Circulating Troponin I Level in Patients with Acute Ischemic Stroke

Diagnostic and prognostic value of cardiac troponins in emergency department patients presenting after a fall: A prospective, multicenter study

BACKGROUND

Emergency department (ED) presentations after a ground-level fall (GLF) are common. Falls were suggested to be another possible presenting feature of a myocardial infarction (MI), as unrecognized MIs are common in older adults. Elevated high-sensitivity cardiac troponin (hs-cTn) concentrations could help determine the etiology of a GLF in ED. We investigated the prevalence of both MI and elevated high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of hs-cTnT and hs-cTnI regarding MI, and their prognostic value in older ED patients presenting after a GLF.

METHODS

This was a prospective, international, multicenter, cohort study with a follow-up of up to 1 year. Patients aged 65 years or older presenting to the ED after a GLF were prospectively enrolled. Two outcome assessors independently reviewed all discharge records to ascertain final gold standard diagnoses. Hs-cTnT and hs-cTnI levels were determined from thawed samples for every patient.

RESULTS

In total, 558 patients were included. Median (IQR) age was 83 (77-89) years, and 67.7% were female. Elevated hs-cTnT levels were found in 384 (68.8%) patients, and elevated hs-cTnI levels in 86 (15.4%) patients. Three patients (0.5%) were ascertained the gold standard diagnosis MI. Within 30 days, 18 (3.2%) patients had died. Nonsurvivors had higher hs-cTnT and hs-cTnI levels compared with survivors (hs-cTnT 40 [23-85] ng/L in nonsurvivors and 20 [13-33] ng/L in survivors; hs-cTnI 25 [14-54] ng/L in nonsurvivors and 8 [4-16] ng/L in survivors; p < 0.001 for both).

CONCLUSIONS

A majority of patients (n = 364, 68.8%) presenting to the ED after a fall had elevated hs-cTnT levels and 86 (15.4%) elevated hs-cTnI levels. However, the incidence of MI in these patients was low (n = 3, 0.5%). Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1 year.

Impact of high-sensitivity troponin elevation and dynamic changes on 90-day mortality in patients with acute ischemic stroke after mechanical thrombectomy: results from an observational cohort

BACKGROUND

A study was undertaken to evaluate the impact of high-sensitivity cardiac troponin I (hs-cTnI) elevation and hs-cTnI dynamic changes on 90-day mortality in patients with acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT).

METHODS

Patients with AIS receiving MT were included in the study. Sixty hours after AIS onset, hs-cTnI levels were measured before and after MT to determine elevated and dynamic changes. Patients were stratified into either normal or hs-cTnI elevation groups according to the pre-MT hs-cTnI cut-off value of 0.03 ng/L. hs-cTnI dynamic changes were defined as an increase or decrease of more than 20% pre-MT and post-MT, and at least one hs-cTnI level >0.03 ng/L. Multivariate Cox regression models were used to investigate the association between hs-cTnI elevation, hs-cTnI dynamic changes, and 90-day mortality in patients with AIS after MT.

RESULTS

A total of 423 patients with AIS after MT were included in our final analysis, of whom only 72 (17%) showed hs-cTnI elevation. Post-MT hs-cTnI retesting was performed in 354 patients, and 90 (25.4%) patients presented with hs-cTnI dynamic changes. 119 patients died within 90 days. After adjusting for potential confounding factors, the Cox regression model showed that patients with hs-cTnI dynamic changes, rather than hs-cTnI elevation, were associated with 90-day mortality (p<0.05). Compared with the hs-cTnI non-dynamic changes, these results showed that a statistical association was present between rising hs-cTnI dynamic changes and 90-day mortality (p>0.05).

CONCLUSIONS

hs-cTnI dynamic changes, dominated by the rising pattern rather than hs-cTnI elevation, were independent factors associated with 90-day mortality in patients with AIS after MT, especially in elderly subjects.

