Positive Troponin Research Articles

Perioperative Troponin is a Predictor of Both Short- and Intermediate-term Mortality Among Patients Undergoing Major Urologic Surgery

ObjectiveTo determine whether a positive troponin is a predictor of intermediate- and long-term mortality in patients undergoing major urologic surgeries at our institution. MethodsThis is a retrospective analysis of patients undergoing major urologic surgery at the Cleveland Clinic from 2010-2015. Patients were stratified by the presence and maximum value of troponin blood-draw, if performed within 30 days of surgery. Survival analysis was performed using Kaplan-Meier function (univariate) and Cox regression analysis (continuous) to assess mortality risk. ResultsWithin 30 days of surgery, 1305 (15.5%) patients a troponin drawn, and 304 (3.6%) of them had an abnormal troponin level (>0.01 ng/mL). Patients with positive troponin drawn for cause within 30 days of surgery had a significantly decreased overall survival at 5 years of 70.6% (95% CI 62.6, 77.2) when compared to patients with negative troponin (81.7% [95% CI 77.4, 85.3]) and no troponin drawn (90.4% [95% CI 89.0, 91.6]). ConclusionFor cause serum troponin blood draw and peak levels demonstrated a positive correlation with all-cause mortality in patients undergoing major urologic surgeries Prospective studies are needed to better understand the utility of postoperative troponin as predictive marker of mortality.

Anévrisme non rompu du sinus de Valsalva non coronaire déversant dans l’auricule droit (Type IV de la classification de Sakakibara) traité par chirurgie

A 26-year-old woman of Cap Verdean origin was admitted to emergency unit with chest pain and dyspnea. Because of sinus tachycardia without any other electrocardiogram abnormalities, high NT-pro BNP level, and weakly positive cardiac troponin I and D-dimer levels, an aortic and pulmonary non ECG-gated CT-angiography was performed that excluded pulmonary embolism and aortic dissection. Transthoracic echocardiography (TTE) showed a contained rupture of the non-coronary sinus of Valsalva aneurysm sized 23 to 24mm into the right atrium. According to the high rupture risk, patient had been immediately transferred in a cardiologic surgical center where transesophageal echocardiography (TEE) and thoracic angiography ECG-gated Multiple Detector Computerized Tomography (ECG-gated MDCT) reinforced the diagnosis. Patient underwent surgical repair resection of the aneurysmal sac, which was described as “tissue paper thin” and at risk for impending rupture, without evidence of communication between the aorta and the right atrium. Anatomopathological examination described a thick sclerotic and oedematous aneurysm wall without inflammation, and bacteriological examination was negative. It is a rare case of contained rupture of the congenital non-coronary sinus of Valsalva aneurysm into the right atrium (Type IV of Sakakibara classification), with a high rupture risk. This case shows that the use ECG-gated-MDCT is more appropriate when aortic dissection is suspected, allowing a detailed analysis of aorta, especially the proximal portion which is more susceptible to motion artifacts.

Feasibility and accuracy of speckle tracking echocardiography in emergency department patients

BackgroundSpeckle tracking echocardiography (STE) is a novel technology that measures regional wall-motion abnormalities that may speed diagnosis and intervention of acute coronary occlusion in Emergency Department (ED) patients with non-ST elevation ACS (NSTE-ACS). STE provides an objective measurement of myocardial strain that is superior to visual assessment of wall motion when performed as part of a point-of-care (POC) echocardiogram. We determined the feasibility and preliminary accuracy of POC STE operated by emergency providers when compared to comprehensive echocardiography or final diagnosis of ACS. MethodsWe retrospectively reviewed 187 emergency provider POC echocardiograms with STE from 7/2014–5/2016 for suspected ACS at a large academic trauma center. Feasibility of POC STE was determined by calculating the percentage of complete exams (adequate apical 4-chamber and parasternal short axis views) out of all STE exams. We then used two different criterion standards for calculating diagnostic accuracy of STE: comprehensive echocardiograms with wall motion abnormalities or formal diagnosis of ACS based on elevated cardiac troponins, unstable angina, percutaneous coronary intervention, or coronary artery stenosis >70% on catheterization. ResultsOf 187 STE studies performed, 75 (40%) were considered complete. Ultrasound-experienced providers had higher rates of complete exams (65% vs. 35%, P = 0.01). 16 of 75 exams (21%) were positive for myocardial strain, and of these 16 (100%) were admitted, 12 (75%) had positive troponins, 6 (46%) had positive comprehensive echocardiograms, and 3 (19%) had PCI or >70% stenotic lesion on catheterization. Compared with comprehensive echocardiography, POC STE had 35% sensitivity, 70% specificity, 46% positive predictive value (PPV), and 59% negative predictive value (NPV). Compared with formal diagnosis of ACS, POC STE had 29% sensitivity, 88% specificity, 75% positive predictive value (PPV), and 51% negative predictive value (NPV). ConclusionSTE is a potentially feasible adjunct to standard bedside echocardiography in ED patients with suspected ACS when operated by experienced ultrasound-trained physicians in the ED. This data shows STE performed by emergency providers is not yet sensitive enough alone to diagnose ACS, and has low accuracy when compared to comprehensive echocardiography. However, the PPV and specificity improve when performed by expert ultrasound-trained providers. STE should be considered for inclusion in the Emergency Ultrasound Fellowship curriculum.

