Non-cardiac Pathologies Research Articles

Computed tomography for the detection of myocardial hypoperfusion in acute myocardial infarction and the associated CT-to-catheter time

Emergency computed tomography (CT) often does not allow for comprehensive coronary artery assessment. However, CT may reveal pathological myocardial hypoperfusion suggestive of acute myocardial infarction (AMI), especially in patients presenting with a different diagnostic hypothesis. CT hypoperfusion is known to be associated with myocardial infarction, however the diagnostic value of CT hypoperfusion for the detection of AMI is still not well evaluated. This was a single-centre retrospective study including patients who underwent invasive coronary angiography (ICA) due to suspected AMI based on incidental perfusion defects upon emergency CT imaging between 2018 and 2023. A total of 22 patients (mean age 66.3 ± 10.8 years, 11 female) were included in this analysis. The diagnosis of AMI was established in all cases leading to ICA. Culprit coronary artery lesions with an indication of percutaneous coronary intervention were detected in all patients who underwent ICA. Spearmann correlation for hypoperfused segments on CT imaging and the corresponding vascular territory upon ICA was significantly substantial (ρ = 0.73, p = < 0.001). The higher the number of affected myocardial segments, the faster ICA was initiated. Mean time between the suspicion of AMI on CT imaging and ICA was 196 (29–4044) minutes. Myocardial hypoperfusion on emergency CT imaging should be considered as AMI until proven otherwise, independent of the clinical scenario leading to performance of CT imaging and whether imaging was performed for the exclusion of non-cardiac pathologies. Early initiation of further diagnostic workup may potentially avoid delays to invasive treatment and reduce the CT-to-catheter-time. Our study explicitly underlines that myocardial hypoperfusion upon contrast enhanced CT imaging needs to be considered as sign of acute myocardial infarction and indicates targeted clinical workup to rule out this diagnosis and to shorten the timeframe from imaging diagnosis to interventional treatment.

Multiple beta cell-independent mechanisms drive hypoglycemia in Timothy syndrome

The canonical G406R mutation that increases Ca2+ influx through the CACNA1C-encoded CaV1.2 Ca2+ channel underlies the multisystem disorder Timothy syndrome (TS), characterized by life-threatening arrhythmias. Severe episodic hypoglycemia is among the poorly characterized non-cardiac TS pathologies. While hypothesized from increased Ca2+ influx in pancreatic beta cells and consequent hyperinsulinism, this hypoglycemia mechanism is undemonstrated because of limited clinical data and lack of animal models. We generated a CaV1.2 G406R knockin mouse model that recapitulates key TS features, including hypoglycemia. Unexpectedly, these mice do not show hyperactive beta cells or hyperinsulinism in the setting of normal intrinsic beta cell function, suggesting dysregulated glucose homeostasis. Patient data confirm the absence of hyperinsulinism. We discover multiple alternative contributors, including perturbed counterregulatory hormone responses with defects in glucagon secretion and abnormal hypothalamic control of glucose homeostasis. These data provide new insights into contributions of CaV1.2 channels and reveal integrated consequences of the mutant channels driving life-threatening events in TS.

Clinical profile of patients with non-ST segment elevation acute coronary syndrome: experience of a regional vascular center

