there is a notable absence of specific guidelines for their management. Through a comprehensive literature search, we synthesized findings from recent studies to elucidate the mechanisms underlying SHS and identified gaps in the current understanding. Our findings underscore the importance of early detection and multidisciplinary management of cardiac complications post-stroke. Future research should focus on establishing evidence-based protocols to improve clinical outcomes for stroke patients with SHS. Addressing this unmet need will enhance the care of stroke survivors and reduce mortality rates associated with cardiac complications.

GIANT CELL MYOCARDITIS: AUTOPSY CONFIRMATION OF A DIAGNOSTIC DILEMMA - A RARE CASE REPORT

Abstract Introduction/Objective Giant cell myocarditis (GCM) is a rare and rapidly progressive form of myocarditis, commonly leading to fulminant heart failure (HF), refractory ventricular arrhythmias or conduction system abnormalities and carrying a high mortality rate without prompt treatment. Due to its rarity, there is limited data on its prevalence, although studies show an incidence of 0.007–0.053% among autopsied cases. This entity primarily affects the heart, exhibiting a rapid clinical course and a poor prognosis necessitating immunosuppressive therapy and, in most instances, heart transplantation to improve survival rates. Methods/Case Report We present a case of a 62-year-old male with a prior history of complete heart block status post permanent pacemaker placement, presenting with acute decompensated heart failure. Laboratory investigations revealed elevated cardiac troponin levels (&amp;gt;35000) with echocardiography showing a reduced ejection fraction of 25% and an initial diagnosis of non-ST elevation myocardial infarction (NSTEMI) was made. Endomyocardial biopsy revealed GCM. Despite aggressive management, including immunosuppressive therapy and mechanical circulatory support, his condition deteriorated rapidly, leading to multiorgan failure and eventual death. The diagnosis was confirmed on autopsy. The diagnostic challenge of GCM lies in its clinical or pathologic overlap with other myocardial disorders such as cardiac sarcoidosis, viral myocarditis, and cardiac amyloidosis. Endomyocardial biopsy (EMB) remains the gold standard for diagnosing this entity which is characterized by a widespread inflammatory cell infiltrate with multinucleated giant cells in association with myocyte damage. The etiology of GCM remains unclear, but it is believed to be immune-mediated, possibly triggered by an autoimmune response. Results (if a Case Study enter NA) NA Conclusion Pathologists should give importance to consider GCM in the differential diagnosis of patients presenting with acute heart failure refractory to standard therapy. Early recognition and prompt initiation of immunosuppressive therapy are crucial for improving outcomes in patients with GCM. Awareness of this entity is crucial to make a timely diagnosis.

Demand Ischemia due to Gastrointestinal Bleeding Secondary to Ticagrelor

Ticagrelor, an orally consumed antiplatelet medication, acts as an antagonist on the P2Y12 receptor preventing adenosine diphosphate-induced platelet aggregation. Gastrointestinal bleeding triggered by ticagrelor can lead to demand ischemia, as the demand for oxygen by the tissues surpasses the oxygen supply available following acute blood loss. A male patient in his 80s had his antiplatelet medication switched from clopidogrel to ticagrelor following a cardiac stent. He presented to the emergency department a few months later due to black stools and fatigue. The patient had a critically elevated initial troponin level of 780 ng/L which increased to 892 ng/L two hours later. Hemoglobin was low at 8.5 g/dL. The patient suspended usage of ticagrelor and switched back to clopidogrel. Three weeks later, he had an endoscopy, which demonstrated no active bleeding sources.

Elevated Cardiac Troponin Levels as a Predictor of Increased Mortality Risk in Non-Cardiac Critically Ill Patients Admitted to a Medical Intensive Care Unit.

