High Troponin Research Articles

Abstract 4142798: Differences in Clinical presentation in Spontaneous Coronary Artery Dissection vs. Type 1 Myocardial Infarction

Background: Spontaneous coronary artery dissection (SCAD) refers to the nontraumatic, non-iatrogenic, and nonatherosclerotic separation of the coronary artery wall leading to acute coronary syndrome. This condition predominantly affects women with minimal or no traditional cardiac risk factors. We aimed to determine the differences in clinical presentation between SCAD and Type 1 myocardial infarction (MI) in the Aurora Health Care community. Methods: A retrospective, matched cohort, multicenter community study was carried out on adult patients aged >18 years admitted to all Aurora Hospitals from January 2012 to December 2022. A total of 57 patients were diagnosed with SCAD during that period. SCAD group and Type 1 MI group were matched by age and gender at a 1:5 ratio using a propensity score-based matching. Outcomes between the SCAD and the Type 1 MI groups were compared using chi-squared tests or Fisher’s exact tests, and t-tests or nonparametric equivalents (Wilcoxon). Results: A higher percentage of Type 1 MI patients presented as NSTEMI compared to SCAD patients (70% vs. 59.6%, p=0.028). Although not statistically significant, SCAD patients had a higher occurrence of STEMI than Type 1 MI patients (42.1% vs. 32.6%, p=0.169). On admission, SCAD patients had a higher maximum troponin (12,000 vs. 3,550, p=0.012). Type 1 MI patients had higher HgbA1C (6 vs. 5.4, p=0.0008). Both patients had similar LDL levels, but Type 1 MI had lower HDL levels (44 vs. 48, p=0.024). ESR, CRP, and D-dimer levels showed no significant difference. LV ejection fraction was 53% in both groups, and the LV global longitudinal strain was similar. The Type 1 MI group exhibited higher grades of diastolic dysfunction (Grade 2 and Grade 3) and mitral valve disease. E/e was higher in Type 1 MI compared to SCAD (11.5 vs 8.8, p <0.0001). Type 2 SCAD was most prevalent at presentation, with the most frequently affected artery being LAD (47.4%) and the most frequently affected branch vessel being obtuse marginal (36.4%). The most common location was distal (59.6%), followed by mid (22.8%), with the diameter of the vessel involved mostly between 2-3.5 mm. Conclusion: This study observed that although more SCAD patients presented as STEMI with higher troponins, Type 1 MI patients were sicker overall. These differences in clinical findings can aid in diagnosis as the management of these two populations differ.

Impact of High Troponin Level on the Outcome in COVID-19 Positive Patients.

COVID-19 is a new disease caused by the recently discovered SARS-CoV-2 virus. The COVID-19 disease manifests in several ways and it may affect various systems, including the gastrointestinal, musculoskeletal, neurological, cardiovascular, and pulmonary systems. Individuals who have ad-additional health conditions, such as cardiovascular disorders, are particularly more likely to experience illness and death. This study aimed to assess the clinical effect of COVID-19 on myocardial injury, as measured by troponin elevation, and to determine if this effect has an impact on the outcome. This retrospective study was conducted at King Saud Medical City. The electronic medical records used to identify all admitted patients between March 23 and June 15, 2020, with a laboratory-confirmed positive COVID-19 diagnosis who had troponin I measured. During the study period, 768 COVID-19-positive patients were hospitalized. Of those, 187 patients were excluded because the troponin level was not measured. The remaining 581 (75.7%) had troponin I measured. Overall, 89 of 581 (15.3%) patients died. Of those, 67.8% were in the markedly elevated cTnI group, 8.5% were in the mildly elevated cTnI group, whereas no deaths were reported in the group with normal cTnI levels. Myocardial injury was observed in COVID-19-admitted patients at a significant level that warrants attention to this consequence. In older individuals with pre-existing cardiovascular comorbidities, the diagnosis of myocardial injury was linked to a higher likelihood of being admitted to the intensive care unit, experiencing a worse prognosis, and ultimately, death.