Aim. To identify the main clinical and paraclinical characteristics of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) of various risk groups for adverse ischemic events, as well as to describe the in-hospital outcomes of the disease.Material and methods. The retrospective analysis included 600 patients who were hospitalized at the regional vascular center from January 2019 to January 2021 with a diagnosis of NSTE-ACS.Results. Patients were stratified into very high — 208 (34,7%), high — 196 (32,7%), moderate — 108 (18%) and low — 88 (14,6%) risk groups. In the highand very high-risk groups, patients were older, characterized by a significant comorbidity index, increased bleeding risk, decreased left ventricular ejection fraction and glomerular filtration rate in comparison with patients of other groups (p&lt;0,05). Very highrisk patients were characterized by associated clinical conditions, predominantly infectious diseases and decompensated heart failure. Unfavorable outcome of hospitalization was observed in 44 (7,3%) patients. The death probability in the very high-risk group (33; 15,9%) was higher than in the low-risk group (2; 2,3%) (Odds ratio 8,1 (95% confidence interval: 1,9-34,6); p=0,01). Regardless of the risk degree, there was a high (53,5%) likelihood of completing invasive coronary angiography as a diagnostic procedure. Most of the observed complications as a result of invasive coronary angiography were characteristic of the high(18,3%) and very high-risk groups (21,5%).Conclusion. NSTE-ACS patients at very high/high risk of adverse ischemic events represent a heterogeneous group with cardiac and noncardiac pathologies with high comorbidity and bleeding risks, decreased left ventricular ejection fraction and glomerular filtration rate, and associated clinical conditions.

Beyond Cardiology: A Rare Encounter With Small Bowel Obstruction Disguised as Inferior Wall ST-Elevation Myocardial Infarction

ABSTRACT ST segment elevations (STEs) on an electrocardiogram (EKG) gravitate immediate attention to the heart. However, these EKG changes can sometimes be the result of noncardiac pathologies. Here, we present an interesting case of small bowel obstruction (SBO) masquerading as an inferior wall myocardial infarction. A 77-year-old woman with a history of aortic stenosis status postsurgical aortic valve replacement presented with chest pain. Workup revealed elevated high-sensitivity troponins and STE in the inferior leads. She subsequently underwent a left heart catheterization, which showed no critical plaques or stenosis. Persistent abdominal pain prompted further evaluation with a computed tomography scan of the abdomen, which demonstrated evidence of SBO. Conservative treatment with bowel decompression resulted in symptom improvement and complete resolution of the STEs on a follow-up EKG. This case underscores the importance of considering noncardiac etiologies, such as SBO, in the differential diagnosis of STE on EKG for accurate diagnosis and management.

Investigation into the effect of hyperbaric hyperoxia on serum cardiac Troponin T levels as a biomarker of cardiac injury.

There is clinical equipoise as to whether hyperoxia is injurious to the myocardium, both in the setting of acute ischaemic insults and on the stable myocardium. This study examined the effect of extreme hyperoxia - in the form of hyperbaric oxygen treatment - on the myocardium through measurement of high-sensitivity cardiac troponin. Forty-eight individuals were enrolled to undergo a series of 30 exposures to hyperbaric oxygen for treatment of non-cardiac pathologies. High-sensitivity troponin T was measured before and after each session. There was no clinically significant difference in troponin measurements following acute or recurrent sequential exposures to extreme hyperoxia, despite the studied patient population having a high rate of previous ischaemic heart disease or cardiovascular risk factors. This study demonstrates that profound hyperoxaemia does not induce any measurable cardiac injury at a biochemical level. Neither is there a reduction in cardiac troponin to suggest a cardioprotective effect of hyperbaric hyperoxia. This provides some reassurance as to the cardiac safety of the routine use of hyperbaric oxygen treatment in management of non-cardiac pathology.

The Spectrum of Heart Failure Management.

Heart failure, a complex cardiovascular condition, is a huge burden on patients, caregivers, and healthcare systems and it is prevalent worldwide. Heart failure is caused by a wide variety of underlying conditions that include both cardiac and non-cardiac pathologies. Identifying the underlying cause enables us to apply etiology-based interventions. The spectrum of heart failure management ranges from classification to transplantation. In addition toits classification and monitoring, this article reviews various management strategies, including both conventional methods and the latest innovations. These include lifestyle interventions, pharmacotherapy, device therapy, transplantation, and regenerative medicine.

Thoracotomy in Children: Review from a Low-Income Country.