Preoperative oral thyroid hormones to prevent euthyroid sick syndrome and attenuate myocardial ischemia-reperfusion injury after cardiac surgery with cardiopulmonary bypass in children: A randomized, double-blind, placebo-controlled trial.

Background:Both euthyroid sick syndrome and myocardial ischemia-reperfusion injury are common and have been significantly associated with morbidity and mortality after pediatric cardiac surgery with cardiopulmonary bypass. This single-center, prospective, double-blind, randomized placebo-controlled clinical pilot trial was designed to assess if preoperative oral thyroid hormone therapy could prevent the occurrence of euthyroid sick syndrome (ESS) and attenuate myocardial ischemia-reperfusion injury (IRI) after cardiac surgery with cardiopulmonary bypass (CPB) in children.Methods:Forty children aged 3 to 12 year, scheduled for elective congenital heart disease repair surgery with CPB, were randomized into 2 groups of equal size to receive the following treatments in a double-blind manner: placebo (control group) and thyroid tablet 0.4 mg/kg (trial group) taken orally once a day for 4 days before surgery. The perioperative serum thyroid hormone levels and hemodynamic variables were determined. The extubation time, duration of intensive care unit (ICU) stay, and use of inotropic drugs in the ICU were recorded. The myocardial expressions of heat shock protein 70 (HSP70), myosin heavy chain (MHC) mRNA, and thyroid hormone receptor (TR) mRNA were detected. The serum creatine kinase-MB (CK-MB) activity and troponin I (TnI) positive ratio at 24 hour after surgery were assessed.Results:There were no significant differences in hemodynamic variables at all observed points, extubation time, and duration of ICU stay between groups. As compared with baselines on administration, serum triiodothyronine (T3) and free T3 (FT3) levels on the first, second, and fourth postoperative day, and serum thyrotropic-stimulating hormone (TSH), tetraiodothyronine (T4), and free T4 (FT4) levels on the first postoperative day were significantly decreased in the 2 groups. Serum T3, FT3, and T4 levels on the first and second postoperative day, and serum FT4 level on the first postoperative day were significantly higher in the trial group than in control group. As compared with the control group, the number of patients requiring inotropic drugs in the ICU, serum CK-MB activity, serum positive TnI ratio, and myocardial expression of MHCβ mRNA were significantly decreased, and myocardial expressions of both HSP70 and MHCα mRNA were significantly increased in the trial group.Conclusions:In children undergoing cardiac surgery with CPB, preoperative oral small-dose thyroid hormone therapy reduces severity of postoperative ESS and provides a protection against myocardial IRI by increasing HSP70 and MHCα expression.

