Positive Troponin Research Articles

Effect of Prehospital Blood Draws on Length of Stay for Chest Pain Patients in the Emergency Department: A Pilot Study.

This article provides research of cardiac biomarkers being drawn in the prehospital setting compared with the emergency department (ED) on intervals critical to the diagnosis of acute myocardial infarction. This is a retrospective chart review of patients brought to the ED of a single, urban teaching hospital by a single emergency medical service (EMS) agency with a chief complaint of "chest pain." We abstracted specific patient characteristics, intervals, positive troponin values, and rates of hemolysis from hospital records utilizing a custom data abstraction tool designed for this study through consensus of the authors. Data were compared between patients who did and did not have prehospital laboratory work performed for cardiac biomarkers utilizing parametric and nonparametric tests when appropriate. Of the initial 49 patients identified, 41 met inclusion criteria; 20 patients (49%) did not have prehospital EMS laboratory results drawn while 21 (51%) patients did have prehospital laboratory results drawn. Overall, 17% (7/41) had positive cardiac biomarkers. The groups were similar with regard to age, gender, race, and medical history. Median time (interquartile range) in minutes, from ED arrival to laboratory results available was shorter for patients with EMS laboratory results compared with those without EMS laboratory results: 53 (45-64) versus 71 (54-95) (P = .02). Time from ED arrival to disposition decision (P = .39) and total ED length of stay (P = .12) were similar between groups. In this preliminary study, prehospital laboratory results were associated with shorter times from ED arrival to the results being available.

Rose Angina Questionnaire: Validation in emergency department to detect myocardial infarction in a tertiary hospital of eastern Nepal

Background: Rose Angina Questionnaire (RAQ) is a useful screening questionnaire for ischemic heart disease validated in different settings; however, its diagnostic ability to predict myocardial infarction (MI) in the emergency is less clear. Objectives: To find out the usefulness of RAQ to predict MI in patients presenting to the emergency. Methods: A cross-sectional study was conducted at the BP Koirala Institute of Health Sciences (BPKIHS), a teaching hospital in eastern Nepal from 1 January to 30 March 2017, after ethical clearance from the Institutional Review Committee. Informed consent was obtained from the patients for their anonymised information to be published in this study The samples were collected from 100 patients with chest pain aged 40 to 70 years presenting to the emergency. RAQ was applied and its performance to detect MI was compared with emergency and cardiologist diagnosis of MI. Sensitivity, specificity, positive predictive value and negative value were calculated along with descriptive analysis. Results: A total of 100 patients were analysed with the mean age of 63.78 years (SD 11.60) and male to female ratio of 1.94. RAQ detected 58 cases (63.8%) with emergency department (ED) diagnosis of MI (true positive) and identified 3 (33.3%) cases with non-MI (true negative). The true positive rate for RAQ to detect MI after cardiologist consultation was 71.6%. RAQ had a sensitivity of 84.91% (95% confidence interval (CI) 72.41% –93.25%) to detect positive troponin, 63.74% (52.99–73.56) to detect positive electrocardiogram (ECG) and 71.60% (95% CI 60.5% to 81.07%) to detect final diagnosis of MI. Conclusion: RAQ is a good screening tool to detect MI in the emergency that can be used in isolation or in combination with other diagnostic modalities to detect it early.

Cardiac Biomarkers Predict Large Vessel Occlusion in Patients with Ischemic Stroke

Background and PurposeCardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). We hypothesized that cardiac biomarkers (cardiac troponin and left atrial diameter [LAD]) would be associated with the presence of LVO. MethodsData were abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with CT angiography of the head and neck. The presence of LVO was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers (positive troponin [troponin ≥0.1 ng/mL] and LAD on transthoracic echocardiogram) and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF). ResultsWe identified 1234 patients admitted with AIS; 886 patients (71.8%) had vascular imaging to detect LVO. Of those with imaging available, 374 patients (42.2%) had LVO and 207 patients (23.4%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age, sex and other risk factors (adjusted OR 1.69 [1.08-2.63], P = .022) and this association persisted after including AF in the model (adjusted OR 1.60 [1.02-2.53], P = 0.043). There was an association between LAD and LVO after adjusting for age, sex, and risk factors (adjusted OR per mm 1.03 [1.01-1.05], P = 0.013) but this association was not present when AF was added to the model (adjusted OR 1.01 [0.99-1.04], P = .346). Sensitivity analyses using thrombectomy as an outcome yielded similar findings. ConclusionsCardiac biomarkers, particularly serum troponin levels, are associated with acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.