Thoracotomy is indicated for several congenital and acquired disorders in children. It is among the surgical procedures which require a well-trained and dedicated surgical, anesthesia and critical care team which can be difficult to assemble in a low-income country setup. As the pattern and outcome of thoracotomy in children remained unreported from such setting, this study aims to shed light on this matter. A descriptive cross-sectional review was conducted. Children who have undergone thoracotomy for non-cardiac pathologies were included in the study. Demographic and clinical data were collected by chart review. Frequencies and percentages were used to describe categorical variables while mean, median, standard deviation and interquartile range were calculated for continuous variables. A total of 68 patients were operated on in the study period, out of which 44 (64.7%) were males. The mean ages of the children at the time of diagnosis and procedure were 4.05 ± 3.9 years and 4.14 ± 4.03 years, respectively. The most common indication for thoracotomy was pulmonary hydatid cyst (17; 25%) followed by congenital lobar emphysema (11; 16.2%). Muscle sparing posterolateral thoracotomy was the most common approach in 66 (97.1%) patients. The analgesic medications that were used in the post-operative period were paracetamol, diclofenac, ibuprofen, tramadol and morphine. Combined analgesics were administered in two-thirds of the patients while a single analgesic was used in the rest of the children. No regional blocks were administered post operatively as pediatric size catheters were not available. The morbidity and mortality rates were found to be 11.8% and 8.8%, respectively. The most common indication for thoracotomy in this study was pulmonary hydatid cyst. The provision of post-thoracotomy analgesia in our institution is suboptimal as evidenced by no use of regional blocks and poor practice of administering multimodal analgesia. Thoracotomy was associated with fairly high morbidity and mortality.

Clinical and Anamnestic Characteristics, Cardiovascular Pharmacotherapy and Long-term Outcomes in Multimorbid Patients after COVID-19

Aim. To study the clinical and anamnestic characteristics, pharmacotherapy of cardiovascular diseases (CVD) and long-term outcomes in post-COVID-19 patients with cardiovascular multimorbidity (CVMM), enrolled in the prospective hospital registry.Material and methods. In patients with confirmed COVID-19 included in the TARGET-VIP registry, the CVMM criterion was the presence of two or more CVDs: arterial hypertension (AH), coronary heart disease (CHD), chronic heart failure (CHF), atrial fibrillation (AF). There were 163 patients in the CVMM group and 382 – in the group without CVD. The information was obtained initially from hospital history sheet, and afterwards – from a telephone survey of patients after 30-60 days, 6 and 12 months, from electronic databases. The follow-up period was 13.0±1.5 months.Results. The age of post-COVID patients with CVMM was 73.7±9.6 years, without CVD – 49.4±12.4 years (p&lt;0.001), the proportion of men was 53.9% and 58.4% (p=0.34). In the group with CVMM the majority of patients had AH (92.3-93.3%), CHD (90.4-91.4%), and minority – CHF (42.7-46.0%) and AF (42.9-43.4%). The combination of 3-4 CVDs prevailed (58.9-60.3%). The proportion of cases of chronic non-cardiac pathologies was higher in the CVMM group (80.9%) compared to the group without CVD (36.7%; p&lt;0.001). The frequency of proper cardiovascular pharmacotherapy during the follow-up period decreased from 56.8% to 51.3% (p for trend = 0.18). The frequency of anticoagulant therapy in AF decreased significantly: from 89.1% at the discharge from the hospital to 56.4% after 30-60 days (p=0.001), 57.1% and 53.6% after 6 and 12 months of monitoring (p for a trend &lt;0.001). There were no other significant changes in the frequency of other kinds of the proper cardiovascular pharmacotherapy (p&gt;0.05). There were higher rate of all-cause mortality among patients with CMMM (12.9% vs 2.9%, p&lt;0.001) as well as rates of hospitalization (34.7% and 9.9%, p&lt;0.001) and non-fatal myocardial infarction (MI) – 2.5% vs 0.5% (p=0.048). The proportion of new cases of CVD in the groups with CVMM and without CVD was 5.5% and 3.7% (p=0.33). The incidence of acute respiratory viral infection (ARVI)/influenza was higher in the group without CVD – 28.3% vs 19.0% (p=0.02). The proportion of cases of recurrent COVID-19 in groups with CVMM and without CVD was 3.7 % and 1.8% (p=0.19).Conclusion. Post COVID-19 patients with CVMM were older and had the bigger number of chronic non-cardiac diseases than patients without CVD. The quality of cardiovascular pharmacotherapy in patients with CVMM was insufficient at the discharge from the hospital with following non-significant decrease during 12 months of follow-up. The frequency of anticoagulant therapy in AF decreased by 1.6 times after 30-60 days and by 1.7 times during the year of follow-up. The proportion of new cases of CVD was 5.5% and 3.7% with no significant differences between compared groups. The rate of all-cause mortality, hospitalizations and non-fatal MI was significantly higher in patients with CVMM, but the frequency of ARVI/influenza was significantly higher in patients without CVD. Recurrent COVID-19 was registered in 3.7% and 1.8% of cases, there were no significant differences between compared groups.