Differentiating Takotsubo cardiomyopathy from ST-segment elevation myocardial infarction

Background: Takotsubo cardiomyopathy affects between 1.7% and 2.2% of patients hospitalized with suspected acute coronary syndromes. Characterized by chest pain, electrocardiogram changes, and transient left ventricular apical wall motion abnormality, it is under-recognized and often misdiagnosed. Objectives: In order to better differentiate between St-segment myocardial infarction and Takotsubo cardiomyopathy, we developed a scoring system. Methods: Of the 82 patients enrolled with Takotsubo cardiomyopathy, 67 had ST-segment elevation on electrocardiogram and were compared with 79 ST-elevation myocardial infarction patients. A multi-variant logistic regression model was used to find factors independently associated with Takotsubo cardiomyopathy. The Platelets and Thrombosis in Sheba (PLATIS)-Takotsubo cardiomyopathy is based on a 10-point scoring system: stressful events (3), females (2), no history of diabetes mellitus (2), estimated left ventricular ejection fraction ≤ 40% on admission echo (1), positive troponin on admission (1), and no smoking (1). Patients with Takotsubo cardiomyopathy were older (66 ± 11 vs 60 ± 11 years, p < 0.001), predominantly female (90% vs 15%, p < 0.001), with a lower incidence of diabetes mellitus, dyslipidemia, and smoking. Nevertheless, in-hospital mortality was similar in both groups. Results: In a multivariate logistic regression analysis, the average Platelets and Thrombosis in Sheba-Takotsubo cardiomyopathy scoring was significantly higher in Takotsubo cardiomyopathy compared with ST-elevation myocardial infarction patients (8.35 ± 1.7 vs 3.42 ± 1.6, p < 0.001). With an overall score of ≥7, the receiver-operating characteristic curve was 0.82 with a sensitivity of 75% and a specificity of 89% (positive predictive value = 85% and negative predictive value = 80%). Conclusion: The Takotsubo cardiomyopathy scoring system is a simple, reliable tool that can assist in diagnosing and differentiating between patients with Takotsubo cardiomyopathy and those with ST-elevation myocardial infarction.

Abstract 346: A Standard Flow Cytometry Protocol for Assessing Human Pluripotent Stem Cell-derived Cardiomyocyte Identity by Troponin Positivity

Directed differentiation of human pluripotent stem cells (hPSC) into cardiomyocytes (hPSC-CM) offers an inexhaustible supply of cells for basic science research and translational applications. However, despite significant advancements in defining the factors most critical for differentiation, the resulting cultures remain a heterogeneous mixture of cells. Ultimately, as heterogeneity can pose challenges to interpreting functional data, the ability to accurately and precisely assess cell identity in differentiation cultures is paramount to well-defined and reproducible studies. To date, a standardized flow cytometry protocol that is broadly accepted among laboratories has not been established for assessing cell type heterogeneity within hPSC-CM cultures, posing challenges to evaluating outcomes generated among laboratories and studies. A survey of studies published over the past seven years (1/2010-10/2017) reveals the wide range of antibodies and experimental conditions reported for flow cytometry-based assessment of hPSC-CM. Although our literature survey revealed that a preponderance of studies relied on TNNT2 as a marker of cardiomyocyte identity, TNNI3 is more specific to cardiomyocytes than TNNT2 throughout development. We applied targeted mass spectrometry to confirm the presence of TNNI3 in our hPSC-CM. We then investigated five commercially available anti-TNNI3 and three sample preparation techniques for use in the assessment of heterogeneity of hPSC-CM cultures by flow cytometry. Results demonstrate two of the five anti-TNNI3 clones appear suitable for marking hPSC-CM and reveal differential susceptibility of antibody clones to sample preparation conditions. To further test the rigor and utility of our flow cytometry protocol, it was shared with two collaborating laboratories and applied to heterogeneous mixtures of positive and negative cell types. Results from these two laboratories demonstrate the protocol successfully distinguishes positive and negative cell types similarly, despite using different cell lines and differentiation protocols. We propose a workflow for establishing the fit-for-purpose use of antibodies and a standard protocol for assessing hPSC-CM identity by troponin positivity.

1089Prognostic value of a positive troponin across the age spectrum in over a quarter of a million patients (NHIC Troponin Study)

1089Prognostic value of a positive troponin across the age spectrum in over a quarter of a million patients (NHIC Troponin Study)

Assessment of the Utility of Ordering a Troponin in Low- and Intermediate-Risk Patients Presenting to the Emergency Department with Supraventricular Tachycardia: A Retrospective Chart Review

