Elevated Troponin T Research Articles

Increased Cardiac Troponin-T in Patients without Myocardial Infarction

There have been recently reports on elevated levels of cardiac troponins in patients without acute myocardial infarction (AMI). The purpose of the study was to analyze final diagnoses in patients with elevated cardiac troponin-T levels without clinical manifestations and characteristic ECG changes in AMI. Subjects and materials. The study included 72 patients (48 males and 24 females whose age ranged from 54 to 87 years (mean 69.8±11.2 years)). The criterion for inclusion was increased cardiac troponin-T; the primary criteria for exclusion were AMI-specific anginal pains and characteristic ECG changes (ST-segment elevation, abnormal Q waves). The definitive diagnosis of AMI was established only in 29 (40.3%) patients; the remaining 43 patients were diagnosed as having the following diseases: sepsis (n=21), cancer (n=10), diabetic nephropathy with chronic renal failure (n=6), cerebral infarction (n=4), and B12-deficiency anemia (n=2). In deceased patients, the level of troponin-T was higher than that in those who was discharged from hospital irrespective of the underlying disease. Results. There was a direct correlation between the level of cardiac troponin-T and the SAPS II index that reflects the general condition of a patient (r=0.44; p=0.0001) and an inverse correlation between the former and the left ventricular ejection fraction (r=-0.45; p=0.003). Conclusion. Thus, despite its cardiac specificity and its detection in the blood of critically ill patients without other manifestations of AMI, cardiac troponin-T is not a specific symptom of AMI, but suggests the severity of the disease, possibly, with the involvement of the myocardium in the pathological process. Key words: cardiac troponins, myocardial infarction, multiple organ dysfunction, systemic inflammatory reaction.

Minimally Elevated Cardiac Troponin T and Elevated N-Terminal Pro-B-Type Natriuretic Peptide Predict Mortality in Older Adults: Results From the Rancho Bernardo Study

This study investigated the prognostic value of detectable cardiac troponin T (TnT) and elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in a population of community-dwelling older adults. Minimally elevated levels of TnT, a marker of cardiomyocyte injury, have been found in small subsets of the general population, with uncertain implications. A marker of ventricular stretch, NT-proBNP has clinical utility in many venues, but its long-term prognostic value in apparently healthy older adults and in conjunction with TnT is unknown. Participants were 957 older adults from the Rancho Bernardo Study with plasma NT-proBNP and TnT measured at baseline (1997 to 1999) and followed up for mortality through July 2006. Participants with detectable TnT (>/=0.01 ng/ml, n = 39) had an increased risk of all-cause and cardiovascular death (adjusted hazard ratio [HR] by Cox proportional hazards analysis: 2.06; 95% confidence interval [CI]: 1.29 to 3.28, p = 0.003 for all-cause mortality; HR: 2.06, 95% CI: 1.03 to 4.12, p = 0.040 for cardiovascular mortality); elevated NT-proBNP also predicted an increased risk of all-cause and cardiovascular mortality (adjusted HR per unit-log increase in NT-proBNP: 1.85, 95% CI: 1.36 to 2.52, p < 0.001 for all-cause mortality; HR: 2.51, 95% CI: 1.55 to 4.08, p < 0.001 for cardiovascular mortality). Those with both elevated NT-proBNP and detectable TnT had poorer survival (HR for high NT-proBNP and detectable TnT vs. low NT-proBNP and any TnT: 3.20, 95% CI: 1.91 to 5.38, p < 0.001). Exclusion of the 152 participants with heart disease at baseline did not materially change the TnT mortality or NT-proBNP mortality associations. Apparently healthy adults with detectable TnT or elevated NT-proBNP levels are at increased risk of death. Those with both TnT and NT-proBNP elevations are at even higher risk, and the increased risk persists for years.