Abstract P1099: Evidence Of Sialylation Pathway Alterations In Peripheral Blood Of Brugada Syndrome Patients

Brugada syndrome (BrS) is a cardiac arrhythmia associated with a higher risk of SCD. BrS is considered a genetic disorder, and the most commonly mutated gene is SCN5A, encoding the alpha subunit of the voltage-gated cardiac sodium channel (NaV1.5). Mutations of SCN5A usually lead to impairment of NaV1.5 functionality, which is considered the main mechanism of the disease. However, SCN5A mutations are responsible for only 30% of BrS cases. Therefore, it is conceivable that other mechanisms such as post-translational modifications (PTMs) affect NaV1.5 activity. Among others, sialylation may alter ion channel activity by carrying a sugar with a negative charge. Alterations in sialylation have been described in several cardiovascular diseases, as myocardial infarction, Chagas disease, and congenital disorders of glycosylation. For these reasons, the aim was to investigate changes in sialylation in BrS patients to obtain new information on the pathogenesis of BrS. Peripheral blood mononuclear cells (PBMCs) were collected from BrS patients and healthy controls. SNA lectin, a sialic acid-binding protein, was used to characterize the protein sialylation status of PBMCs by Western blot and flow cytometry. Gene expression of enzymes involved in the sialic acid pathway was also examined. The results showed a significant decrease in intracellular and extracellular protein sialylation levels in BrS PBMCs compared with controls. In addition, changes in gene expression of enzymes involved in the sialic acid pathway were detected. Moreover, these changes correlated with clinical parameters associated with phenotypic expression of the disease, such as arrhythmogenic BrS substrate area and potential duration. These findings support that BrS should be considered a systemic disease and are consistent with the presence of overlapping non-cardiac pathologies, as epilepsy, cancer, diabetes, skeletal muscle channelopathies, and laminopathies in BrS patients. Moreover, the discovery that molecular alterations can be found in the peripheral blood of BrS patients supports the existence of a biomarker of the disease. It is a challenge to develop an effective diagnostic test to screen broadly for BrS. In this direction, a multiomic study is ongoing in our center.

Lithotripsy of Calcified Aortic Valve Leaflets by a Novel Ultrasound Transcatheter-Based Device

The increasing incidence of calcific aortic valve disease necessitates the elaboration of new strategies to retard the progression of the pathology with an innovative solution. While the increasing diffusion of the transcatheter aortic valve replacements (TAVRs) allows a mini-invasive approach to aortic valve substitution as an alternative to conventional surgical replacement (SAVR) in an always larger patient population, TAVR implantation still has contraindications for young patients. In addition, it is liable to undergo calcification with the consequent necessity of re-intervention with conventional valve surgery or repeated implantation in the so-called TAVR-in-TAVR procedure. Inspired by applications for non-cardiac pathologies or for vascular decalcification before stenting (i.e., coronary lithotripsy), in the present study, we show the feasibility of human valve treatment with a mini-invasive device tailored to deliver shockwaves to the calcific leaflets. We provide evidence of efficient calcium deposit ruptures in human calcified leaflets treated ex vivo and the safety of the treatment in pigs. The use of this device could be helpful to perform shockwaves valvuloplasty as an option to retard TAVR/SAVR, or as a pretreatment to facilitate prosthesis implantation and minimize the occurrence of paravalvular leak.