BackgroundA troponin assay is commonly sent for patients presenting to emergency departments (EDs) with supraventricular tachycardia (SVT). Multiple studies suggest that elevated troponin levels do not predict coronary artery disease in these patients. Patients with elevated troponins are more likely to have additional cardiac testing, which can lead to increased health care costs and unnecessary invasive procedures. ObjectiveOur objective was to evaluate low- to intermediate-risk patients (HEART [history, electrocardiography, age, risk factors and troponin] Score 1–6) presenting to the ED with SVT. Our hypothesis was that an elevated troponin would not predict major adverse cardiac events (MACE), but would be associated with increased hospital admission rates and lengths of stay. MethodsThis was a retrospective cohort study of adult patients who presented with SVT to a large, urban, academic hospital ED over 4 years who had a troponin result. A total of 46 patients were included in the study. ResultsPatients with a positive troponin (>0.05 ng/mL) had a hospital admission rate of 86% versus 21% for patients with negative troponin (p = 0.006); rate of cardiology consult of 86% versus 21% (p < 0.001); and a mean total length of stay of 4157 min versus 1347 min (p = 0.04). At 3 months, none of the patients with a positive troponin had an MACE, death from any cause, or positive results of cardiac testing. ConclusionsPatients with a positive troponin result had significantly more admissions, cardiology consults, and longer hospital stays. These patients did not have an increased prevalence of MACE.

A clinical decision instrument to predict 30-day death and cardiovascular hospitalizations after an emergency department visit for atrial fibrillation: The Atrial Fibrillation in the Emergency Room, Part 2 (AFTER2) study

BackgroundIn previous work, we derived and validated a tool that predicts 30-day mortality in emergency department atrial fibrillation (AF) patients. The objective of this study was to derive and validate a tool that predicts a composite of 30-day mortality and return cardiovascular hospitalizations. MethodsThis retrospective cohort study at 24 emergency departments in Ontario, Canada, included patients with a primary diagnosis of AF who were seen between April 2008 and March 2009. We assessed a composite outcome of 30-day mortality and subsequent hospitalizations for a cardiovascular reason, including stroke. ResultsOf 3,510 patients, 2,343 were randomly selected for the derivation cohort, leaving 1,167 in the validation cohort. The composite outcome occurred in 227 (9.7%) and 125 (10.7%) patients in the derivation and validation cohorts, respectively. Eleven variables were independently associated with the outcome: older age, not taking anticoagulation, HAS-BLED score of ≥3, 3 laboratory results (positive troponin, supratherapeutic international normalized ratio, and elevated creatinine), emergency department administration of furosemide, and 4 patient comorbidities (heart failure, chronic obstructive lung disease, cancer, dementia). In the validation cohort, the observed 30-day outcomes in the 5 risk strata that were defined using the derivation cohort were 2.0%, 6.6%, 10.7%, 12.5%, and 20.0%. The c statistic was 0.73 and 0.69 in the derivation and validation cohort, respectively. ConclusionsUsing a population-based sample, we derived and validated a tool that predicts the risk of early death and rehospitalization for a cardiovascular reason in emergency department AF patients. The tool can offer information to managing physicians about the risk of death and rehospitalization for AF patients seen in the in emergency department, as well as identify patient groups for future targeted interventions aimed at preventing these outcomes.

Lung ultrasound evaluation of diabetic patients with acute onset dyspnea and its relationship with established markers of heart failure

ObjectiveThe aim of the study was to assess the interrelation between sonographic pleural B-Line, left ventricular function and Naturetic Peptides in type 2 Diabetics with acute onset class III-IV dyspnea. There is dearth of data in this subset of patients in Asian population. MethodsSubjects (n=73) were divided into those with pleural B line (Group A, n=41) and those without (Group B) and their serum B type Naturetic Peptide (BNP) and Echocardiography evaluated. ResultsThe serum BNP was significantly higher and mean Left Ventricular Ejection Fraction (LVEF) lower in Group A compared to Group B (p<0.001). There was a significant negative correlation between LVEF and BNP and positive correlation between E/E’ and BNP. Among patients with LVEF 40% and above (n=36), patients with B line had significantly higher BNP and E/E’ compared to those without. Group A had significantly more patients on insulin therapy and troponin positivity than Group B (p<0.01). On auscultation though crepitations was found more frequently in group A but it was present in only 50% of the subset. ConclusionPleural B-Lines, LVEF and mitral inflow E/septal E’ can be used to rule in heart failure in the above population.