Cardiac blood biomarkers in patients receiving thoracic (chemo)radiation

Cardiotoxicity is a known consequence of thoracic irradiation and there are multiple overlapping risk factors for cardiac disease and thoracic malignancies. In this study, we quantified the impact of thoracic (chemo)radiation on cardiac troponin T (TnT), creatine kinase-myocardial band (CK-MB) and aminoterminal pro-brain natriuretic peptide (NT-proBNP). Thirty patients receiving radiation therapy to the thorax with or without concurrent chemotherapy were evaluated. Serum was collected at baseline, 2 weeks into treatment and at the completion of radiation therapy. TnT, CK-MB and NT-proBNP were quantified using commercially available immunoassays. Cardiac dosimetric parameters and clinical risk factors were examined. In 29 of 30 patients, serum TnT remained undetectable (<0.01ng/mL) throughout (chemo)radiation. In the one patient with detectable serum TnT, levels did not change significantly with treatment. Similarly, thoracic (chemo)radiation did not cause statistically significant elevations in serum CK-MB and NT-proBNP. Thus, contemporary thoracic (chemo)radiation does not commonly result in elevations of serum TnT, CK-MB or NT-proBNP. Elevations in these markers during treatment merit further evaluation.

Changes of C-reactive Protein are Associated With Myocardial Injury After Successful Percutaneous Coronary Intervention

Background and Objectives: Myocardial injury after percutaneous coronary intervention (PCI) occurs frequently and it is associated with an adverse clinical outcome. Mechanical factors have been implicated in this complication and the role of inflammation has not yet been clearly determined. We evaluated the effect of an inflammatory response during PCI on periprocedural myocardial injury. Subjects and Methods: We prospectively studied 231 patients (mean age: 62.8±10.6 years, males: 60.6%) who underwent elective coronary stenting. For the exclusion of mechanical injury to the myocardium, we excluded those patients who developed complications during PCI. Blood samples for measuring the high sensitivity C-reactive protein (hsCRP) and troponin T (TnT) were obtained before the procedure and at 6 hours and 24 hours after PCI. The inflammatory response to PCI was calculated as the difference between the peak postprocedural hsCRP level and the preprocedural hsCRP level (delta CRP). We divided the patients according to the median value of delta CRP: Group I <2.2 mg/dL and Group II ≥2.2 mg/dL. Results: Postprocedural TnT elevation was were observed in 72 (31.2%) patients. The baseline clinical and angiographic characteristics were not difference between the two groups. The incidence of any TnT elevations was higher in the Group II than that in Group I (19.8% vs 42.6%, respectively, p<0.001). The incidences of TnT levels over 3 times the upper normal limit and 5 times the upper normal limit were also higher in Group II than in Group I (11.2% vs 21.7%, respectively, p=0.031, for a TnT level 3 times the upper normal limit, and 6.0% vs 13.9%, respectively, for a TnT level 5 times the upper normal limit). Multivariate analysis revealed that postprocedural hsCRP elevation and complex lesion were the significant independent predictors of postprocedural TnT elevation. Conclusion: Elevated hsCRP levels were associated with a higher risk of postprocedural troponin elevation in patients undergoing uncomplicated PCI. These results emphasized the role of inflammation in the pathogenesis of periprocedural myocardial injury. (Korean Circ J 2008;38:135-139)

Troponin T elevation and prognosis after multivessel compared with single-vessel elective percutaneous coronary intervention.

BACKGROUND.: Although techniques for percutaneous coronary intervention (PCI) have improved, patients with PCI of more vessels may still have an increased risk. We performed a prospective observational study evaluating the differences between multivessel and single-vessel procedures according to postprocedural troponin T (TnT) elevation and events during follow-up. METHODS.: The study included 713 patients without elevated TnT (<0.05 ng/ml) before PCI. Primary endpoint was the combined endpoint of death, myocardial infarction, stroke, repeat coronary angiography and readmission for anginal symptoms during the mean follow-up of 10.9 months. RESULTS.: TnT after PCI was elevated in 150 patients (21%) and was significantly associated with an increased incidence of the primary endpoint (RR 1.55, 95% CI 1.01 to 2.38). PCI of more than one vessel was performed in 146 patients (20%). These patients more often had increased TnT levels after the procedure (31.5 vs. 18.3%, p=0.001) and an increased incidence of the primary endpoint during follow-up (28 vs. 19%, p=0.01). After multivariable analysis, multivessel PCI was a statistically significant predictor of postprocedural TnT increase (OR 1.90, 95% CI 1.17 to 3.06). Multivessel PCI was also associated with an increased risk of the primary endpoint (OR 1.73, 95% CI 1.18 to 2.52), but after adjusting for multivessel disease this association was not statistically significant (OR 1.42, 95% CI 0.92 to 2.19). CONCLUSION.: Elective PCI of more vessels in one session is, in comparison with single-vessel PCI, more often associated with postprocedural troponin T rise and a (nonsignificantly) higher incidence of cardiac events during follow-up. Whether staged PCI is associated with less morbidity has to be assessed. (Neth Heart J 2007;15:178-83.).