Inherited and Acquired Rhythm Disturbances in Sick Sinus Syndrome, Brugada Syndrome, and Atrial Fibrillation: Lessons from Preclinical Modeling.

Rhythm disturbances are life-threatening cardiovascular diseases, accounting for many deaths annually worldwide. Abnormal electrical activity might arise in a structurally normal heart in response to specific triggers or as a consequence of cardiac tissue alterations, in both cases with catastrophic consequences on heart global functioning. Preclinical modeling by recapitulating human pathophysiology of rhythm disturbances is fundamental to increase the comprehension of these diseases and propose effective strategies for their prevention, diagnosis, and clinical management. In silico, in vivo, and in vitro models found variable application to dissect many congenital and acquired rhythm disturbances. In the copious list of rhythm disturbances, diseases of the conduction system, as sick sinus syndrome, Brugada syndrome, and atrial fibrillation, have found extensive preclinical modeling. In addition, the electrical remodeling as a result of other cardiovascular diseases has also been investigated in models of hypertrophic cardiomyopathy, cardiac fibrosis, as well as arrhythmias induced by other non-cardiac pathologies, stress, and drug cardiotoxicity. This review aims to offer a critical overview on the effective ability of in silico bioinformatic tools, in vivo animal studies, in vitro models to provide insights on human heart rhythm pathophysiology in case of sick sinus syndrome, Brugada syndrome, and atrial fibrillation and advance their safe and successful translation into the cardiology arena.

Brugada Syndrome: Warning of a Systemic Condition?

Brugada syndrome (BrS) is a hereditary disorder, characterized by a specific electrocardiogram pattern and highly related to an increased risk of sudden cardiac death. BrS has been associated with other cardiac and non-cardiac pathologies, probably because of protein expression shared by the heart and other tissue types. In fact, the most commonly found mutated gene in BrS, SCN5A, is expressed throughout nearly the entire body. Consistent with this, large meals and alcohol consumption can trigger arrhythmic events in patients with BrS, suggesting a role for organs involved in the digestive and metabolic pathways. Ajmaline, a drug used to diagnose BrS, can have side effects on non-cardiac tissues, such as the liver, further supporting the idea of a role for organs involved in the digestive and metabolic pathways in BrS. The BrS electrocardiogram (ECG) sign has been associated with neural, digestive, and metabolic pathways, and potential biomarkers for BrS have been found in the serum or plasma. Here, we review the known associations between BrS and various organ systems, and demonstrate support for the hypothesis that BrS is not only a cardiac disorder, but rather a systemic one that affects virtually the whole body. Any time that the BrS ECG sign is found, it should be considered not a single disease, but rather the final step in any number of pathways that ultimately threaten the patient's life. A multi-omics approach would be appropriate to study this syndrome, including genetics, epigenomics, transcriptomics, proteomics, metabolomics, lipidomics, and glycomics, resulting eventually in a biomarker for BrS and the ability to diagnose this syndrome using a minimally invasive blood test, avoiding the risk associated with ajmaline testing.

Clinical and Diagnostic Value of Highly Sensitive Cardiac Troponins in Arterial Hypertension.