Differential diagnosis of acute coronary syndrome without ST-segment elevation in a middle-aged patient

Acute Coronary Syndrome (ACS) is an initial diagnosis, which is transformed into the diagnosis of “myocardial infarction”, “unstable angina” or other diagnosis during the diagnostic process. If a patient meets the criteria for myocardial infarction (according to the Fourth Universal Definition of Myocardial Infarction), in the presence of atherothrombosis in the infarct-related coronary artery, Type 1 myocardial infarction is diagnosed. In most of the remaining cases Type 2 myocardial infarction is diagnosed. Acute myocardial injury due to various conditions is separately classified. In the presented case, a 54-year-old patient with a history of arterial hypertension and diabetes mellitus, not adherent to treatment and suffering from obesity, a smoker, was hospitalized with typical new-onset angina pectoris and ischemic changes on the ECG, by ambulance, with the initial diagnosis of “ACS without ST-segment elevation”. The diagnosis changed several times during the examination: “ACS without ST-segment elevation”, “CAD: myocardial infarction without ST-segment elevation”, “Myocardial infarction with non-obstructive coronary arteries (MINOCA)”, “Severe calcified aortic stenosis. Anemia. Type 2 myocardial infarction”. The peculiarity of this case is the debut of high-gradient aortic stenosis in a middle-aged man with clinical manifestations of ACS and high blood troponin level. Causes of severe aortic stenosis manifestation as myocardial infarction with elevation of cardiac-specific troponin in the blood, despite intact coronary vessels, are discussed in this article. The differential diagnosis of myocardial injury is discussed, as the correct diagnostic judgment directly determines the patient’s management strategy.

A DIFFERENT VIEW OF MINOCA; A RARE CASE OF CORONARY CAMERAL FISTULA

Abstract Coronary cameral fistula (CCF) is defined as an abnormal connection between the coronary artery and the heart chambers. Although rare, most are asymptomatic, usually arising from the right coronary artery and terminating in the right ventricle or right atrium. Often detected incidentally, CCFs may present with symptoms of heart failure or rarely with anginal symptoms. Introduction A coronary cameral fistula is defined as an abnormal connection between the coronary artery and the heart chambers. CCFs are found in less than 1% of the population.[1] The most common coronary artery fistula is that arising from the right coronary artery and spilling into the right ventricle.[2] In particular, CCFs arising from all three epicardial coronary arteries are rare but can be clinically significant. These cases may present with acute coronary syndrome causing steal syndrome. Since there is usually no underlying obstructive lesion, these cases may be diagnosed as myocardial infarction without obstructive coronary arteries (MINOCA)[3] Case; A 51 years old male patient was admitted to the emergency room with a complaint of stabbing chest pain for the last one week. In his anamnesis, he described that the chest pain increased with exertion and radiated to the back. It was learned that he had no known disease and coronary history, was a 20 pack/year smoker, had no family history and was not taking any medication regularly. Vital signs in the emergency room revealed a blood pressure of 120/80 mmHg, pulse rate of 85 per minute and normal saturation. Electrocardiography (ECG) showed sinus rhythm V 1-6 with T negativity 85/min. (Figure 1) Echocardiography revealed no wall motion defect and no major valve pathology. Laboratory findings showed renal function tests within normal range, C-reactive protein within normal range, hemoglobulin level 17.6 gr/dl, HS Troponin-T level 12.9 ng/l (upper limit 14 ng/l). At 3 hours, the control HS Troponin-T level was 69.2 ng/l and the patient was hospitalized in the coronary intensive care unit with a prediagnosis of acute coronary syndrome. Coronary angiography was performed during follow-up. Angiography showed dilatation in the main coronary artery (LMCA), ectasia in the left anterior descending artery (LAD) and circumflex artery (CX), and diffuse tortuosity in the coronaries. CCF formed by the LAD, CX and right coronary artery (RCA) together and spilled into the left ventricle. Opaque filling was observed in the left ventricle. (Figure 2) Although the patient had a low body mass index, dilatation of the coronary arteries was thought to be the effect of steal syndrome caused by multiple fistulas. The patient was admitted to the coronary intensive care unit with medical follow-up. The patient's medical treatment was adjusted as acetylsalicylic acid (ASA) 100 mg pill 1*1, metaprolol 50 mg pill 1*1 and rosuvastatin 20 mg pill 1*1 due to an LDL cholesterol level of 149 mg/dl. In the patient who currently had no signs of heart failure, medical treatment was decided primarily in terms of CCF. The patient was discharged with the recommendation of outpatient follow-up. Discussion and Conclusion; CCFs are rare coronary anomalies.[1] When we look at the etiology, the most common cause of CCFs is abnormal embryogenesis.[4] While the diagnosis can be made at any age, the diagnosis is usually made in early childhood when a heart murmur occurs in an asymptomatic child or in a child with symptoms of heart failure. However, cases of CCF diagnosed at an advanced age with anginal complaints and signs of acute heart failure are seen in the literature. [5]Treatment depends on the anatomical features of the fistula and, of course, the patient's symptoms. While small fistulas may close spontaneously with age, large fistulas may require closure.It may cause anginal symptoms by causing heart failure symptoms and steal syndrome. [6]When we look at the literature, we can see that patients with CCF also present with acute coronary syndrome. [2, 4, 5,] As in the case reported by Alsancak Y et al., CCFs originating from all three coronary arteries cause steal syndrome and are often diagnosed with a prediagnosis of acute coronary syndrome.[7] The absence of an occlusive lesion after angiography in these patients with high troponin levels suggests atherosclerosis at the microvascular level and the diagnosis of MINOCA. [3]Angiography performed with suspicion of stenosis in the coronary arteries and finding a CHF instead of a stenosis may be considered lucky in these patients. The size of the fistula and the possibility that it may lead to heart failure in the follow-up will be the other side of the unlucky coin.