Troponin-T and myoglobin plus echocardiographic evaluation for monitoring early cardiotoxicity of weekly epirubicin–paclitaxel in metastatic breast cancer patients

Increased serum level of troponin-T and myoglobin has been recently reported to be related to cumulative anthracycline exposure. Left ventricular ejection fraction seems accurate in monitoring systolic function according to the latest version of Toxicity Criteria by chemotherapeutics 3.0. From January 2002, 20 patients with untreated advanced breast cancer received epirubicin (25 mg/m/week) and paclitaxel (80 mg/m/week) for 24 weeks. Troponin-T, myoglobin and biochemical serum enzymes circulating levels were measured immediately before and 4 h after epirubicin administration every week. Patients underwent electrocardiography and echocardiography at weeks 0, 8, 16 and 24. The number of courses administered was 352 (median 18, range 4-24). Epirubicin median dose administered was 600 mg/m and paclitaxel median dose administered was 1760 mg/m. Troponin-T never overcame the upper normal limit; one patient experienced troponin-T elevation without any clinical or instrumental sign of cardiac failure. Myoglobin never significantly increased with the exception of a patient who underwent several abdominal fluid drainages. Creatine kinase MB and C-reactive protein never moved outside the upper normal limit. No symptomatic cardiac event was recorded. In 55 performed echocardiograms at weeks 0, 8, 16 and 24, neither left ventricular ejection fraction nor early peak flow/atrial flow velocity registered any significant decrease. No troponin-T or myoglobin serum elevations and Left ventricular ejection fraction/early peak flow/atrial flow velocity changes were registered in our series of nonsymptomatic women during epirubicin/paclitaxel weekly chemotherapy in the absence of clinical cardiac toxicity. Longer follow-up is needed, however, to understand whether the troponin-T or myoglobin circulating level measurement is able to detect subclinical, early-stage doxorubicin-induced cardiotoxicity.

The association between the proximal extension of the clot and the severity of pulmonary embolism (PE): a proposal for a new radiological score for PE

The aim of the study was to investigate the association between the proximal level of the clot and the severity of pulmonary embolism (PE). The cohort consisted of 99 consecutive patients with PE diagnosed by multi-detector computed tomography. A new score was constructed by calculating the mean value of the largest affected vessel [sub-segmental = 1, segmental = 2, lobar = 3, main pulmonary artery (MPA) = 4] in each lung. A significant association was found between the most proximal level of PE and pulmonary artery obstruction index (PAOI) (P < 0.0001), right ventricular (RV)/left ventricular (LV) ratio (P < 0.0001), and PaO(2) (P = 0.004). No significant association was found between systolic blood pressure and the level of PE. Troponin-T was elevated in none of the sub-segmental, 5% of segmental, 20% of lobar, and in 56% of PEs in the MPA (P = 0.001). Significant association was found between the proposed score and PAOI (P < 0.0001), RV/LV ratio (P < 0.0001), PaO(2) (P < 0.008). Troponin-T was elevated in 10% of level 1, 0% of level 2, 43% level of 3, 66% of level 4 PE (P < 0.0001). Cut-off level score 4 yielded a sensitivity of 84% and a specificity of 74% for the detection of elevated troponin-T. In conclusion, the study indicates that both the most proximal level of PE and the proposed score are related to the severity of PE as determined by blood oxygenation, biochemical and radiological parameters and could therefore be of value for rapid risk stratification of PE. However, the prognostic value of these classifications and their clinical significance needs to be evaluated in properly designed studies.