In modern laboratory diagnostics of cardiovascular diseases (CVD), there is a clear tendency toward an increase in the sensitivity of methods for determining key CVD biomarkers, among which highly sensitive cardiac troponins (hs-Tn) deserve special attention. The introduction of the latter into clinical practice made it possible not only to improve the early diagnosis of acute myocardial infarction but also to open up a number of additional valuable opportunities for the use of hs-Tn, including the assessment of the risk of developing CVD in a healthy population, detection and monitoring of early myocardial injuries in the early stages of CVD development (for example, with ischemic heart disease and arterial hypertension), with noncardiac pathologies (for example, sepsis, chronic obstructive pulmonary disease, chronic renal failure, stroke, cancer, etc), and diagnostics of CVD by using biological fluids that can be obtained by noninvasive methods. This article discusses in detail the diagnostic value of hs-Tn in serum and urine in cases of arterial hypertension. Also, the paper pays considerable attention to the consideration of the mechanisms underlying the increase in hs-Tn in serum and urine in cases of arterial hypertension.

Cardiac Biomarkers in Pediatrics: An Undervalued Resource.

The clinical use of common cardiac biomarkers, such as brain natriuretic peptides and troponins, has traditionally been limited to adult populations in the assessment of heart failure and acute coronary syndrome, respectively. While many have discounted the value of these markers in pediatric populations, emerging evidence suggests they may be useful in the diagnosis and prognostication of many cardiac and noncardiac pathologies in neonates, children, and adolescents, and an increasing number of pediatric hospitals are routinely measuring cardiac markers in their clinical practice. This review summarizes and critically evaluates the current literature regarding the application of cardiac biomarkers for clinical decision-making in the pediatric population. Main potential clinical indications discussed herein include primary cardiac disease, immune-related conditions, and noncardiac disease. Important diagnostic and interpretative challenges are also described in relation to each potential indication. Despite a general lack of clinical awareness regarding the value of cardiac biomarkers in pediatrics, there is increasing literature to support their application in various contexts. Cardiac biomarkers should be considered an undervalued resource in the pediatric population with potential value in the diagnosis and prognosis of myocarditis, congenital heart disease, and heart failure, as well as in the assessment of severity and cardiac involvement in immune-related and other systemic conditions. While interpretation remains challenging in pediatrics due to the age- and sex-specific dynamics occurring throughout growth and development, this should not prevent their application. Future research should focus on defining evidence-based cut-offs for specific indications using the most up-to-date assays.

Cardiopulmonary Exercise Testing in Percutaneous Mitral Valve Repair: A Single Centre’s Experience

Chronic severe mitral regurgitation (MR) confers negative hemodynamic consequences and long-term morbidity and mortality1. The adverse remodeling processes result in the inability of mitral valve leaflets to co-apt optimally in functional MR (FMR)2. Even after optimal medical therapy, or revascularization, FMR may not necessarily be reduced adequately. In such patients who remain persistently symptomatic from residual MR, the next course of management may be the surgical or percutaneous intervention of the mitral valve apparatus. Subsequently, percutaneous repair via transcatheter delivered systems has emerged as the treatment of choice; especially, in patients assessed to be at a high operative risk with a suitable anatomy for minimally invasive approaches to re-appose the mitral leaflets3. This has also revolutionized the approach to the management of primary mitral regurgitation (PMR), such as from mitral valve prolapse. It was treated conventionally by the surgical intervention with mitral valve repair or replacement, allowing an alternative option for the high surgical risk patients 4. In our center, the transcatheter mitral valve repair procedure (MitraClip) has been introduced in the year 2012, providing an option of percutaneous intervention to the patients where MR is unsuitable for the surgical correction. However, persistent symptoms may occur due to the concomitant non-valvular or non-cardiac pathologies, particularly chronic pulmonary diseases. Also, assessment of functional class is subjective and may be confounded by other variables, such as sedentary lifestyle, self-imposed exercise restrictions, or orthopedic conditions. The cardiopulmonary exercise test (CPET) provides an objective assessment of the exercise capacity, obviating the subjective aspects of self-reported symptoms and functional status Besides, CPET is also useful to discern pulmonary and functional status. Besides, CPET is also useful to discern pulmonary and non-cardiac contributory components of the perceived decreased functional capacity, including motivational factors. Multiple CPET parameters, related to hemodynamic surrogates before and after the MitraClip procedure, also enable a more objective evaluation of the cardiovascular impact of the repair, allowing insights into the improvements in cardiac hemodynamics post intervention7-10.