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.

Management of Acute Coronary Syndrome in Elderly Patients: A Narrative Review through Decisional Crossroads.

Diagnosis and treatment of acute coronary syndrome (ACS) pose particular challenges in elderly patients. When high troponin levels are detected, the distinction between non-ischemic myocardial injury (NIMI), type 1, and type 2 myocardial infarction (MI) is the necessary first step to guide further care. However, the assessment of signs of ischemia is hindered in older patients, and no simple clinical or laboratory tool proved useful in this discrimination task. Current evidence suggests a benefit of an invasive vs. conservative approach in terms of recurrence of MI, with no significant impact on mortality. In patients with multivessel disease in which the culprit lesion has been treated, a physiology-guided complete percutaneous revascularization significantly reduced major events. The management of ACS in elderly patients is an example of the actual need for a multimodal, thorough clinical approach, coupled with shared decision-making, in order to ensure the best treatment and avoid futility. Such a need will likely grow throughout the next decades, with the aging of the world population. In this narrative review, we address pivotal yet common questions arising in clinical practice while caring for elderly patients with ACS.

Comparison of efficiency of PFA catheter designs by computer modeling.

Various catheter designs are appearing for Pulsed Field Ablation (PFA). It is unclear if they differ in terms of safety and efficiency. PFA studies have reported hemolysis, kidney injury, high troponin, among other side effects. Using a CT-derived computer model, we compared catheter designs using two metrics: (1) efficiency: power delivered to an atrial wall target, expressed as a percent of total generator power; and (2) safety: electric current to achieve 90% transmurality (since more energy causes more collateral effects), as well as the corresponding electrode current density (ECD), a heat and bubble metric. The following catheter designs were compared: penta-spline basket, Nitinol spheres (focal 9 mm and large 1-shot), circular, balloon, and flex-circuit. Target was a 6 × 47 mm circumferential segment of atrial wall at LPV antrum. Transmurality was defined as percent of target having >600 volts per centimeter (V/cm) electric field needed for electroporation. Efficiency was 0.9, 1.4, 2.7, 5.9, 10, and 12% for the large 1-shot and 9 mm Nitinol spheres, penta-spline, circular, flex spline, and balloon catheters, respectively. Regarding safety, currents for 90% transmurality were 70, 39,36,12.5, 5.3, and 4 Amps for the same respective catheters, with less being safer. ECD was 124, 25, 74, 83, 41, and 31 A/cm2, respectively. Computer models demonstrated a remarkable range in efficiency among catheters studied. Those having less atrial blood exposure had the highest efficiencies, with factors of up to 13X more efficiency compared to exposed ones. Higher efficiency designs have less collateral current and are safer. Confirmatory in-vivo studies are required.

A-315 Cardiac Troponin Concentrations in Pediatric Patients Infected with Respiratory Syncytial Virus