Abstract WP279: Cardiac Biomarkers Predict Large Vessel Occlusion in Patients With Ischemic Stroke

Background and Purpose: Cardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and large vessel occlusion (LVO) in patients with acute ischemic stroke (AIS). We aim to determine the association between cardiac biomarkers [cardiac troponin and left atrial diameter (LAD)] and the presence of large vessel occlusion. Methods: Data was abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with intracranial vascular imaging (CT angiogram or MR angiography). The presence of large vessel occlusion was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers [positive troponin (troponin > 0.1) and LAD on transthoracic echocardiogram] and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF). Results: We identified 1234 patients admitted with AIS; 886 patients (71.8%) had intracranial MRA or CTA. Of those with imaging available, 398 patients (44.9%) had LVO and 232 patients (26.2%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age and sex and other risk factors [adjusted OR 1.97 (1.29-3.00), P=0.002)] and this association persisted after including AF in the model [adjusted OR 1.90 (1.24-2.93), p=0.003]. There was an association between LAD and LVO after adjusting for age, sex, and risk factors [adjusted OR per mm 1.04 (1.01-1.06), p = 0.002] but this association was not present when AF was added to the model [adjusted OR 1.01 (0.99-1.04), p = 0.323]. Sensitivity analyses using thrombectomy as an outcome yielded similar findings. Conclusion: Cardiac biomarkers predict acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.

Abstract WP263: Wall Motion Abnormalities on Transthoracic Echocardiography in the Setting of Ischemic Stroke Reflect Underlying Cardiac Disease and May Warrant an Ischemic Cardiac Evaluation

Background and Purpose: Patients with acute ischemic stroke (AIS) are at a heightened risk of cardiovascular events. We hypothesize that wall motion abnormalities (WMA) on transthoracic echocardiography (TTE) in the setting of AIS reflect underlying heart disease rather than reversible cardiac strain caused by the stroke. Methods: Data was abstracted from a single center prospective AIS database over 18 months and included all patients with acute ischemic stroke who underwent a TTE. The presence of WMA was abstracted from the TTE report. Univariate analyses and predefined multivariable models were performed to determine factors associated with WMA, including demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, atrial fibrillation, congestive heart failure, coronary heart disease, and smoking), NIHSS score, cardiac markers (positive troponin, ECG evidence of prior myocardial infarction, ejection fraction), and insular location of infarct. Results: We identified 1044 patients who met the inclusion criteria; 139 (13.3%) had evidence of WMA, of which only 23 patients had no history of heart disease or ECG evidence of prior myocardial infarction. Among these 23 patients, 12 had a follow up TTE after the stroke and WMA persisted in 92.7% (11/12) of patients. On fully adjusted models, factors associated with WMA are older age (OR per SD 1.03, 95% CI 1.001-1.05; p=0.009), congestive heart failure (OR 4.44, 95% CI 2.39-8.33, p<0.001), history of coronary artery disease or ECG evidence prior myocardial infarction (OR 27.03, 95% CI 14.93-50.0, p<0.001), and elevated serum troponin levels (OR 2.00, 95% CI 1.06-3.75, p=0.031). Conclusion: In AIS patients, WMA on TTE may reflect underlying cardiac disease and warrant further cardiovascular evaluation particularly in those without known history of cardiac disease. Future studies are needed to investigate the cost-effectiveness of this approach.

Vasospastic coronary event following a single dose of amoxicillin in a patient with normal coronary arteries: Kounis syndrome and the myocardial infarction with normal coronary arteries conundrum.