Factors Associated With Survival Following Extracorporeal Cardiopulmonary Resuscitation in Children.

We examined a large single-institution experience in extracorporeal cardiopulmonary resuscitation (ECPR) in children having cardiac arrest refractory to conventional resuscitation measures with focus on factors affecting survival. Between 2002 and 2017, 184 children underwent ECPR at our institution. We entered demographic, anatomic, clinical, surgical, and ECPR support details into a multivariable logistic regression models to determine factors associated with mortality. Median age was 54 days (interquartile range [IQR]: 11-272). In all, 157 (85%) patients had primary cardiac disease, including 136 (74%) with congenital heart disease (71 with single ventricle). Extracorporeal cardiopulmonary resuscitation occurred following cardiac surgery in 124 (67%) patients. Median cardiopulmonary resuscitation (CPR) duration was 27 minutes (IQR: 18-40) and median support duration was 3.0 days (IQR: 1.6-5.3). Overall, ECPR was weaned in 115 (63%), with 79 (43%) surviving to hospital discharge. Survival for patients with congenital heart disease, noncongenital cardiac, and noncardiac pathologies was 44%, 71%, and 15%, respectively. On multivariable regression analysis, risk factors associated with mortality were presupport pH <7.1 (odds ratio [OR] = 3.7, 95% confidence interval [CI]: 1.11-12.41, P = .033), mechanical complications (OR = 8.33, 95% CI: 1.91-36.25, P = .005), neurologic complications (OR = 6.27, 95% CI: 1.40-28.10, P = .017), and renal replacement therapy (OR = 3.31, 95% CI: 1.03-10.66, P = .045). Extracorporeal cardiopulmonary resuscitation plays a valuable role salvaging children with refractory cardiac arrest. Survival varies with underlying pathology and can be expected even with relatively longer CPR durations. Efforts to improve systemic output before and after institution of ECPR might mitigate some of the significant risk factors for mortality.

What is the Significance of Elevated Troponin I in Children and Adolescents? A Diagnostic Approach.

Troponin is a marker that displays cardiac injury quickly and accurately. In adults, troponin elevation is usually associated with coronary artery disease and requires urgent cardiac catheterization. In healthy children, myocardial injury is rare and may develop due to many different causes. Therefore, troponin elevation in children and adolescents does not usually require emergency cardiac catheterization. The aim of this study is to assess the most common causes of troponin elevation in children and adolescents and to show which diagnostic tests are helpful in assessing pediatric patients with elevated troponin. Patients who had been diagnosed with troponin I elevation (> 0.06ng/ml) at Dr. Sami Ulus Maternity, Children's Health and Disease Training and Research Hospital between 2007 and 2018 were retrospectively evaluated. Patients undergoing cardiac surgery and those with severe congenital heart disease were excluded from the study. The medical records of the patients were examined and age, gender, diagnostic tests, and diagnosis were evaluated. During the study period, the records of 972 patients were obtained. 213 patients were excluded from the study because of heart surgery, congenital heart disease, and neonatal asphyxia or sepsis. Of the remaining 759 patients, 58% were male, 42% were female, and the median age was 4years (3days to 17years). The most frequent causes are myopericarditis (n: 164), drug intoxications (n: 85), carbon monoxide poisoning (n: 74), perimyocarditis (n: 65), and intensive inhalation β agonist use in acute asthma and lower respiratory tract infections (n: 70). Patients diagnosed with myocarditis and myopericarditis were admitted with a complaint of chest pain, and the diagnosis was made by history, physical examination, ECG, and echocardiographic findings. Unlike adults, troponin I elevation may be associated with many cardiac and non-cardiac pathologies in children. The most common pathologies in cardiac etiology are myopericarditis and perimyocarditis and can be diagnosed by history, physical examination, ECG, and echocardiography. Cardiac catheterization is not necessary except for rare cardiac pathologies and does not alter the prognosis.