Background: Cardiac troponin I (TnI) is a specific marker of myocardial damage used in the diagnosis of acute coronary syndrome (ACS). TnI levels can also be elevated in patients without ACS, which is linked to a worse prognosis and mortality. We evaluated the clinical implications and prognostic significance of serum TnI levels in critically ill non-cardiac patients admitted to the intensive care unit (ICU) at a tertiary-level hospital. Materials and Methods: A three-year retrospective study including the years 2017-2020 was conducted to evaluate in-hospital mortality during ICU stay and mortality rates at 28 and 90 days, as well as one and two years after admission, in 557 patients admitted to the medical ICU for non-cardiac causes. Results: TnI levels were elevated in 206 (36.9%) patients. Patients with elevated TnI levels were significantly older and had higher rates of comorbidities, including chronic heart failure, coronary heart disease, and chronic kidney disease (p < 0.05 for all). Patients with elevated TnI levels required more invasive mechanical ventilation, vasopressor infusion, and dialysis in the ICU and experienced more shock within the first 72 h (p = 0.001 for all). High TnI levels were associated with higher Acute Physiological and Chronic Health Evaluation (APACHE) II (27.6 vs. 20.3, p = 0.001) and Sequential Organ Failure assessment (8.8 vs. 5.26, p = 0.001) scores. Elevated TnI levels were associated with higher mortality rates at 28 days (58.3% vs. 19.4%), 90 days (69.9% vs. 35.0%), one year (78.6% vs. 46.2%), and two years (82.5% vs. 55.6%) (p < 0.001 for all). Univariate logistic regression analysis revealed that high TnI levels were a strong independent predictor of mortality at all time points: 28 days (OR = 1.2, 95% CI: 1.108-1.3, p < 0.001), 90 days (OR = 1.207, 95% CI: 1.095-1.33, p = 0.001), one year (OR = 1.164, 95% CI: 1.059-1.28, p = 0.002), and two year (OR = 1.119, 95% CI: 1.026-1.22, p = 0.011). Multivariate analysis revealed that age, albumin level, APACHE II score, and requirements for dialysis and vasopressor use in the ICU were important predictors of mortality across all timeframes, but elevated TnI levels were not. Conclusions: Elevated TnI levels in critically ill non-cardiac patients are markers of disease severity. While elevated TnI levels were significant predictors of mortality in the univariate analysis, they lost significance in the multivariate model when adjusted for other factors. Patients with elevated TnI levels had higher mortality rates across all timeframes, from 28 days to two years.

Carbon monoxide-releasing molecule-3 ameliorates traumatic brain injury-induced cardiac dysfunctions via inhibition of pyroptosis and apoptosis.

Traumatic brain injury (TBI) frequently results in cardiac dysfunction and impacts the quality of survivors' life. It has been reported that carbon monoxide-releasing molecule-3 (CORM-3) administration immediately after hemorrhagic shock and resuscitation (HSR) ameliorated the HSR‑induced cardiac dysfunctions. The purpose of this study was to determine whether the application of CORM-3 on TBI exerted therapeutic effects against TBI-induced cardiac dysfunctions. Rats were randomly divided into four groups (n = 12) including Sham, TBI, TBI/CORM-3 and TBI/inactive CORM-3 (iCORM-3) groups. TBI was established by a weight-drop model. The rats in the TBI/CORM-3 group and TBI/iCORM-3 group were intravenously injected with CORM-3 and iCORM-3 (4mg/kg) following TBI, respectively. The time of death in the rats that did not survive within 24h was recorded. 24h post-trauma, the cardiac function, pathological change, serum troponin T and creatine kinase-MB (CK-MB) levels, pyroptosis, apoptosis and expressions of TUNEL staining, Gasdermin D (GSDMD), IL-1β, IL-18, ratio Bax/Bcl-2 were assessed by echocardiography, hematoxylin-eosin staining, chemiluminescence, immunofluorescence, and western blot assays, respectively. TBI-treated rats exhibited dramatically decreased ejection fraction and aggravated myocardial injury, increased mortality rate, elevated levels of serum troponin T and CK-MB, promoted cardiac pyroptosis and apoptosis, and upregulated expressions of cleaved caspase-3, GSDMD N-terminal fragments, IL-1β, IL-18, and ratio of Bax/Bcl-2, whereas CORM-3 partially reversed these changes. CORM-3 ameliorated TBI-induced cardiac injury and dysfunction. This mechanism may be responsible for the inhibition of pyroptosis and apoptosis in cardiomyocyte.