Randomized Trial of Statin Administration for Myocardial Injury

Minor myocardial damage after percutaneous coronary intervention (PCI) is associated with cardiac risks, which statins seem to reduce. The aim of this study was to examine whether intensive lipid-lowering therapy is more effective in decreasing the risk of cardiac injury after PCI than moderate lipid-lowering therapy. Subjects comprised 42 patients with stable angina without previous statin treatment, randomly assigned to either an intensive lipid-lowering group (Group A: target low-density lipoprotein-cholesterol (LDL-C)<70 mg/dl) or a moderate lipid-lowering group (Group B: target LDL-C<100 mg/dl) 2 weeks before PCI. All patients took statins to reach target LDL-C levels. Incidence of periprocedural myocardial injury was assessed by analyzing levels of creatine kinase myocardial isozyme (CK-MB) and cardiac troponin T (TnT) before and 6, 12 and 24 h after PCI. Minor myocardial damage was defined as TnT elevation to >0.01 ng/ml. Frequency of minor myocardial damage was 14.2% in Group A and 47.6% in Group B (p=0.043). CK-MB was above the upper limit of normal (ULN) in 19% of Group A and 33.3% of Group B (p=0.44), and CK-MB was >3x ULN in 9.5% of Group A and 19% of Group B (p=0.66). Intensive lipid-lowering therapy before PCI reduces minor myocardial damage during PCI with stenting compared with moderate lipid-lowering therapy.

Drive-Through Angioplasty

In this issue of Circulation , Bertrand et al1 report the results of the Early Discharge after Transradial Stenting of Coronary Arteries (EASY) Study. After receiving a standard bolus of abciximab and undergoing a successful and uncomplicated transradial stent placement, 1005 patients were randomized to a traditional strategy with overnight hospitalization or early discharge after 4 to 6 hours. All patients received aspirin, clopidogrel, and a bolus dose of abciximab before their procedure. Those in the traditional strategy group also received a 12-hour abciximab infusion, whereas those in the early discharge group did not. The goal of the EASY study was to show that stent implantation by the radial approach with only a bolus of abciximab and then early discharge was not inferior to the traditional strategy in terms of effectiveness and safety. The primary composite end point was the 30-day incidence of death, any myocardial infarction, unplanned revascularization, major bleeding, repeat hospitalization, access-site complications, or severe thrombocytopenia. On the basis of their data, the authors concluded that the abbreviated abciximab therapy with same-day discharge was clinically not inferior to the traditional strategy after uncomplicated stent placement. Article p 2636 With healthcare costs increasing, strategies to limit expenditures are popular and deserve careful examination. Accepted cardiology practice has moved toward dramatically shortened hospital stays for diagnostic coronary angiography and percutaneous coronary intervention (PCI) as well as many other procedures. The present study suggests that many patients who undergo PCI could be managed safely as outpatients. Substantial accomplishments in the practice of PCI have resulted in the excellent success and safety of the procedure we now observe, but are we ready for routine outpatient PCI? The use of radial artery access has been well described in the literature. Despite studies demonstrating the feasibility, safety, and acceptance by patients of this …

Insufficient Inhibition by Aspirin of Platelet TXA2 Synthesis and Platelet Recruitment Is Associated with Myonecrosis in Patients with ST-Segment Elevation Myocardial Infarction.

Heterogeneity in response to aspirin (ASA) treatment or “aspirin resistance” could be of importance in patients with ST-segment elevation myocardial infarction (STEMI). Reduced effect of ASA in platelets could be due to partial inhibition of cyclooxygenase-1 (COX-1) or to COX-1-independent mechanisms. We evaluated the effect of ASA treatment in patients with STEMI for: a) platelet TXA2 synthesis; b) platelet recruitment elicited by TXA2-dependent and -independent mechanisms and c) the possible association of these aspects of platelet reactivity with serum markers of myonecrosis. We studied 62 consecutive ASA-treated patients shortly after the onset of the acute event. Analytical determinations were performed within 48 h of the onset of the acute event (mean ± SD, 23.12 ± 11.61 h). Fifty-two of the patients were treated with fibrin-specific fibrinolytic agents and 56 were also anticoagulated with enoxaparin. A group of 62 ASA-free and 10 ASA-treated controls were also evaluated. TXA2 synthesis and platelet recruitment (fluid-phase pro-aggregatory activity of cell-free releasates) were assessed after collagen stimulation (1 μg/mL) of whole blood in patients and control subjects. Optimal inhibition of TXA2 and platelet recruitment was assumed if these were greater than 95% and 80%, respectively, compared with the ASA-free population of normal donors. Comparisons between categorical data were performed using chi-squared tests. The Kruskal-Wallis non-parametric test was used for comparisons between groups. A two-sided P value < 0.05 was considered significant. Partial inhibition of TXA2 by ASA was found in 21 patients (34%). This was associated with significant elevations of Troponin-T, CK-MB mass, CK and recruiting activity vs. 41(66%) patients with blocked TXA2 production. This was independent of fibrinolysis and platelet COX-2 expression was not augmented. TXA2 blockade was achieved after subsequent daily treatments or platelet incubation with ASA in vitro, suggesting reduced sensitivity of COX-1 to ASA. In addition, 28 patients (45%) had an abnormally elevated recruiting activity, despite TXA2 blockade, which was also associated with increased myonecrosis. In conclusion, aspirin resistance, elicited by both TXA2-dependent and TXA2-independent mechanisms, was prevalent in patients with STEMI. This study describes for the first time the association of partial platelet TXA2 inhibition with myonecrosis.