Abstract Background Respiratory syncytial virus (RSV) is associated with considerable morbidity and mortality in pediatric patients. Cardiac troponin I (TnI) has been shown to increase in patients with acute respiratory illness, including COVID-19. The impact of RSV infection on circulating TnI has been formally demonstrated in the literature. The goal of this study was to assess the relationship between TnI and respiratory syncytial virus (RSV) in pediatric patients. Methods A prospective study was conducted at St. Louis Children’s Hospital from October 2023 to February 2024. Patients older than 6 months who presented to the ED and had a CBC ordered within 6 hours of testing positive for RSV on the Biofire® FilmArray® Respiratory Panel were enrolled. Patients with Rhinovirus, Enterovirus, Streptococcus pneumoniae, or Adenovirus infections were included as controls. Remnant EDTA specimens were tested on an Abbott ARCHITECT i2000 for high sensitivity TnI (hs-TnI) with a limit of detection of 1.4 ng/L and a limit of quantitation of 3.5 ng/L. 99% upper reference limits from the CALIPER database on the Abbott of &amp;lt;7 ng/L were used as a threshold for positive results. The electronic medical record (EPIC) was assessed for demographic information and outcomes including length of stay (LOS), intensive care unit (ICU) length of stay, requirement of supplemental oxygen, white blood cell count (WBC), and creatinine. Results A total of 103 patients had RSV and 35 had other respiratory infections (ORI). The average age for the RSV positive group was 2.3 and for the ORI group was 2.4. Males made up 61% of the RSV+ group and 51% of the ORIs. 93 patients in the RSV group were admitted. The median TnI for RSV patients was 1.4 (IQR, 1.2-2.9) and for ORIs was 1.4 (IQR, 1.4-6.8). TnI was measurable in 58% of those with RSV and 54% in ORIs. We next assessed the correlation between hospital LOS and TnI in RSV+ patients, with a Pearson r of 0.42 (95% CI= 0.23-0.58). There was no correlation between WBC and LOS (r=-0.04, 95% CI=-0.25-0.17). There was also no correlation between TnI and WBCs or creatinine. Of admitted patients, 44 (47%) in the RSV group were in the ICU compared to 18 (51.4%) in those with ORIs. RSV+ patients that required ICU treatment had comparable TnI (1.4, IQR, 0.9-3.5) to those that didn’t require ICU stay (1.4, IQR, 0.75-1.5). There was no correlation between ICU LOS and TnI in RSV+ patients (r=-0.08, 95% CI=-0.39-0.24). There was a significant difference in mean TnI concentrations in RSV+ patients that required supplemental oxygen (8.7, 95% CI: 0-19) versus those that did not (1.7, 95% CI: 1.1-2.4). Conclusions There was no difference in TnI in patients hospitalized for RSV relative to ORIs. While TnI concentration was associated with LOS, there were minimally other associations between TnI and outcomes in patients hospitalized with RSV. While TnI elevations are associated with acute respiratory infections in adults, the impact on pediatric patients is not as clear. Future investigation is needed to understand how severe respiratory infections impact pediatric cardiac function.

Analytical verification of the Atellica VTLi point of care high sensitivity troponin I assay.

The Siemens Point-of-Care Testing (POC) Atellica® VTLi high-sensitivity troponin I (hsTnI) device has been previously validated. Verification independently provides evidence that an analytical procedure fulfils concordance with laboratory assays, imprecision, and hemolysis interference requirements. Five whole blood samples spanning the measuring interval were analysed 20 times in succession. Hemolysis interference was assessed at three troponin concentrations by spiking five hemolysate concentrations to plasma to achieve free hemoglobin concentrations 35-1,000 mg/dL. Concordance between whole blood (VTLi) and plasma on laboratory analysers (Beckman, Roche, Siemens) was assessed by Pearson correlation and kappa statistics at the (LOQ) and upper reference limit (URL). This was repeated for frozen plasma samples. Coefficients of variation for whole blood were <10 % for whole blood troponin concentrations of 9.2 and 15.9 ng/L, thus below the URL. Hemolysis positively interfered; at 250 mg/dL affecting the low troponin sample (+3 ng/L; +60 %) and high troponin sample (+37 ng/L; +24 %). Correlation coefficients were 0.98, 0.90 and 0.97 between VTLi and Beckman, Roche and Siemens assays respectively. Corresponding kappa statistics were 0.80, 0.73 and 0.84 at the LOQ and 0.70, 0.44 and 0.67 at the URL. Concordances between VTLi and laboratory assays were at least non-inferior to those between laboratory assays. Imprecision met manufacturer claims and was consistent with a high sensitivity assay. There is potential for hemolysis interference, highlighting the need for quality samples. The results support performance characteristics previously reported in validation studies, and the device offers acceptable performance for use within intended medical settings.

Diagnostic value of a point-of-care cardiac troponin-I assay (i-STAT®) for clinical application in canine and feline cardiology

Introduction/ObjectivesThis study was performed to evaluate the diagnostic value and net benefits, including cost-effectiveness, of a point-of-care analyser (i-STAT®) for measurement of cardiac troponin I (cTnI) in dogs and cats. Animals, Materials and Methods120 dogs and 120 cats presented with signs of cardiac disease and suspected myocardial insult on cardiac assessment. This was a validation study expressed as agreement between the i-STAT® analyser and two common commercial reference methods (IMMULITE® 2000 and ACCESS® hsTnI). ResultsThe comparison between methods showed a negative bias between the i–STAT® and the two commercial cTnI assays. The bias was more evident when the i-STAT® values were compared to the traditional cTnI assay (IMMULITE® 2000), with a calculated difference of −1.14 ng/mL (dogs) and −0.96 ng/mL (cats). However, the bias was distinctly lower when the i-STAT® measurements were compared to the high-sensitivity cTnI assay (ACCESS®), namely −0.3 ng/mL in dogs and −0.17 in cats. DiscussionThe i-STAT® method can reliably detect normal, low and elevated cTnI values, which is fundamental to differentiate pets with and without myocardial damage and, with the rapid availability of results, this confirms the clinical utility of the i-STAT® method. ConclusionscTnI concentrations measured with the i-STAT® have good comparability with those obtained with both commercial assays for low and elevated cTnI values. However, results should be cautiously interpreted for high troponin values, especially if a strict cut-off value is adopted for diagnostic or prognostic purposes in critical clinical conditions, such as myocarditis or acute myocardial ischaemia.