Review article: Utility of troponin after syncope: A systematic review and meta-analysis.

The role of serum troponin testing in patients presenting to the ED after syncope is unclear. The aim of this systematic review was to examine the practice and utility of troponin testing among patients presenting to the ED after syncope. We conducted a search of MEDLINE, Embase, Cochrane Library, Web of Science and Scopus databases from 1990 to February 2017 using keyword and subject headings for syncope and troponin testing. Design and results of the included studies are extracted. Studies were assessed for heterogeneity and the pooled proportion of measured troponin and positive troponin result described. There were nine studies included for analysis. Significant statistical heterogeneity among studies was observed (P < 0.001). Using the random effects model, the pooled proportion of patients presenting to the ED after syncope who had troponin measured was 0.64 (95% CI 0.46-0.82). Among patients who had been troponin tested, the pooled proportion who had a positive result was 0.19 (95% CI 0.13-0.26). Variability among reported outcomes prevented further meta-analysis. Troponin testing was commonly performed for the assessment of patients with syncope with a substantial proportion returning positive results. The correlation between raised troponin and patient outcomes was not adequately reported. It is possible that an elevated troponin may indicate serious illness, rather than myocardial damage alone.

Abstract P-560: MYOCARDITIS IN THE PAEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: The aim the study was to assess the incidence of acute myocarditis in neonates and children in our paediatric intensive care unit (PICU). Methods In this observational study, we included all consecutive patients from 15 days to 16 years of age who were admitted to the PICU in “P. and A. Kyriakou” Athens Children’s Hospital, Greece, due to clinically suspected myocarditis, between January 1, 2013 and December 31, 2017. The parameters of age, gender, troponin, assessment of left ventricular function by cardiac ultrasound (ejection fraction - EF), cardiac MRI, complications, results of biopsy were reviewed. Results A total of 34 patients 1–192 months (median age: 119,7 months; male/female: 26/8) were included in the study. Out of 34 patients: 31 had positive troponin (cardiac troponin I or high-sensitive cardiac troponin T), 7 had decreased EF (<50%), 14 (out of 14 who had MRI) were positive for myocarditis according Lake Louis criteria, 1 relapsed, 2 died and 5 underwent myocardial biopsy. Out of 5 patients that underwent biopsy, 4 had positive findings according Dallas criteria for myocarditis, 2 were offered heart transplant surgery, but 1 died after transplantation. Conclusions Myocarditis has a wide range of clinical presentation, from subtle symptoms to heart failure and sudden cardiac death. Definite myocarditis is only histologically confirmed. Thus, most children with clinically suspected myocarditis who have a benign course are not referred for biopsy. In our study 31 (91%) of the patients survived long term, and we noticed a 3,3: 1 male preponderance

The new bedside ROCky score to predict the complications in patients with intermediate-risk pulmonary embolism

ObjectivePulmonary embolism (PE) remains one of the leading causes of mortality among cardiovascular diseases. We aimed at investigating risk factors of PE complications in patients with intermediate risk and integrate them into a simple model for its' bedside prediction. MethodsAmong 173 patients with PE, 136 were classified as high or intermediate risk. Patients were retrospectively divided into groups of complicated (n = 44) or uncomplicated (n = 92) course. Study endpoints: obstructive shock, recurrent PE, needs for resuscitation/thrombolysis/hemodynamic support and death during 30 days. ResultsPredictors of PE complications were: chronic heart failure, diabetes mellitus (DM), atrial fibrillation, permanent risk factor of venous thromboembolism, syncope, positive heart-type fatty acid binding protein (hFABP), positive troponin I, heart rate (HR) ≥ 110 bpm, systolic blood pressure (SBP) ≤ 100 mmHg, creatinine clearance ≤ 70 ml/min. Multivariate logistic regression analysis was used to model a simple predictive score named ROCky (Risk of Complications): HR ≥ 110 bpm (1.5 points), SBP ≤ 100 mmHg (2.5 points), positive hFABP (2 points) and presence of DM (2.5 points). The AUROC of this model was 0.89 to predict any complication, 0.83 for obstructive shock and 0.92 for death from any cause; the optimal cut-off scores for any complication was ≥2.5 points, ≥3.5 for obstructive shock and ≥4.5 points for death within 30 days. ConclusionhFABP, tachycardia, hypotension and DM were identified as the major independent determinants of complications development in patients with pulmonary embolism and may be used in combination as the bedside simple predictive ROCky score for early risk stratification in intermediate-risk group.