Prevalence of myocardial injury in patients after acute ischaemic stroke according to standard criteria

This study examined the prevalence of acute and chronic myocardial injury according to standard criteria in patients after acute ischaemic stroke (AIS) and its relation to stroke severity and short-term prognosis. Between August 2020 and August 2022, 217 consecutive patients with AIS were enrolled. Plasma levels of high-sensitive cardiac troponin I (hs-cTnI) were measured in blood samples obtained at the time of admission and 24 and 48 h later. The patients were divided into three groups according to the Fourth Universal Definition of Myocardial Infarction: no injury, chronic injury, and acute injury. Twelve-lead ECGs were obtained at the time of admission, 24 and 48 h later, and on the day of hospital discharge. A standard echocardiographic examination was performed within the first 7 days of hospitalization in patients with suspected abnormalities of left ventricular function and regional wall motion. Demographic characteristics, clinical data, functional outcomes, and all-cause mortality were compared between the three groups. The National Institutes of Health Stroke Scale (NIHSS) at the time of admission and the modified Rankin Scale (mRS) 90 days following hospital discharge were used to assess stroke severity and outcome. Elevated hs-cTnI levels were measured in 59 patients (27.2%): 34 patients (15.7%) had acute myocardial injury and 25 patients (11.5%) had chronic myocardial injury within the acute phase after ischaemic stroke. An unfavourable outcome, evaluated based on the mRS at 90 days, was associated with both acute and chronic myocardial injury. Myocardial injury was also strongly associated with all-cause death, with the strongest association in patients with acute myocardial injury, at 30 days and at 90 days. Kaplan-Meier survival curves showed that all-cause mortality was significantly higher in patients with acute and chronic myocardial injury than in patients without myocardial injury (P < 0.001). Stroke severity, evaluated with the NIHSS, was also associated with acute and chronic myocardial injury. A comparison of the ECG findings between patients with and without myocardial injury showed a higher occurrence in the former of T-wave inversion, ST segment depression, and QTc prolongation. In echocardiographic analysis, a new abnormality in regional wall motion of the left ventricle was identified in six patients. Chronic and acute myocardial injury with hs-cTnI elevation after AIS are associated with stroke severity, unfavourable functional outcome, and short-term mortality.

The prognostic value of cardiac troponin T in different age groups of traumatic brain injury patients

BACKGROUND

The cardiac dysfunction has been confirmed as a common non-neurological complication and associated with increased mortality in traumatic brain injury (TBI) patients. As a biological marker of cardiac injury, the cardiac troponin T (TnT) has been verified correlated with the outcome of some non-traumatic brain injury patients. However, the prognostic value of TnT in TBI patients has not been clearly illustrated. We designed this study to explore the association between TnT and the outcome of TBI patients in different age subgroups.

METHODS

Patients diagnosed with TBI in a prospective critical care database were eligible for this study. Univariate logistic regression analysis was firstly performed to explore the relationship between included variables and mortality. Then, the real effect of TnT on the outcome of different age subgroups was analyzed by multivariate logistic regression analysis adjusting the confounding effects of other significant risk factors. Finally, we draw receiver operating characteristic (ROC) curves to evaluate the prognostic value of TnT in different age groups of TBI patients.

RESULTS

520 patients were included in this study with a mortality rate of 20.2%. There were 112 (21.5%) non-elderly patients (age < 65) and 408 (78.5%) elderly patients (age ≥ 65). Non-survivors had a higher percentage of previous acute myocardial infarction (p = 0.019) and pupil no-reaction (p = 0.028; p = 0.011) than survivors. Survivors had higher GCS (p < 0.001) and lower TnT than non-survivors (p < 0.001). TnT was significantly associated with mortality in non-elderly patients (p = 0.031) but not in overall patients (p = 0.143) and elderly patients (p = 0.456) in multivariate logistic regression analysis. The AUC (area under the ROC curve) value of TnT in overall, non-elderly and elderly patients was 0.644, 0.693 and 0.632, respectively. Combining TnT with GCS increased the sensitivity of predicting the poor outcome in both non-elderly and elderly TBI patients.