Frequency and Significance of Troponin T Elevation in Acute Ischemic Stroke

Elevated levels of troponin have been reported in patients with acute ischemic stroke. In this prospective study, the prevalence and characteristics of troponin elevation were examined in 244 patients with acute ischemic stroke but without overt ischemic heart disease. Troponin T (TnT) and creatine kinase-MB (CK-MB) concentrations were measured and 12-lead electrocardiograms obtained daily during the first 5 days of admission. Myocardial perfusion scintigraphy was performed in patients with TnT levels of 0.10 micro g/L and in comparable controls without elevation of TnT. Patients were followed for a mean of 19 +/- 7 months, with all-cause mortality as the clinical end point. Elevated levels of TnT (>0.03 micro g/L) and creatine kinase-MB (> or =10 micro g/L) were observed in 10% and 9% of patients, respectively. Patients with elevated TnT had higher frequencies of heart and/or renal failure. Perfusion abnormalities on myocardial perfusion scintigraphy at rest were not more frequent or pronounced in patients with TnT levels of > or =0.10 micro g/L than in the control group. Only 7 patients (3%) had elevations of TnT or creatine kinase-MB and electrocardiographic changes suggesting acute myocardial infarctions. According to univariate and multivariate analyses, elevation of TnT was significantly associated with mortality. In conclusion, elevated levels of TnT are rare in patients presenting with ischemic stroke but without overt ischemic heart disease. Heart and renal failure rather than myocardial infarction are the most likely causes. When present, elevation of TnT seems to be useful in identifying patients who are at increased risk of dying within the following 2 years.

D-dimer level is associated with the extent of pulmonary embolism

ObjectivesOur aim was to study the association between the level of D-dimer and the severity of pulmonary embolism (PE) as determined by various biochemical and radiological prognostic markers in order to investigate the potential value of D-dimer as a prognostic marker for the severity of PE. Patients and methodsPE was diagnosed in 100 consecutive out-patients by multi-detector computerized tomography. One patient was excluded and the final cohort consisted of 99 patients. Pulmonary Artery Obstruction Index (PAOI) and Right Ventricular/Left Ventricular (RV/LV) ratio were assessed. ResultsThe median value for D-dimer was 5.0 mg/L (inter-quartile range: 1.8, 12.2). There was a significant association between log D-dimer, and between log RV/LV (r=0.45), log PAOI (r=0.5), and PaO2 (r=0.40). The multivariate analysis showed an increased association between log D-dimer and between log RV/LV ratio (r=0.54) and log PAOI (r=0.52) after adjusting for age, gender and for the duration of symptoms. Significant association was found between the level of D-dimer and the most proximal level of PE (p<0.0005). There was a significant dose–response relationship between the level D-dimer and between Troponin-T and the frequency of thrombolysis (p<0.0005). In the subgroup of patients with D-Dimer over the upper quartile (>12.2), 12 (67%) patients had elevated Troponin-T and 8 (32%) patients received thrombolysis, compared to 1 (5%) patient with elevated Troponin-T and none treated with thrombolysis in the subgroup of patients with D-dimer<lower quartile. ConclusionsWe have shown that the level of D-dimer is related to the severity of PE assessed by various radiological, biochemical and clinical markers and might have a potential value as prognostic marker for the severity of PE.

Is “compassionate use” compassionate?