Review article: The utility of troponin and other investigations in patients presenting to the emergency department with supraventricular tachycardia.

Patients with supraventricular tachycardia commonly present to the ED. There is a lack of consensus regarding assessment of these patients. Our aim was to determine the utility of troponin and four other investigations (full blood examination, electrolyte levels, thyroid function tests and chest X-rays) commonly requested for these patients. MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (January 1992-March 2017) were searched for randomised controlled trials and observational studies (of sample size greater than 10). Our search strategy yielded no randomised controlled trials and seven observational studies with significant statistical heterogeneity among selected studies (I2 87.3%, P < 0.001). Included studies investigated a total of 1155 patients. All studies reported on the utility of troponin testing in this patient population. The pooled proportion of patients investigated with troponin was 0.66 (95% confidence interval 0.44-0.88). The pooled proportion of positive troponin tests was 0.32 (95% confidence interval 0.23-0.41). Only one study reported on the utility of the remaining four investigations with abnormal results as follows: thyroid stimulating hormone 14%, haemoglobin 6%, white cell count 19% and chest X-ray 22%. Investigations are commonly requested for patients presenting with supraventricular tachycardia. Troponin testing is commonly performed with a high proportion of positive findings although these results did not appear to be associated with major adverse cardiac events. Heterogeneity among studies and low levels of evidence precluded conclusions on full blood examinations, electrolyte levels, thyroid testing and utility of chest X-rays in this patient population.

Cardiac Troponins in Low-Risk Pulmonary Embolism Patients: A Systematic Review and Meta-Analysis.

Patients with low-risk pulmonary embolism (PE) should be considered as per current scoring systems for ambulatory treatment. However, there is uncertainty whether patients with low scores and positive troponins should require hospitalization. We searched MEDLINE, SCOPUS, and Cochrane Library databases from inception to December 2016 and collected longitudinal studies that evaluated the prognostic value of troponins in patients with low-risk PE. The primary outcome measure was 30-day all-cause mortality. We calculated odds ratio (OR), likelihood ratios (LRs), and 95% confidence intervals (CI) by using randomeffects models. The literature search identified 117 candidate articles, of which 16 met the criteria for review. Based on pulmonary embolism severity index (PESI) or simplified PESI score, 1.2% was the all-cause mortality rate across 2,662 participants identified as low-risk. A positive troponin status in patients with low-risk PE was associated with an increased risk of 30-day all-cause mortality (odds ratio [OR]: 4.79; 95% confidence interval [CI]: 1.11 to 20.68). The pooled likelihood ratios (LRs) for all-cause mortality were positive LR 2.04 (95% CI, 1.53 to 2.72) and negative LR 0.072 (95% CI, 0.37 to 1.40). The use of positive troponin status as a predictor of increased mortality in low-risk PE patients exhibited relatively poor performance given the crossed negative LR CI (1.0) and modest positive LR. Larger prospective trials must be conducted to elucidate if patients with low-risk PE and positive troponin status can avoid hospitalization.

Multimodality Assessment of Right Ventricular Strain in Patients With Acute Pulmonary Embolism

Optimal risk stratification is essential in managing patients with an acute pulmonary embolism (PE). There are limited data evaluating the potential additive value of various methods of evaluation of right ventricular (RV) strain in PE. We retrospectively evaluated RV strain by computed tomography (CT), transthoracic echocardiography (TTE), electrocardiography (ECG), and troponin levels in consecutive hospitalized patients with acute PE (May 2007 to December 2014). Four-hundred and seventy-seven patients met inclusion criteria. RV strain on ECG (odds ratio [OR] 1.9, confidence interval [CI] 1.1 to 3.3; p = 0.03), CT (OR 2.7, CI 1.5 to 4.8, p <0.001), TTE (OR 2.8, CI 1.5 to 5.4, p <0.001), or a positive troponin (OR 2.7, CI 2.0 to 6.9, p <0.001) were associated with adverse events. In patients with ECG, CT, and TTE data, increased risk was only elevated with RV strain on all 3 parameters (OR 4.6, CI 1.8 to 11.3, p <0.001). In all patients with troponin measurements, risk was only elevated with RV strain on all 3 parameters plus a positive troponin (OR 8.8, CI 2.8 to 28.1, p <0.001) and was similar in intermediate-risk PE (OR 11.1, CI 1.2 to 103.8, p = 0.04). In conclusion, in patients with an acute PE and evaluation of RV strain by ECG, CT, and TTE, risk of adverse events is only elevated when RV strain is present on all 3 modalities. Troponin further aids in discriminating high-risk patients. Multimodality assessment of RV strain is identified as a superior approach to risk assessment.