In the interesting report of Pradhan, Christ and Trapper (1) published in the Journal of Cardiovascular Diagnosis and Therapy , a 22-year-old man developed acute retrosternal pain and chest tightness with ischemic changes in inferolateral wall (ST elevation =0.2 mV) and positive troponin following a single dose of amoxicillin administered for acute tonsillitis treatment. Urgent coronary angiography demonstrated normal coronary arteries. The initial diagnosis of acute ST elevation myocardial infarction (STEMI) was attributed to coronary artery spasm, whereas acute myocarditis considered as a differential diagnosis.

Carbon Monoxide: A Rare Cause of Myocardial Ischemia

In an acute care setting, chemical asphyxiants (CA) are a vice which cause debilitating injury. Carbon monoxide (CO) is one well known CA which causes hypoxic injury to cardiovascular and neurological tissue. CO poisoning is one of the leading causes of death in USA. As many as 6% of patients who get admitted with CO poisoning in the USA have acute myocardial infarction. A strong positive correlation of CO Hb concentration has been established with increased incidence of MIs. We present a case of a 75-year-old male with complaints of chest discomfort, dyspnea, diaphoresis that was attributed to CO poisoning. Over the course of his stay he had two sets of positive serial troponins and was diagnosed with a non-ST elevation MI. Most of the recent literature focuses on ST elevation and T wave inversions in patients with CO poisoning. Contrary to this, our patient did not exhibit any EKG changes at any point during his hospital course. CO poisoning can cause fatal complications including an MI.

Serum Troponin Level in Acute Ischemic Stroke Identifies Patients with Visceral Infarcts

Background and Purpose: Patients with ischemic stroke of cardioembolic origin are at risk of visceral (renal or splenic) infarction. We hypothesized that serum troponin level at time of ischemic stroke would be associated with presence of visceral infarction. Methods: Data were abstracted from a single center prospective stroke database over 18 months and included all patients with ischemic stroke who underwent contrast-enhanced computerized tomography (CT) of the abdomen and pelvis for clinical purposes within 1 year of stroke. The primary predictor was troponin concentration ≥.1ng/mL. The primary outcome was visceral infarct (renal and/or splenic) on CT abdomen and pelvis. Univariate and multivariable logistic regression models were used to estimate the odds ratio and 95% confidence intervals (OR, 95% CI) for the association of troponin with visceral infarction. Results: Of 1233 patients with ischemic stroke, 259 patients had a qualifying visceral CT. Serum troponin level on admission was measured in 237 of 259 patients (93.3%) and 41 of 237 (17.3%) had positive troponin. There were 25 patients with visceral infarcts: 16 renal, 7 splenic, and 2 both. In univariate models, patients with a positive troponin level (versus negative) were more likely to have visceral infarcts (39.1% [9/23] versus 15.0% [32/214], P = .008) and this association persisted in multivariable models (adjusted OR 3.83; 95% CI 1.42-10.31, P = .006). Conclusions: In ischemic stroke patients, elevated serum troponin levels may help identify patients with visceral infarcts. This suggests that troponin in the acute stroke setting is a biomarker of embolic risk. Larger studies with systematic visceral imaging are needed to confirm our findings.

CCTA in patients with positive troponin and low clinical suspicion for ACS: a useful diagnostic option to exclude obstructive CAD.

It is uncertain whether patients with elevated troponin and non-classical presentation of acute coronary syndrome (ACS) should receive coronary CT angiography (CCTA). A proportion of these patients will have no coronary artery disease (CAD) and would benefit from non-invasive investigations and expedited discharge. Objectives were to determine most common diagnoses and rate of ACS among patients with positive troponin and low clinical suspicion of ACS who received CCTA. IRB approved retrospective analysis of 491 consecutive patients in a level I trauma center ED referred for CCTA between April 4, 2015 to April 2, 2017. Patients were included if there was an elevated troponin (TnI > 0.045μg/L) and atypical chest pain within 24h prior to imaging. One hundred one patients met inclusion criteria; 17 excluded due to technical factors or history. Scans performed on dual-source CT. Eighty-four patients (47 men, 37 women) with median TnI of 0.11 ± 0.21μg/L underwent CCTA 8.20 ± 6.41h after first elevated Tn. Mean age was 53.2 ± 14.6years. CCTA demonstrated absence of CAD in 39 patients (46.4%; 20 M, 19 F). CAD < 25% stenosis was observed in 24 (28.6%; 9 M, 15 F). CAD with 25-50% stenosis was observed in seven (8.3%; six M, one F). CAD > 50% stenosis was observed in 11 (13.1%; 9 M, 2 F), and non-diagnostic in three (3.6%, 3 M, 0 F). Forty-six (56.8%) were discharged directly from ED with median stay 15.82 ± 6.41h. Use of CCTA in ED patients with elevated troponin and low clinical suspicion for ACS allowed obstructive CAD to be excluded in 83%.