Should we screen patients undergoing thoracic surgery for aortic stenosis pre-operatively?

Aortic stenosis (AS) is the most prevalent valvular heart disease in the elderly. Depending on the severity of the disease, an intervention is required through either surgical or percutaneous approach. Presence of AS adds significant morbidity and mortalities to non-cardiac pathologies. Current guidelines recommend postponing non-cardiac surgery in individuals with severe AS; however, this may not always be possible in thoracic surgery as having to postpone or cancel a surgery may be the difference between patients receiving life-prolonging treatment or not. Screening for AS therefore has a role in detecting asymptomatic patients prior to their development of severe, symptomatic AS which can allow us to intervene prior to further disease progression. This, as a result, serves as a mean of potentially prolonging patients’ wellbeing and have a satisfactory perioperative outcome. In this paper, we evaluate the role of screening in AS in patients undergoing thoracic surgery and the possibility of combined aortic valve intervention and resection of lung cancer.

The Confounding Effects of Non-cardiac Pathologies on the Interpretation of Cardiac Biomarkers

Cardiac biomarkers play important roles in routine evaluation of cardiac patients. But while these biomarkers can be extremely valuable, none of them should ever be used by themselves-without adding the clinical context. This paper explores the non-cardiac pathologies that can be seen with the cardiac biomarkers most commonly used. High-sensitivity troponin assay gained FDA approval for use in the USA, and studies demonstrated its diagnostic utility can be extended to patients with renal impairment. Gender-specific cut points may be utilized for high-sensitivity troponin assays. In the realm of the natriuretic peptides, studies demonstrated states of natriuretic peptide deficiency in obesity and in subjects of African-American race. Regardless, BNP and NT-proBNP both retained prognostic utilities across a variety of comorbid conditions. We are rapidly gaining clinical evidence with use of soluble ST2 and procalcitonin levels in management of cardiac disease states. In order to get the most utility from their measurement, one must be aware of non-cardiac pathologies that may affect the levels of biomarkers as although many of these are actually true values, they may not represent the disease we are trying to delineate. A few take-home points are as follows: 1. A biomarker value should never be used without clinical context 2. Serial sampling of biomarkers is often helpful 3. Panels of biomarkers may be valuable.

What Raises Troponins in the Paediatric Population?

Troponin I is a cardiac enzyme that is released during myocardial injury. However, cardiac enzymes are non-specific and can occur in many cardiac and non-cardiac pathologies. We aim to (1) describe the range of acute conditions that were associated with raised troponins in the paediatric population in our institution and (2) quantify the extent of troponin elevation and correlate it with the underlying aetiology. We performed a retrospective observational study in a tertiary institution which included patients from 1 January 2009 to 31 December 2013. We identified patients with troponin I levels of more than 0.1ng/ml who have not had cardiac surgery before. We recorded their final diagnoses, and then compared the peak troponin levels and the eventual final diagnoses. We identified 100 patients. The top few common diagnoses resulting in a raised troponin were sepsis (29%), cardiac pathologies (29%) such as tachyarrhythmias and cardiomyopathies and myocarditis (21%). Other pathologies included trauma and other causes of multiorgan dysfunction. The median peak troponin I was higher in cardiac as compared to non-cardiac pathologies: 2.15 (0.52-15.0) and 0.44 (0.21-1.68), respectively. There was no statistically significant difference in the peak troponin I values in the presence of hypotension or renal impairment. We described the range of conditions that may result in raised troponin I levels. The extent of raised troponin I levels may potentially be useful in differentiating between cardiac and non-cardiac pathologies. However, further studies on a larger scale are required to establish whether extent of troponin I elevation has a diagnostic role for cardiac pathologies.