The possibility that recombinant activated factor VII (rFVIIa) improves outcome following acute intracerebral hemorrhage (ICH)1 has clinicians racing their engines in anticipation of at last having an effective treatment for ICH. At this exciting time, two articles2,3 published in this issue of Neurology wave, if not the red “stop” flag, at least a yellow flag for “hazard on the track.” In non-randomized, open-label series of patients with ICH treated with rFVIIa, Subramaniam et al.2 report an unexpectedly high incidence of post-ICH hydrocephalus and Sugg et al.3 an increased incidence of post-ICH troponin-T elevation and myocardial infarction (MI). Five of nine ICH patients (56%) receiving 40 μg/kg rFVIIa in the study by Subramaniam et al. developed hydrocephalus. Although all five had intraventricular blood, their baseline CT scans suggested relatively low risk of subsequent hydrocephalus according to validated radiographic criteria4; the study did not include a concurrent control group. Sugg et al. evaluated 20 patients with ICH treated with 80 μg/kg rFVIIa and found troponin elevations in 4 (20%) and symptomatic MI in 2 (10%), …

Troponin-T and N-Terminal Pro-B-Type Natriuretic Peptide Predict Mortality Benefit From Coronary Revascularization in Acute Coronary Syndromes: A GUSTO-IV Substudy

This study was designed to evaluate biomarkers for selection of patients with non-ST-segment elevation acute coronary syndromes (ACS) that derive mortality benefit from revascularization. Biomarkers are essential for identification of patients at increased risk, which may be reduced by revascularization. During the initial 30 days, 2,340 patients of 7,800 (30%) with non-ST-segment elevation ACS in the GUSTO (Global Utilization of Strategies To open Occluded arteries)-IV trial underwent coronary revascularization. The 1-year mortality was calculated in 30-day survivors stratified by status of revascularization and levels of biomarkers. A propensity score for receiving revascularization was constructed and included in a survival analysis that also included the time point of revascularization as a time-dependent covariate. Elevation of troponin-T or N-terminal pro-B-type natriuretic peptide (NT-proBNP) was associated with a high mortality. In patients with either or both of these markers elevated, a lower mortality following revascularization was observed. In contrast, patients without elevation of these markers had low 1-year mortality without any reduction in mortality following revascularization. In fact, in patients with normal levels of both troponin-T and NT-proBNP, a significant increase in 1-year mortality after revascularization was observed. Elevation of C-reactive protein, interleukin-6, creatinine clearance, and ST-segment depression was also related to a higher mortality. However, independent of these markers, mortality was lower after revascularization. Markers of troponin-T and NT-proBNP not only assist in risk stratification of patients with non-ST-segment elevation ACS but also appear to identify patients who have a reduced mortality associated with early coronary revascularization.

Genetic variation in the interleukin-6 gene in relation to risk and outcomes in acute coronary syndrome

Background The concept of inflammation in the acute coronary syndrome (ACS) is today well established. Interleukin-6 (IL-6), a pleiotropic, proinflammatory cytokine, seems to play an important role in the development and progression of ACS. Aim The aim was to investigate whether IL6 polymorphisms are associated with patient/control status, outcome in patients with ACS and plasma concentrations of IL-6 and C-reactive protein (CRP). Methods Samples for citrated plasma and DNA were obtained on admission from 3027 patients with non-ST-elevation ACS in the FRISC-II study. A group of 447 healthy controls of similar age and gender as the patients was also recruited. Eight IL6 polymorphisms were genotyped and plasma concentrations of IL-6 and CRP measured in patients and controls. Results No associations between patient/control status, clinical outcome, ST-depression, troponin-T elevation or a history of myocardial infarction and IL6 polymorphisms were observed. In the full patient group, there was a trend towards association of the − 572 G > C polymorphism with plasma concentrations of IL-6 ( p = 0.07). This association was statistically significant in patients with available high-sensitivity measurements of IL-6 ( p = 0.01). The − 572 CG genotype was predictive for IL-6 levels above 5 ng/L in patients with a subsequent cardiovascular event, 2.3 (1.1–4.3) (adjusted odds ratio, 95% confidence interval). Comparison with data from HapMap showed that our panel of polymorphisms covered information on ∼ 30 other IL6 variants. Conclusion The − 572 G > C and other polymorphisms in the study were not associated with outcome in ACS patients. However, the − 572 CG genotype may contribute to a more distinct inflammatory response in patients with ACS.