Positive Troponin and Negative Stress Test: Why the Conundrum?

A 70-year old man otherwise physically active and healthy except having a history of gastroesophageal reflux presented to the local emergency room (ER) with chest discomfort while getting ready to go to work in the morning.

Behavioral Influence of Known Prognostic Markers on the Cardiologist's Decision following Acute Coronary Syndrome: the GRACE Score Paradox.

BackgroundBehavioral scientists consistently point out that knowledge does not influence decisions as expected. GRACE Score is a well validated risk model for predicting death of patients with acute coronary syndromes (ACS). However, whether prognostic assessment by this Score modulates medical decision is not known.ObjectiveTo test the hypothesis that the use of a validated risk score rationalizes the choice of invasive strategies for higher risk patients with non-ST-elevation ACS.MethodsACS patients were consecutively included in this prospective registry. GRACE Score was routinely used by cardiologists as the prognostic risk model. An invasive strategy was defined as an immediate decision of the coronary angiography, which in the selective strategy was only indicated in case of positive non-invasive test or unstable course. Firstly, we evaluated the association between GRACE and invasiviness; secondly, in order to find out the actual determinants of the invasive strategy, we built a propensity model for invasive decision. For this analysis, a p-value < 0.05 was considered as significant.ResultsIn a sample of 570 patients, an invasive strategy was adopted for 394 (69%). GRACE Score was 118 ± 38 for the invasive group, similar to 116 ± 38 for the selective group (p = 0.64). A propensity score for the invasive strategy was derived from logistic regression: positive troponin and ST-deviation (positive associations) and hemoglobin (negative association). This score predicted an invasive strategy with c-statistics of 0.68 (95%CI: 0.63-0.73), opposed to GRACE Score (AUC 0.51; 95%CI: 0.47-0.57).ConclusionThe dissociation between GRACE Score and invasive decision in ACS suggests that the knowledge of prognostic probabilities might not determine medical decision.

Troponin Assay (cTnI) in the Real World: Is it Always a Diagnosis of Acute Myocardial Infarction?

Background: The soon to be implemented state-wide introduction of high-sensitivity troponin assays (hscTn) will allow the use of a lower threshold in identifying patients with acute myocardial infarction (AMI). Whether this assay will be too sensitive and therefore produce increased false positive results is still unclear. We aim to investigate whether a significantly elevated cardiac troponin using the current troponin assay (cTnI) will result in a clinical diagnosis of AMI. Methods: A retrospective study was performed at a Queensland Hospital with all cTnI ordered across a single month reviewed. Patients who were diagnosed with NSTEMI or STEMI were labelled as having an AMI. Results: In total, 944 investigations were ordered for 628 patients. Using the hospital laboratory cutoff of >0.040 μg/L (>99th percentile) for significance, a positive result was obtained in 105 patients (16.7%) and a negative result in 523 patients (83.3%). The positive troponin results were attributed to AMI (20%), congestive heart failure (20%), sepsis (19%), tachyarrhythmias (16.2%), renal failure (8.6%), airway disease (8.6%), pulmonary embolism (3.8%) and others - pericarditis, post angioplasty etc (3.8%). cTnI was found to be highly sensitive (100%, 95%CI 84–100%) and specific (86%, 95%CI 83–89%) for AMI. However, only 21 (3.3%) of 628 patients investigated received a diagnosis of AMI. The positive predictive value was poor (20%,95%CI 13–29%), with the negative predictive value absolute (100%, 95%CI 99–100%). Conclusion: Current troponin assays (cTnI) were found to be highly sensitive and specific in diagnosing AMI. However, its poor positive predictive value may be contributed by inappropriate requests.