Does Preoperative Troponin Level Impact Outcomes After Coronary Artery Bypass Grafting?

As a marker of myocardial injury, troponin level correlates with adverse outcomes after myocardial infarction (MI). We hypothesized that patients with a higher preoperative troponin level would have increased morbidity and mortality after coronary artery bypass grafting (CABG). Preoperative troponin measurements were available for 1,272 patients who underwent urgent or emergent isolated CABG at our institution from 2002 to 2016. Logistic regression assessed the risk-adjusted effect of peak troponin level on morbidity and mortality. Long-term survival analysis was performed with Kaplan-Meier and Cox proportional hazards models. Preoperative troponin was positive in 835 patients (65.6%). The median peak troponin for this group was 3.2 ng/mL (interquartile range, 0.6 to 11.9 ng/mL), with a median time from peak troponin to the operation of 3 days (interquartile range, 1 to 4 days). Positive troponin was associated with more significant comorbid conditions and more extensive coronary artery disease. Operative mortality (3.7% versus 1.1%, p= 0.009), major morbidity (11.7% versus 3.9%, p < 0.001), and long-term mortality (median survival 12.5 years versus 13.6 years, p= 0.01) were increased in the positive troponin group. After risk adjustment, positive troponin was not independently associated with increased operative mortality (odds ratio, 2.61; p= 0.053). Adjusted and unadjusted analysis showed the peak preoperative troponin level did not independently predict death at any time point (all odds ratios, 1.0; p > 0.05). A positive preoperative troponin correlates with worse outcomes after CABG, but risk adjustment eliminates much of the short-term predictive value of this biomarker. Peak troponin level does not influence outcomes after CABG and is a poor predictor of events when The Society of Thoracic Surgeons predictive models are used.

Risk Stratification and in Hospital Morality in Patients Presenting with Acute Coronary Syndrome (ACS) in Bahrain.

Background:Risk factors and short-term mortality in patients presented with Acute Coronary Syndrome (ACS) in Bahrain has not been evaluated before.Aim:In this prospective observational study, we aim to determine the clinical risk profiles of patients with ACS in Bahrain and describe the incidence, pattern of presentation and predictors of in-hospital clinical outcomes after admission.Methods:Patients with ACS were prospectively enrolled over a 12 month period. The rate of incidence of risk factors in patients was compared with 635 non-cardiac patient admissions that matched for age and gender. Multiple logistic regression analysis was used to predict poor outcomes in patients with ACS. The variables were ages >65 years, body mass index (BMI) >28 kg/m2, GRACE (Global Registry of Acute Coronary Events) score >170, history of diabetes mellitus (DM), systolic hypertension >180 mmHg, level of creatinine >160 μmol/l and Heart Rate (HR) on admission >90 bpm, serum troponin rise and ST segment elevation on the ECG.Results:Patients with ACS (n=635) were enrolled consecutively. Mean age was 61.3 ± 13.2 years, with 417 (65.6%) male. Mean age for patients with ST-segment elevation myocardial infarction (STEMI, n=156) compared with non-STEMI (NSTEMI, n=158) and unstable angina (UA, n=321) was 56.5± 12.8 vs 62.5±14.0 years respectively. In-hospital mortality was 5.1%, 3.1% and 2.5% for patients with STEMI, NSTEMI, and UA, respectively. In STEMI patients, thrombolytic therapy was performed in 88 (56.5%) patients and 68 (43.5%) had primary coronary angioplasty (PCI). The predictive value of different clinical variables for in-hospital mortality and cardiac events in the study were: 2.8 for GRACE score >170, 3.1 for DM, 2.2 for SBP >180 mmHg, 1.4 for age >65 years, 1.8 for BMI >28, 1.7 for creatinine >160 μmol/L, 2.1 for HR >90 bpm, 2.2 for positive serum troponin and 2.3 for ST elevation.Conclusion:Patients with STEMI compared with NSTEMI and UA were of younger age. There was higher in-hospital mortality in STEMI compared with NSTEMI and UA patients. The most significant predictors of death or cardiac events on admission in ACS were DM, GRACE Score >170, systolic hypertension >180 mmHg, positive serum troponin and HR >90 bpm.