CONCLUSION

The prognostic value of TnT differed between elderly and non-elderly TBI patients. Level of TnT was associated with mortality of non-elderly TBI patients but not elderly patients. Combining the TnT with GCS could increase the sensitivity of prognosis evaluation.

Association of Atrial Fibrillation Detected after Stroke with Cardiac Dysfunction and Features of Neurogenic Cardiac Injury

OBJECTIVES

Understanding the link between markers of cardiac injury and atrial fibrillation (AF) detected after stroke (AFDAS) may help refine stroke risk stratification and therapeutic approaches in AFDAS.

MATERIALS AND METHODS

We retrospectively analyzed 988 adult patients admitted for acute ischemic stroke and transient ischemic attack, who presented within 4.5 h from last known well. Pertinent clinical variables including features of neurogenic cardiac injury (so-called stroke heart syndrome [SHS]) as well as electrocardiographic and echocardiographic markers of cardiac dysfunction, and AF status (no AF n = 574; known AF n = 311; AFDAS; n = 103) were collected. Multivariable logistic regression was used to determine the independent associations of variables with AFDAS.

RESULTS

A total of 264 (26.7%) subjects fulfilled criteria for SHS. Of these, 174 of had SHS features other than AFDAS (non-AF SHS). Among 677 subjects without known AF, presence of non-AF SHS was associated with a 5-fold odds of AFDAS (OR 5.0, 95%-CI 3.1-8.0, p < 0.001). After adjustment, non-AF SHS (OR 3.2, 95%-CI 1.6-6.4, p = 0.001) and the left atrial volume index (OR 1.04, 95%-CI 1.01-1.08, p = 0.004) remained independently associated with AFDAS.

CONCLUSIONS

The presence of non-AF SHS features and the left atrial volume index were independently associated with AFDAS indicating diverse mechanisms relating to new onset AF. A better understanding of the links between these markers and AFDAS may help uncover potentially modifiable risk factors for AFDAS as well as aid treatment decisions in patients at risk for new onset AF and ischemic stroke.

Cardiac Troponin I and Risk of Stroke: A Mendelian Randomization Study

Purpose

Methods

Results

Conclusion

Cerebral-Cardiac Syndrome and Diabetes: Cardiac Damage After Ischemic Stroke in Diabetic State

Cerebral-cardiac syndrome (CCS) refers to cardiac dysfunction following varying brain injuries. Ischemic stroke is strongly evidenced to induce CCS characterizing as arrhythmia, myocardial damage, and heart failure. CCS is attributed to be the second leading cause of death in the post-stroke stage; however, the responsible mechanisms are obscure. Studies indicated the possible mechanisms including insular cortex injury, autonomic imbalance, catecholamine surge, immune response, and systemic inflammation. Of note, the characteristics of the stroke population reveal a common comorbidity with diabetes. The close and causative correlation of diabetes and stroke directs the involvement of diabetes in CCS. Nevertheless, the role of diabetes and its corresponding molecular mechanisms in CCS have not been clarified. Here we conclude the features of CCS and the potential role of diabetes in CCS. Diabetes drives establish a “primed” inflammatory microenvironment and further induces severe systemic inflammation after stroke. The boosted inflammation is suspected to provoke cardiac pathological changes and hence exacerbate CCS. Importantly, as the key element of inflammation, NOD-like receptor pyrin domain containing 3 (NLRP3) inflammasome is indicated to play an important role in diabetes, stroke, and the sequential CCS. Overall, we characterize the corresponding role of diabetes in CCS and speculate a link of NLRP3 inflammasome between them.