Effectiveness of the physical activity intervention program in the PREDIMED-Plus study: a randomized controlled trial

BackgroundThe development and implementation of effective physical activity (PA) intervention programs is challenging, particularly in older adults. After the first year of the intervention program used in the ongoing PREvención con DIeta MEDiterránea (PREDIMED)-Plus trial, we assessed the initial effectiveness of the PA component.MethodsPREDIMED-Plus is an ongoing randomized clinical trial including 6874 participants randomized to an intensive weight-loss lifestyle intervention based on an energy-restricted Mediterranean diet (MedDiet), physical activity promotion and behavioral support and to a control group using MedDiet recommendations but without calorie restriction or PA advice. Body mass index (BMI) and waist circumference (WC) are measured by standard clinical protocols. Duration and intensity of PA is self-reported using the validated REGICOR Short Physical Activity Questionnaire. The primary endpoint of the PREDIMED-Plus trial is a combined cardiovascular outcome: myocardial infarction (acute coronary syndromes with positive troponin test), stroke, or cardiovascular mortality. The present study involved secondary analysis of PA data (n = 6059; mean age 65 ± 4.9 years) with one-year changes in total, light, and moderate-to-vigorous PA within and between intervention groups as the outcome. Generalized estimating equation models were fitted to evaluate time trends of PA, BMI, and WC within groups and differences between intervention and control groups.ResultsAfter 12 months, average daily MVPA increased by 27.2 (95%CI 5.7;48.7) METs-min/day and 123.1 (95%CI 109.7–136.6) METs-min/day in the control and intervention groups, respectively. Total-PA, light-PA, and MVPA increased significantly (p < 0.01) in both groups. A significant (p < 0.001) time*intervention group interaction was found for Total-PA and MVPA, meaning the PA trajectory over time differed between the intervention and control groups. Age, sex, education level, and BMI did not moderate the effectiveness of the PA intervention. BMI and WC decreased significantly with increasing MVPA, compared with participants who reported no changes in MVPA.ConclusionAfter one year of follow-up, the PREDIMED-Plus PA intervention has been effective in increasing daily PA in older adults.Trial registrationRetrospectively registered at the International Standard Randomized Controlled Trial (http://www.isrctn.com/ISRCTN89898870), registration date: 24 July 2014.

Troponin Improves the Yield of Transthoracic Echocardiography in Ischemic Stroke Patients of Determined Stroke Subtype.

Background and Purpose- Transthoracic echocardiography (TTE) is widely used in the ischemic stroke setting. In this study, we aim to investigate the yield of TTE in patients with ischemic stroke and known subtype and whether the admission troponin level improves the yield of TTE. Methods- Data were abstracted from a single-center prospective ischemic stroke database for 18 months and included all patients with ischemic stroke whose etiologic subtype could be obtained without the need of TTE. Unadjusted and adjusted regression models were built to determine whether positive cardiac troponin levels (≥0.1 ng/mL) improve the yield of TTE, adjusting for demographic and clinical characteristics. Results- We identified 578 patients who met the inclusion criteria. TTE changed clinical management in 64 patients (11.1%), but intracardiac thrombus was detected in only 4 patients (0.7%). In multivariable models, there was an association between TTE changing management and positive serum troponin level (adjusted odds ratio, 4.26; 95% CI, 2.17-8.34; P<0.001). Conclusions- In patients with ischemic stroke, TTE might lead to a change in clinical management in ≈1 of 10 patients with known stroke subtype before TTE but changed acute treatment decisions in <1 percent of patients. Serum troponin levels improved the yield of TTE in these patients.