Electrocardiographic and troponin T changes in acute ischaemic stroke

The mechanisms explaining morphological electrocardiogram (ECG) changes and increased troponin T (TnT) in acute stroke are unclear. The aims of the present study were to assess the prevalence of ECG and TnT changes in acute ischaemic stroke, to investigate whether ischaemic-like ECG changes correlate to a rise in TnT and to examine whether ECG changes and elevated TnT predict a poor short-time outcome. From 2000 to 2002 a total of 279 patients suffering from acute ischaemic stroke were included prospectively in the present study. ECG was carried out at admission and on day 1 in all patients. TnT was analysed at admission and on day 1. The most frequent ECG changes were: prolonged QTc 36.0%, ST depression 24.5%, atrial fibrillation 19.9% and T wave inversion 17.8%. In logistic regression analyses, ST depression and Q waves were significantly associated with a rise in TnT. TnT was elevated (>0.04 microg L(-1)) in 26 patients (9.6%). In logistic regression analyses, a rise in TnT was significantly associated with a poor short-term outcome (modified Rankin scale >3). ECG changes are prevalent in acute ischaemic stroke. ST depression and Q waves are related to an increase in TnT, suggesting that these ECG changes may indicate coexisting ischaemic heart disease. A rise in TnT predicts a poor outcome. Patients with acute ischaemic stroke should be offered adequate treatment with secondary prevention and preferably a follow-up with focus on cardiologic as well as neurological aspects.

The Evaluation of Short and Long Term Administration of Drugs Improving Life Expectancy in Patients with Myocardial Infarction in a Hungarian County Hospital

The patients after myocardial infarction could hope for a significant improvement in their life expectancy when complying with the principles of the secondary prevention. Today there is no doubt that the administration of ACE-inhibitors, beta-blockers, aspirin and statins decrease mortality in these patients. Although the clinicians are aware of the guidelines of Evidence Based Medicine, international and Hungarian surveys show that in their everyday application there is still much to improve. The authors studied the therapy of 200 consecutive patients (115 men and 85 women) who suffered from acute myocardial infarction (either STAMI or NSTAMI) in 1999-2000 at the discharge from their internal medicine department with cardiological profile and 6 months later during outpatient check-up. Having these therapeutic data a special emphasise was given to the same group of drugs and their administration was investigated in patients suffering from acute coronary syndrome with elevated troponin-T levels in the year 2002. In the study of years 1999-2000 at the discharge 175 of 200 patients received ACE-inhibitor (87%), 121 (60%) beta-blocker, 180 (90%) antiplatelet and 102 (51%) statin therapy. At the time of the control performed 6 months later 85% of the patients were on ACE-inhibitor, 88% on beta-blocker, 77% on aspirin and 47% on statin therapy. In this high risk population during the 6 months control the LDL-cholesterol goal of 2.5 mmol/l was attained in the 17% of patients. In the survey performed in 2002 the use of beta-receptor blocker increased to 85%, antiplatelet drug and statin administration to 95% and 57%, respectively. Although the administration of drugs improving life expectancy in the authors' department is comparable with the published Hungarian and international data, effort to the widespread application of the ever growing principles of the Evidence Based Medicine and continuous self-control are essential.

Association between cardiac troponin T elevation and angioscopic morphology of culprit lesion in patients with non–ST-segment elevation acute coronary syndrome