Exercise-Induced Cardiac Troponin I Elevation Is Associated With Regional Alterations in Left Ventricular Strain in High-Troponin Responders.

The implications of exercise-induced cardiac troponin elevation in healthy individuals are unclear. This study aimed to determine if individuals with a high exercise-induced cardiac troponin I (cTnI) response have alterations in myocardial function following high-intensity endurance exercise compared with normal-cTnI responders. Study individuals were recruited from previous participants in a 91-km mountain bike cycling race (the North Sea Race) and were classified as high- (n=34) or normal-cTnI responders (n=25) based on maximal cTnI values after the recruitment race. The present study exposed all participants to 2 prolonged high-intensity exercises: a combined lactate threshold and cardiopulmonary exercise test and repeated participation in the North Sea Race. Echocardiography was performed before, immediately after, and 24 hours following exercise. All study individuals (n=59) had normal coronary arteries, and were aged 51±10 years; 46 (74%) were men. There were no differences in baseline characteristics between the high- and normal-cTnI responders. Maximal cTnI levels 3 hours after exercise were significantly higher in the high- compared with normal-cTnI group (P<0.001-0.027). Following exercise, there were no differences in global ventricular function between the 2 groups. In contrast, high-cTnI responders had significantly lower regional strain in the anteroseptal segments following exercise, with more profound changes after the race. High-cTnI responders had lower anteroseptal segmental strain shortly after exercise than normal-cTnI responders. However, there were no permanent alterations in myocardial strain, indicating no short- or long-term adverse consequences of these exercise-induced alterations in myocardial function. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02166216.

Follow Up of Cardiovascular Affection in Covid-19 Pediatrics Survivors

Abstract Background Multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 is a rare complication of (SARS-CoV-2) infection. Presenting (4–6) weeks after infection as high fever, organ dysfunction, and strongly elevated markers of inflammation which is mostly due to post infection immune reaction. Aim of the Work to evaluate cardiac outcomes 6 months after initial presentation with MIS-C associated with cardiac affection. Patients and Methods This was a retrospective cohort study on 28 patients (19 boys &amp; 9 girls) who were diagnosed as multi system inflammatory syndrome in children (MIS-C) related to COVID19 six months ago at children`s hospital, Ain shams university from January 2021 to October 2021. All patients were subjected to the following: (demographic data, clinical signs and symptoms, laboratory investigations) in the acute phase (obtained from patient’s medical records) and at follow up after 6- months. Results in our study all patients fulfilled criteria of MIS-C presented with fever, shock or cardiac dysfunction and gastrointestinal symptoms in addition to conjunctivitis and skin rash. Our patients were presented with hypotension with mean systolic blood pressure (87) mmHg &amp; mean diastolic blood pressure (48) mmHg. Regarding symptoms: vomiting was seen in (60.7%), diarrhea in (32.1%), conjunctivitis in (82.1%) and cardiovascular abnormalities were seen in (100%) in the form of (myocardial dysfunction in (50%), coronary dilatation in (28.8%), valvular regurgitation in (100%) and pericardial effusion in (7.2%)). After 6 months there was significant improvement regarding vital signs. Regarding laboratory findings: at time of presentation most of the patients had high CRP, high troponin, and high CK-MB. On follow up after 6 months, all patients had normal values. Conclusion Our follow up study suggests that functional recovery and coronary outcomes are good in multisystem inflammatory syndrome in children.

Prevalence of influenza and other acute respiratory illnesses in patients with acute myocardial infarction in Bangladesh: A cross-sectional study.