The Use of Routine Troponins Following Endovascular Repair of Abdominal Aortic Aneurysms to Detect Perioperative Cardiovascular Events

Introduction: Incidence of perioperative cardiac complications following endovascular aneurysm repairs (EVAR) range from 2-10% (1). Approximately 60% of all perioperative deaths in EVAR surgery are from cardiac causes (2, 3, 4). Detecting myocardial infarctions in the post-operative period remains challenging as the majority of patients remain asymptomatic during an event (5). Methods: In a retrospective cohort study a total list of 105 patients over 18 months were identified in this hospital that had EVARs. 25 of these were excluded from the study as they failed to get an ECG or troponins performed postoperatively. Routine troponins and ECGs within 12 hours and again within 48 hours of the EVAR procedure in order to detect acute cardiovascular events. Results: 16% (n=13) of patients had a positive troponin detected routinely. Of these, 15% (n=2) were diagnosed with an acute myocardial event based on ECG findings, coronary angiogram and assessment by a cardiologist. Two further patients had acute myocardial events, however these were detected after routine troponins and ECGs were taken. Of our four patients with cardiac events, only one reported signs or symptoms consistent with a classical myocardial infarction. Discussion: Positive predictive value of routine troponins is 15% in detecting acute myocardial events. As a result, their routine use is not advised. ECGs could be performed routinely pre- and post-operatively and troponins taken if there are ECG changes in keeping with a myocardial event.

27-Year-Old Man with a Positive Troponin: A Case Report.

In this case report, we describe a young athletic male with a family history of early sudden cardiac death who presented with atypical chest pain and was found to have a positive serum troponin. Although his symptoms resolved without intervention, workup revealed hypertension, hyperlipidemia, mild left ventricular hypertrophy, non-obstructive coronary artery disease, and the presence of serum heterophile antibodies. Ultimately, it was concluded that his rigorous exercise regimen as well as the presence of heterophile antibodies may have contributed to his positive serum troponin. This case serves as a reminder of the nonspecific diagnostic value of modern troponin assays, and that the results of these tests should always be incorporated into the clinical context.

This Article Corrects: “Coronary Disease in Emergency Department Chest Pain with Recent Negative Stress Testing”

[This corrects the article on p. 384 in vol. 11, PMID: 21079714.].

195 Screening Electrocardiograms in Cocaine-Positive Chest-Pain-Free Psychiatric Patients Requiring Medical Clearance

Current practice at our large, public, urban academic emergency department (ED) is to obtain a screening electrocardiogram (ECG) as part of the medical clearance process on all patients who require transfer to an inpatient psychiatric facility and test positive for cocaine on a urine toxicology screen regardless of the presence or absence of chest pain. The purpose of this retrospective quality improvement study is to examine the utility and impact of a screening ECG for patients with urine toxicology screening positive for cocaine who are chest-pain-free and require medical clearance prior to transfer to an inpatient psychiatric facility. An institutional review board-approved, retrospective chart review between January 2014 - December 2015 was performed of all ED patients (1) over 18 years of age, (2) without chest pain documented in the medical record, (3) who required medical clearance in the ED prior to transfer to an inpatient psychiatric facility, (4) who tested positive for cocaine on a screening urine toxicology test, and (5) for whom a screening ECG was obtained. All ECGs were interpreted by an attending physician. Abnormal ECGs were defined as: nonspecific ST changes, T wave inversions, sinus tachycardia, ST elevation, or ST depression. All abnormal ECGs were compared to prior ECGs if available, and if no change noted then these were categorized as normal. Primary outcome was disposition of the patient to an inpatient psychiatric facility versus inpatient medical admission. Secondary outcomes were rates of a subsequent cardiac workup, including inpatient medical admission, cardiac enzymes, stress testing, cardiology consultation, and cardiac catheterization. During the study period, 1968 ED patients tested positive for cocaine on a urine toxicology screen and 853 met inclusion criteria. ECGs were normal in 809 (95%, 95% CI [93%, 96%]) patients, and abnormal in 44 (5%, 95% CI [4%, 7%]) patients. Of the 44 patients with abnormal ECGs, 4 were admitted for a cardiac workup. Two patients had positive troponins in the ED. Two patients had cardiology consultations and 3 had further cardiac stress testing performed, all of which were negative or non-diagnostic. No cardiac catheterizations were performed on any patients. Based on the results of our study, the majority of ED patients with recent cocaine use but without chest pain have a normal ECG. Of the minority of patients with an abnormal ECG, there were no cases of acute myocardial ischemia or infarction identified in the absence of chest pain. Therefore, a screening ECG in patients without chest pain simply because of a cocaine-positive urine toxicology test does not appear to identify any cases of myocardial ischemia or infarction and may, in fact, lead to over-testing, increased admission, misuse of resources, and increased cost. Limitations of this study include its retrospective, chart review design. Additionally, there is the possibility of a patient not being forthcoming regarding the presence or absence of chest pain and being categorized incorrectly.