The utility of the triage electrocardiogram for the detection of ST-segment elevation myocardial infarction

IntroductionCurrent AHA/ACC guidelines on the management of ST-elevation myocardial infarction (STEMI) suggest that an ECG is indicated within 10minutes of arrival for patients arriving to the Emergency Department (ED) with symptoms concerning for STEMI. In response, there has been a creep towards performing ECGs more frequently in triage. The objectives of this study were to quantify the number of triage ECGs performed at our institution, assess the proportion of ECGs performed within current hospital guidelines, and evaluate the rate of STEMI detection in triage ECGs. MethodsA retrospective chart review of all emergency department patients presenting over a period of 8days who had a triage ECG performed. Cases of bradycardia or tachycardia were excluded. Data collection included patient demographics, presenting complaint, cardiac risk factors, troponin values, and final diagnosis. Summary statistics are reported in a descriptive manner. ResultsDuring the study period, 538 patients had a triage ECG for possible STEMI with no STEMI identified and 16 NSTEMI diagnoses (confirmed as positive troponins following ED assessment). Sixty-three (11.7%) patients did not meet internal criteria for a triage ECG. A NSTEMI ED diagnosis was identified in 3% of patients who met internal triage ECG criteria and 1.6% who did not meet criteria (p=0.29). A cost analysis was performed using an average of 50 STEMI cases diagnosed in our ED per given year. Current institutional ECG billing rates for ECGs performed and interpreted is $125 per ECG, providing an estimated triage ECG charge to detect one STEMI at $54,295. DiscussionThis retrospective study of 538 triage ECG's performed over an 8day period identified no STEMIs and 16 NSTEMIs. A very large number of ECGs were done at triage overall and included patients who do not meet our own hospital criteria. Given the extremely low yield and high associated charges, current guidelines for triage ECG for identifying a possible STEMI should be reviewed.

Abstract 66: Practical Application of Serial Measurement of Cardiac Troponin I for Risk Stratification in Acute Ischemic Stroke

Background: Serum cardiac troponin can be increased in acute ischemic stroke and regarded as a prognostic marker after stroke as similar as coronary artery disease (CAD). However, interpretation of troponin elevation in ischemic stroke patients is complex. Therefore, the aim of this study was to elucidate the possible causes and long-term prognostic value of troponin elevation in ischemic stroke patients. Methods: In a prospective, single center cohort study, we performed serial measurement of serum troponin and 12-lead electrocardiogram (ECG) at 48 hours after stroke onset followed by admission. Based on troponin I level at 48 hours, patients were categorized into 3 groups; elevated (≥0.04 ng/mL), minimally elevated (0.040-0.010 ng/mL) and non-detectable (&lt;0.010 ng/mL) level. Comorbidities with possible impact on troponin elevation were documented based on either historical information or abnormalities in disease-related biomarkers. The primary endpoint was death and major adverse cardiac and cerebrovascular event (MACCE). Results: Among 1092 consecutive patients during 2-year period, 145 patients (13.3%) and 335 patients (30.7%) had a positive and minor elevation troponin. Multivariable analysis identified six-comorbidities included atrial fibrillation (AF), hypertrophic myocardium (HM), heart failure (HF), chronic kidney disease (CKD), active cancer and possibly ischemic heart disease (IHD), and composite neurological factor (defined as moderate to severe deficits or insular lesions) associated with troponin elevation. In a multivariate Cox model, minimally and elevated troponin were independently associated with death (hazard ratio [HR]: 1.77, 95% confidence interval [CI]: 1.07-2.91 for minor elevation and HR: 3.63, 95% CI: 2.13-6.19 for positive troponin) and combined endpoints of MACCE. Conclusions: Troponin elevation even minor elevation are associated with mortality and MACCE in patients with acute stage of ischemic stroke.