Several studies imply that influenza and other respiratory illnesses could lead to acute myocardial infarction (AMI), but data from low-income countries are scarce. We investigated the prevalence of recent respiratory illnesses and confirmed influenza in AMI patients, while also exploring their relationship with infarction severity as defined by ST-elevation MI (STEMI) or high troponin levels. This cross-sectional study, held at a Dhaka tertiary hospital from May 2017 to October 2018, involved AMI inpatients. The study examined self-reported clinical respiratory illnesses (CRI) in the week before AMI onset and confirmed influenza using baseline real-time reverse transcription polymerase chain reaction (qRT-PCR). Of 744 patients, 11.3% reported a recent CRI, most prominently during the 2017 influenza season (35.7%). qRT-PCR testing found evidence of influenza in 1.5% of 546 patients, with all positives among STEMI cases. Frequencies of CRI were higher in patients with STEMI and in those with high troponin levels, although these relationships were not statistically significant after adjusting for other variables. The risk of STEMI was significantly greater during influenza seasons in the unadjusted analysis (relative risk: 1.09, 95% confidence interval [CI]: 1.02-1.18), however, this relationship was not significant in the adjusted analysis (adjusted relative risk: 1.03, 95% CI: 0.91-1.16). In Bangladesh, many AMI patients had a recent respiratory illness history, with some showing evidence of influenza. However, these illnesses showed no significant relationship to AMI severity. Further research is needed to understand these relationships better and to investigate the potential benefits of infection control measures and influenza vaccinations in reducing AMI incidence.

Sex Difference in Characteristics and Predictors of In-Hospital Mortality among Patients with COVID-19

Introduction: With a surge in the prevalence of coronavirus disease-2019 (COVID-19) in Beijing starting in October 2022, hospitalisation rates increased markedly. This study aimed to evaluate factors associated with in-hospital mortality in patients with COVID-19. Methods: Using data from hospitalised patients, sex-based differences in clinical characteristics, in-hospital management, and in-hospital mortality among patients diagnosed with COVID-19 were evaluated. Predictive factors associated with mortality in 1,091 patients admitted to the Beijing Anzhen Hospital (Beijing, China) for COVID-19 between October 2022 and January 2023 were also evaluated. Results: Data from 1,091 patients hospitalised with COVID-19 were included in the analysis. In-hospital mortality rates for male and female patients were 14.9% and 10.4%, respectively. Multifactorial logistic analysis indicated that lymphocyte percentage (LYM%) (odds ratio [OR] 0.863, 95% confidence interval [CI] 0.805–0.925; p < 0.001), uric acid (OR 1.004, 95% CI: 1.002–1.006; p = 0.001), and high-sensitivity C-reactive protein (OR 1.094, 95% CI: 1.012–1.183; p = 0.024) levels were independently associated with COVID-19-related in-hospital mortality. Among female patients, multifactorial analysis revealed that LYM% (OR 0.856, 95% CI: 0.796–0.920; p < 0.001), older age (OR 1.061, 95% CI: 1.020–1.103; p = 0.003), obesity (OR 2.590, 95% CI: 1.131–5.931; p = 0.024), and a high high-sensitivity troponin I level (OR 2.602, 95% CI: 1.157–5.853; p = 0.021) were risk factors for in-hospital mortality. Receiver operating characteristic (ROC) curve analysis, including area under the ROC curve, showed that the efficacy of LYM% in predicting in-hospital death was 0.800 (sensitivity, 63.2%; specificity, 83.2%) in male patients and 0.815 (sensitivity, 87.5%; specificity, 64.4%) in female patients. Conclusion: LYM% is a consistent predictor of in-hospital mortality for both sexes. Older age and markers of systemic inflammation, myocardial injury, and metabolic dysregulation are also associated with a high mortality risk. These findings may help identify patients who require closer monitoring and tailored interventions to improve outcomes.

TAKOTSUBO SYNDROME AND SMALL BOWEL OBSTRUCTION: WHEN THE HEART–GUT AXIS GOES HAYWIRE

Abstract Case Report A 66 years old woman was admitted to our emergency department for the onset of intense epigastric pain, nausea and asthenia after breakfast. She had a history of hypertension, dyslipidemia, COPD and deep venous thrombosis with MTHFR gene mutation. Moreover, she had a positive family history for coronary artery disease (CAD). On arrival, she was apyretic, hemodynamically stable, complaining chest and persisting epigastric pain. A mild and diffuse abdominal tenderness was noted without peritoneal signs. The ECG showed sinus tachycardia, ST elevation (STE) in leads D1, aVL, V2 and V3 and ST depression in leads D3, aVR and V1. Blood test revealed a marked increase of PCR with leukocytosis and elevation of Hs–cTnI (840 ng/L) while serum electrolytes were normal. Bed–side echocardiography revealed apical and mid–ventricular akinesia with a severe reduction of left ventricular ejection fraction (LVEF). InterTAK score was 62 (62,6% probability of Takotsubo syndrome – TTS). An urgent coronary angiography (CA) revealed non– obstructive CAD, while ventriculography showed a typical apical ballooning and hyperkinetic base of the LV suggestive of TTS. Subsequently, the CT abdomen showed extra–luminal free fluid and a dilated proximal small bowel (SB) with air–fluid levels and a bubbly pattern of gas in the wall. These radiological findings were consistent with a mechanical SB obstruction, complicated by mesenteric venous thrombosis and intestinal pneumatosis. Exploratory laparotomy revealed SB necrosis as consequence of bridle–mediated obstruction and therefore an ileum resection was performed. The patient clinically improved post–operatively with a complete recovery of the LVEF. Discussion We described a rare presentation of SB obstruction which induced a TTS in a setting of severe psychophysical stress. The management of this emergency situation in which cardiac injury and acute abdomen occurred simultaneously can be challenging. The consulting cardiologist needs to quickly decide whether to prioritize the heart with urgent CA or the gastroenteric condition with surgery. Despite the likelihood of TTS can be high (even calculating InterTak score), new STE and positive troponins can’t be disregarded especially in patients with significant risk factors as seen in our case. Therefore, the strong evidence of a possible acute coronary syndrome may trump a life–saving treatment for SB obstruction.