Elevated Cardiac Troponin Levels in Geriatric Patients Without ACS: Role of Comorbidities

Background

Elevated levels of cardiac troponin T as measured by a high-sensitivity test (hscTnT) are common in geriatric patients with a large spectrum of comorbidities but without acute coronary syndrome (ACS). However, the relative contribution of individual comorbidities has never been clearly addressed. This study aimed to determine the relationship between hscTnT elevation as a response variable and individual comorbidities, and to estimate the impact of individual comorbidities on hscTnT elevation in geriatric patients free of ACS.

Methods

A nonexperimental, retrospective, matched, longitudinal cohort study was designed to evaluate the files of 7062 geriatric patients (aged ≥ 65 years) without ACS. The hscTnT levels of the patients have already been measured in all evaluated medical records. The dataset was split into 2 groups (0 and 1) based on the individual comorbidity (0 and 1) and hscTnT levels (≤ 14 ng/L = 0 and > 14 ng/L = 1).

Results

Our results show that although age was positively and significantly correlated with hscTnT (r = 0.17, P < 0.0001), the likelihood of experiencing elevated hscTnT levels in older individuals after having excluded ACS was related to the presence of comorbidities independently of their number (P < 0.0001). The regression coefficients (β) associated with renal insufficiency (0.71), cardiomyopathy (0.63), chronic obstructive pulmonary disease (0.30), diabetes (0.25), and anemia (0.22) indicated that there exists a significant association between these comorbidities and the elevated hscTnT levels (P < 0.001). The receiver operating characteristic curve for predictive modeling was estimated at 71% (P < 0.0001).

Conclusions

Elevated hscTnT levels were mostly associated with renal insufficiency, cardiac myopathies, chronic obstructive pulmonary disease, diabetes, and anemia in geriatric patients without ACS. Developing guidelines to accurately evaluate hscTnT elevation in geriatric patients with comorbidities, without ACS, is clinically essential.

The trends in nanomaterial-based biosensors for detecting critical biomarkers in stroke

Acute ischemic stroke (AIS), is the second global cause of death after cardiovascular diseases, accounts for 80-85% of cerebrovascular disease. Stroke diagnosis could be challenging in the acute phase. Detection of biomarkers for evaluating the prognosis of diseases is essential for improving personalized treatment and decreasing mortality. At the present time, the absence of a broadly existing and rapid diagnostic test is an important limitation in the evaluation and treatment of diseases. The use of a biomarker-based diagnostic attitude has confirmed very valuable in acute coronary syndromes, which has been promoted in acute stroke to help early management decisions. Over the past decade, different detection procedures have developed for the assessment of human cardiac troponins (cTnI). This review emphasizes on summarizing optical, and electrochemical biosensors for the detection of cTnI, brain natriuretic peptide (BNP), and neuron-specific enolase (NSE) as a critical biomarker in stroke.

Acute ischemic stroke biomarkers: a new era with diagnostic promise?

Stroke is considered as the first cause of neurological dysfunction and second cause of death worldwide. Recombinant tissue plasminogen activator is the only chemical treatment for ischemic stroke approved by the US Food and Drug Administration. It was the only standard of care for a long time with a very narrow therapeutic window, which usually ranges from 3 to 4.5 h of stroke onset; until 2015, when multiple trials demonstrated the benefit of mechanical thrombectomy during the first 6 h. In addition, recent trials showed that mechanical thrombectomy can be beneficial up to 24 h if the patients meet certain criteria including the presence of magnetic resonance imaging/computed tomography perfusion mismatch, which allows better selectivity and higher recruitment of eligible stroke patients. However, magnetic resonance imaging/computed tomography perfusion is not available in all stroke centers. Hence, physicians need other easy and available diagnostic tools to select stroke patients eligible for mechanical thrombectomy. Moreover, stroke management is still challenging for physicians, particularly those dealing with patients with "wake-up" stroke. The resulting brain tissue damage of ischemic stroke and the subsequent pathological processes are mediated by multiple molecular pathways that are modulated by inflammatory markers and post-transcriptional activity. A considerable number of published works suggest the role of inflammatory and cardiac brain-derived biomarkers (serum matrix metalloproteinase, thioredoxin, neuronal and glial markers, and troponin proteins) as well as different biomarkers including the emerging roles of microRNAs. In this review, we assess the accumulating evidence regarding the current status of acute ischemic stroke diagnostic biomarkers that could guide physicians for better management of stroke patients. Our review could give an insight into the roles of the different emerging markers and microRNAs that can be of high diagnostic value in patients with stroke. In fact, the field of stroke research, similar to the field of traumatic brain injury, is in immense need for novel biomarkers that can stratify diagnosis, prognosis, and therapy.