It is well known that cardiac troponin T (TnT) elevation on admission indicates a high-risk subgroup among patients with non-ST-segment elevation acute coronary syndrome (NSEACS). Although the mechanism of TnT elevation is speculated to be the microthromboembolism from unstable plaques, it has not been clarified. The aim of this study is to clarify the association between the serum TnT elevation and the angioscopically evaluated morphology of culprit lesion in the patients with NSEACS. Among 113 patients with NSEACS who had significant coronary stenosis, 62 patients with successful angioscopic examination were prospectively and consecutively enrolled from October 2001 to August 2002. Patients were divided into 2 groups according to the serum TnT level measured before percutaneous coronary intervention: TnT-positive or TnT-negative group. Thrombus and plaque color at culprit lesion were evaluated by angioscopy and were compared between the groups. Plaque color was determined as yellow or white, and thrombus as none, small, or large. Three different definitions for TnT-positive (> or =0.1, > or =0.03, and > or =0.01 ng/mL) were used and the sensitivity and specificity for detecting thrombus was compared. Prevalence of thrombus, large thrombus, and yellow plaque were all higher in TnT-positive than in TnT-negative group for 3 different cutoff values of TnT. Angiographic slow-flow occurred more frequently after percutaneous coronary intervention in TnT-positive than in TnT-negative group for 3 different cutoff values of TnT. Sensitivity/specificity of detecting large thrombus were 33%/100%, 44%/91%, and 56%/83% when TnT-positive was defined as TnT > or = 0.1, > or =0.03, and > or =0.01 ng/mL, respectively. Serum TnT level was significantly associated with the prevalence of thrombus and yellow plaque at the culprit lesions of NSEACS. Troponin T, when positive was defined as > or =0.01 ng/mL, still have a high specificity for detecting intracoronary thrombus.

Serum Soluble Lectin-Like Oxidized Low-Density Lipoprotein Receptor-1 Levels Are Elevated in Acute Coronary Syndrome

Markers of cardiac injury, including troponin-T (TnT), are used to diagnose acute coronary syndrome (ACS); however, markers for plaque instability may be more useful for diagnosing ACS at the earliest stage. Lectin-like oxidized LDL receptor-1 (LOX-1) appears to play crucial roles in the pathogenesis of atherosclerotic plaque rupture and ACS onset. LOX-1 is released in part as soluble LOX-1 (sLOX-1) by proteolytic cleavage. We examined serum sLOX-1 levels in 521 patients, consisting of 427 consecutive patients undergoing coronary angiography, including 80 ACS patients, 173 symptomatic coronary heart disease patients, 122 patients with significant coronary stenosis without ischemia, and 52 patients without apparent coronary atherosclerosis plus 34 patients with noncardiac acute illness and 60 patients with noncardiac chronic illness. Time-dependent changes in sLOX-1 and TnT levels were analyzed in an additional 40 ACS patients. Serum sLOX-1 levels were significantly higher in ACS than the other groups and were associated with ACS as shown by multivariable logistic regression analyses. Given a cutoff value of 1.0 ng/mL, sLOX-1 can discriminate ACS from other groups with 81% and 75% of sensitivity and specificity, respectively. sLOX-1 can also discriminate ACS without ST elevation or abnormal Q waves and ACS without TnT elevation from non-ACS with 91% and 83% of sensitivity, respectively. Peak values of sLOX-1 in ACS were observed earlier than those of TnT. sLOX-1 appears to be a useful marker for early diagnosis of ACS.

Impact of the Revised Criteria for Acute Myocardial Infarction Using Cardiac Troponins in a Japanese Population With Acute Coronary Syndromes

The clinical implications of applying the new criteria of acute myocardial infarction (AMI) with cardiac troponins in terms of their diagnostic and prognostic impact in patients with suspected acute coronary syndromes (ACS) have not been well evaluated. The study group comprised 973 consecutive patients who were diagnosed as having ACS with or without ST elevation (STE). They were divided into 3 groups: unstable angina (UA) group (n=195) representing patients with no significant elevations of creatine kinase (CK) and troponin T (TnT); TnT-myocardial infarction (MI) group (n=170) with TnT elevation and no CK elevation (additionally detected AMI by the new criteria); CK-MI group (n=608) with significant elevation of CK (AMI by the old criteria). In the TnT-MI group, 140 (76%) patients had non-STE ACS. In-hospital mortality rates for STE ACS were 0%, 2.5% and 9.7% in the UA, TnT-MI and CK-MI groups, respectively. The corresponding values for non-STE ACS were 1.8%, 4.6%, and 16.5%, respectively (p<0.0001), suggesting a pivotal role of TnT. In multiple logistic regression analysis, significant CK elevation was selected as an independent predictor of in-hospital death in concurrence with age > or =75 years, prior MI, shock and low left ventricular ejection fraction in non-STE ACS. The new criteria result in a substantial increase in the diagnosis of AMI from non-STE ACS in particular. They assist greatly in detailed risk stratification of ACS patients, notably in cooperation with the old CK criteria.