Early unfractionated heparin treatment in patients with STEMI – trial design and rationale

The early unfractionated heparin (UFH) treatment in patients with ST-elevation myocardial infarction (STEMI) is a single-center, open-label, randomized controlled trial. The study population are patients with STEMI that undergo primary percutaneous coronary intervention (PPCI). The trial was designed to investigate whether early administration of unfractionated heparin immediately after diagnosis of STEMI is beneficial in terms of patency of infarct-related coronary artery (IRA) when compared to established UFH administration at the time of coronary intervention. The patients will be randomized in 1:1 fashion in one of the two groups. The primary efficacy endpoint of the study is Thrombolysis in myocardial infarction (TIMI) flow grades 2 and 3 on diagnostic coronary angiography. Secondary outcome measures are: TIMI flow after PPCI, progression to cardiogenic shock, 30-day mortality, ST-segment resolution, highest Troponin I and Troponin I values at 24 hours. The safety outcome is bleeding complications. The study of early heparin administration in patients with STEMI will address whether pretreatment with UFH can increase the rate of spontaneous reperfusion of infarct-related coronary artery.

Saddle Pulmonary Embolus Treated With Bilateral Emergent Aspiration Pulmonary Thrombectomy

A 77 year old man with recurrent lower extremity thrombosis presented with acute onset shortness of breath and new onset hypoxemia three days after prostatectomy for adenocarcinoma of the prostate. He had been off anticoagulation during the perioperative period. In addition to his new diagnosis of prostate cancer he also had a remote history of treated non-invasive melanoma. Based on this presentation he was at high risk of developing thromboembolic disease. Computed tomography angiogram (CTA) of his chest confirmed a large saddle pulmonary embolus, echocardiogram was positive for new right ventricular wall motion dyskinesis and lower extremity ultrasound revealed bilateral acute and chronic deep vein thrombosis. Given his high bleeding risk, hypoxia and elevated troponin I, he underwent emergent successful aspiration pulmonary thrombectomy. This case is of interest to hospitalists and intesivists as it provides an overview of the current invasive management of pulmonary embolus in the acute setting when systemic anticoagulation is contraindicated. Emergent Aspiration Pulmonary Thrombectomy can restore pulmonary artery flow and cardiopulmonary hemodynamics. A collaborative team based approach that involves the emergency department, intensive care unit, interventional teams and hospitalists is favored.

The CRP troponin test (CTT) stratifies mortality risk in patients with non-ST elevation myocardial infarction (NSTEMI).

The C-reactive protein (CRP)-troponin-test (CTT) comprises simultaneous serial measurements of CRP and cardiac troponin and might reflect the systemic inflammatory response in patients with acute coronary syndrome. We sought to test its ability to stratify the short- and long-term mortality risk in patients with non-ST elevation myocardial infarction (NSTEMI). We examined 1,675 patients diagnosed with NSTEMI on discharge who had at least two successive measurements of combined CRP and cardiac troponin within 48 h of admission. A tree classifier model determined which measurements and cutoffs could be used to best predict mortality during a median follow-up of 3 years [IQR 1.8-4.3]. Patients with high CRP levels ( > 90th percentile, >54 mg/L) had a higher 30-day mortality rate regardless of their troponin test findings (16.7% vs. 2.9%, p < 0.01). However, among patients with "normal" CRP levels ( < 54 mg/L), those who had high troponin levels ( > 80th percentile, 4,918 ng/L) had a higher 30-day mortality rate than patients with normal CRP and troponin concentrations (7% vs. 2%, p < 0.01). The CTT test result was an independent predictor for overall mortality even after adjusting for age, sex, and comorbidities (HR = 2.28 [95% CI 1.56-3.37], p < 0.01 for patients with high troponin and high CRP levels). Early serial CTT results may stratify mortality risk in patients with NSTEMI, especially those with "normal" CRP levels. The CTT could potentially assess the impact of inflammation during myocardial necrosis on the outcomes of patients with NSTEMI and identify patients who could benefit from novel anti-inflammatory therapies.