Predicting of neuropsychosis in carbon monoxide poisoning according to the plasma troponin, COHb, RDW and MPV levels: Neuropsychoses in carbon monoxide poisoning

ObjectiveCarbon monoxide (CO) poisoning is very common worldwide. In this study, we aimed to evaluate the predictivity of neuro psychosis in carbon monoxide poisoning by the admission levels of red cell distribution (RDW), mean platelet volume (MPV) and troponin I levels which can be measured quickly and easily in the emergency department (ED). Patients and methodsThis single center observational study included a total of 216 consecutive patients who presented to the ED due to CO poisoning between January 2009 and December 2013. The diagnosis of CO poisoning was made according to the medical history and carboxyhemoglobin (COHb) level of >5%. According to the carboxyhemoglobin levels, the patients were classified as mildly (COHb < 20%) and severely poisoned (COHb > 20%). In addition, patients were divided into 2 groups, i.e., those with positive (>0.05 ng/mL for our laboratory) and negative (<0.05 ng/mL for our laboratory) troponin levels. ResultsPatients mean age was 52.58 ± 10.58. 57.9% of the patients had high troponin levels and 51.9% were poisoned severely according to COHb levels. Patients with positive troponin and COHb had longer CO exposure time and higher neutrophil, lymphocyte, mean platelet volume (MPV), COHb and red cell distribution width (RDW) levels at the index admission following CO poisoning than patients with negative troponin (p < 0.05). Age, COHb level, CO exposure time, MPV and RDW (p = 0.001, p < 0.05) remained associated with an increased risk of troponin positivity following adjustment for the variables that were statistically significant. ConclusionsIn patients presenting to the ED with CO poisoning, RDW and MPV can be helpful for risk stratification of neuropsychosis.

Subclinical myocardial injury during vaso-occlusive crisis in pediatric sickle cell disease.

Acute painful crisis is the most frequent complication of sickle cell disease (SCD) in children. Recurrent vaso-occlusion may be associated with cardiac injury. The study aimed to assess silent myocardial injuries for sickle cell children during acute painful crisis by measuring serum level of troponin I and galectin-3. The study included 87 participates; study group (n = 44) sickle cell children presented at Jeddah hospitals in Saudi Arabia by painful crisis or acute illness as fever or cough (2017-2018). The controls were healthy children (n = 43). Demographic and history data were collected from the cases. Troponin I and galectin-3 were measured. Galectin-3 values were higher among cases with significant difference when compared to controls (7.5 ± 3.1 versus 3.2 ± 1.6, < 0.001). Galectin-3 at a cutoff > 5.1ng/ml, the sensitivity was 88.64 and specificity was 88.37. Galectin-3 levels were higher for the pain crisis subgroup in comparison to acute illness group with significant difference (r 0.551*, p < 0.001*). Galectin-3 values were higher among troponin-positive cases with significant difference (p = 0.046) to troponin-negative cases.Conclusion: Positive results of troponin I and high levels of galectin-3 in sickle cell children during acute painful crisis were potent indicators for subclinical myocardial injury. What is Known: • The hallmark of sickle cell disease is recurrent episodes of vaso-occlusive crisis which had deleterious effects on many organs. • Cardiac changes in pediatric sickle cell disease whether structural or functional are mainly attributed to chronic anemia and or pulmonary hypertension. What is New: • The observed positive results of cardiac troponin I and high values of galectin-3 in sickle cell children during vaso-occlusive crisis are strong indicator of myocardial ischemia and ongoing cardiac fibrosis respectively. • The observed correlation between biological markers (positive troponin and high galectin-3) could be an indication of subclinical cardiac injury.