The impact of cardiac troponin in elderly patients in the absence of acute coronary syndrome: A systematic review

Comorbidities are common risk factors for rising cardiac troponin in non-acute coronary syndromes conditions. Furthermore, the risk for all-cause mortality appears to be correlated to the troponin levels. Consequently, measurement of cardiac troponin in hospital admission may contribute to predict the mortality risk in elderly patients. Among geriatric patients without acute coronary syndrome, with concomitant diseases, the correct interpretation of elevated cardiac troponin, particularly in emergency conditions poses a diagnostic dilemma. Although in several studies it is suggested that at the presence of comorbidity, there is an increase in cardiac troponin values, the elderly patients have not been included conclusively. In order to assess the diagnostic and prognostic role of cardiac troponin elevation in geriatric patients suffering from chronic diseases, a systematic review was performed. The study included the elderly patients free of acute coronary syndrome admitted to the hospital with concomitant disease, with a report of at least one cardiac troponin measurement. We found that elevated cardiac troponin is an independent prognostic factor, predicting all-cause morbidity and mortality burden in geriatric patients without acute coronary syndromes.

Association of Baseline Cardiac Troponin With Acute Myocardial Infarction in Stroke Patients Presenting Within 4.5 Hours

Background and Purpose- American Heart Association guidelines recommend obtaining baseline troponin in all patients with acute ischemic stroke. Yet, there is a paucity of data on the prevalence of baseline troponin elevation and specifically its diagnostic yield for acute myocardial infarction (AMI) in patients presenting within the time window for thrombolysis. Methods- We retrospectively analyzed 1072 consecutive patients admitted for acute ischemic stroke or transient ischemic attack, who presented within 4.5 hours of last known well (LKW). Patients who had baseline cardiac troponin I (bcTnI) obtained within 72 hours from LKW (n=525) were included in the study. Multivariable logistic regression was conducted to determine factors independently related to an elevated bcTnI (>0.04 ng/mL). We calculated the area under receiver operator curves, sensitivity, and specificity, to determine the diagnostic accuracy of (i) the bcTnI for AMI stratified by the time to assessment and (ii) the best time cutoff for obtaining bcTnI. Results- Among included subjects, the median time from LKW to the bcTnI was 3.8 hours and 113 (21.5%) subjects had an elevated bcTnI. Assessment of bcTnI within 4.5 hours from LKW was significantly more often associated with normal values as compared to assessment between 4.5 and 72 hours (61.7% versus 38.3%; P=0.001). Fifteen (2.9%) patients were diagnosed with AMI. After adjustment for pertinent confounders, time to bcTnI assessment was independently associated with AMI (odds ratio, 1.04 [95% CI, 1.02-1.07] P=0.001). When stratified by time, bcTnI assessed within 4.5 hours had a sensitivity of 25% and specificity of 83.7% for AMI, whereas bcTnI assessment between 4.5 and 72 hours was associated with a sensitivity of 90.9% and specificity of 74.8%. Conclusions- Assessment of bcTnI after 4.5 hours from LKW was associated with greater diagnostic accuracy than testing within 4.5 hours. This information may inform routine clinical practice.