An Evaluation of the Appropriateness of Prescribing Ultrasensitive Cardiac Troponin I in the Emergency Department of the Mohammed V Military Training Hospital in Rabat

In emergency medicine, Troponin Ic is a useful diagnostic and prognostic biomarker in the management of ischemic cardiac pathologies. However, its prescription often exceeds international recommendations. The aim of this study is to evaluate practices concerning the prescription of Troponin assays in the emergency department of the Mohammed V Military Training Hospital in Rabat. This is a prospective study. Was included in this study, every patient admitted to the emergency department of the Mohammed V Military Training Hospital in Rabat and having at least one troponin assay during the period from December 25, 2020 to January 12, 2021. The assay was performed using the "ARCHITECT STAT Highly sensitive troponin-I" method. 135 patients for whom have prescribed a Troponin assay during the period of study. A total of 219 assays were performed. The mean age was 64 years, with a predominance of males. The main reasons for admission were chest pain (29.6%), dyspnea (26.6%), neurological disorders (16.3%) and respiratory distress (10.3%). A high Troponin Ic value during the first determination was observed in almost 37% of cases. In 63% of cases, the value was negative. 53.3% of prescriptions were considered as irrelevant according to pre-established criteria. A repeated Troponin Ic assays were performed in 31% (n=127) of cases. They were deemed relevant in 25% of cases. In 6% of patients, the appropriateness of repeat assays was not demonstrated. Compliance with good prescribing practices for Troponin significantly reduces the number of unjustified samples, with a real economic impact.

Correlation of osteopontin hormone with TIMI score and cardiac markers in patients with acute coronary syndrome presenting with chest pain.

Rapid evaluation of patients with acute coronary syndrome (ACS) attending the emergency service under emergency room conditions and using appropriate risk scoring would improve treatment success. Calcium levels accumulate in the tissue in people with coronary artery disease and this has been found to correlate with osteopontin levels in some studies. It is predicted that osteopontin level could be used as a biomarker to detect coronary artery calcification. In this study, we aimed to evaluate the use of osteopontin levels in the differential diagnosis of ACS in conjunction with cardiac troponin I (cTnI) levels, and HEART (history, ECG, age, risk factors, troponin) and thrombolysis in myocardial infarction (TIMI) scores in patients with chest pain who attended the emergency service. This study was conducted as a prospective observational clinical study in the Department of Emergency Medicine, Faculty of Medicine, Ataturk University. There was a total of 90 participants, including 60 patients and 30 healthy individuals in the control group. All participants' demographic information, electrocardiography (ECG) findings, cTnI level, TIMI and HEART score, and osteopontin level were evaluated. The patients' mean age was 51.61 ± 17.56 years and 63.3% (n = 57) were male. The body mass index (BMI) of the patients was 25.63 ± 4.67 kg/m2. Patients with chest pain [CP(+)] and high cardiac troponin I levels [cTnl(+)] were found to be older and to have higher HEART and TIMI scores than individuals with CP(+) and normal cardiac troponin I levels [cTnl(-)] and the healthy control group (p < 0.001). While the HEART score was zero in 22 (24.4%) of the patients, the TIMI score was zero in 42 (46.7%). In terms of gender distribution, vital signs and serum osteopontin levels, there was no significant difference between the patient groups (p > 0.05). It was found that patients with CP(+) and cTnl(+) had a higher rate of ECG abnormalities than the CP(+) and cTnl (-) group and the healthy control group (p = 0.13 and p < 0.001, respectively). In 65 (72.2%) of the patients, the ECG results were normal. ST-segment elevation was detected in 13 (14.4%) patients. In our study, cTnl levels were found to be positively correlated with age (r = 0.624), BMI (r = 0.291), HEART score (r = 0.794) and TIMI score (r = 0.805) (p = 0.001, p = 0.005, p = 0.001 and p = 0.001, respectively). In our study, we discovered that osteopontin levels could not reach the differential diagnostic level for ST-elevation myocardial infarction or non-ST-elevation myocardial infarction. No statistically significant difference was found in osteopontin levels between the groups (p > 0.05). While very positive results were obtained in this approach to the ACS diagnosis using HEART and TIMI scores in patients with chest pain who attended the emergency service and were diagnosed with ACS, no significant results could be obtained regarding the use of osteopontin levels as a biomarker. More comprehensive, multicentre studies involving a large number of appropriately selected patients are considered to be necessary.