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Hinton J, Mariathas M, Grocott MPW, Curzen N. High sensitivity troponin measurement in critical care: Flattering to deceive or 'never means nothing'? J Intensive Care Soc 2020; 21:232-240. [PMID: 32782463 PMCID: PMC7401433 DOI: 10.1177/1751143719870095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Troponin elevation is central to the diagnosis of acute type 1 myocardial infarction. It is, however, elevated in a range of other conditions, including type 2 myocardial infarction, and this setting is increasingly associated with adverse clinical outcomes. Patients within intensive care frequently have at least one organ failure together with a range of co-morbidities. Interpretation of troponin assay results in this population is challenging. This clinical uncertainty is compounded by the introduction of ever more sensitive troponin assays. AREAS COVERED The aims of this review are to (a) describe the currently available literature about the use of troponin assays in intensive care, (b) analyse the challenges presented by the introduction of increasingly sensitive troponin assays and (c) assess whether the role of troponin assays in intensive care may change in the future, dependent upon recent and ongoing research suggesting that they are predictive of outcome regardless of the underlying cause: the 'never means nothing' hypothesis.
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Affiliation(s)
- Jonathan Hinton
- Coronary Research Group,
University
Hospital Southampton NHS Foundation Trust,
Southampton, UK
| | - Mark Mariathas
- Coronary Research Group,
University
Hospital Southampton NHS Foundation Trust,
Southampton, UK
| | - Michael PW Grocott
- Faculty of Medicine, University of
Southampton, Southampton, UK
- Anaesthesia and Critical Care Group,
Southampton NIHR Biomedical Research Centre,
University
Hospital Southampton NHS Foundation Trust /
University of Southampton, Southampton, UK
| | - Nick Curzen
- Coronary Research Group,
University
Hospital Southampton NHS Foundation Trust,
Southampton, UK
- Faculty of Medicine, University of
Southampton, Southampton, UK
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Vafaie M, Stoyanov KM, Giannitsis E. [Diagnosis of myocardial infarction in critically ill, ventilated patients]. Med Klin Intensivmed Notfmed 2019; 114:290-296. [PMID: 30923853 DOI: 10.1007/s00063-019-0572-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 01/20/2019] [Accepted: 03/04/2019] [Indexed: 11/25/2022]
Abstract
Elevated cardiac troponin values are frequently observed in critically ill patients. These are often not due to myocardial infarction (MI) but caused by various other etiologies of myocardial injury. Understanding the etiology of any troponin elevation is of enormous importance for management and therapy. According to the fourth version of the Universal Definition of MI, myocardial injury is present if at least one troponin value is above the 99th percentile upper reference limit and considered acute, when a rise and/or fall occurs. Patients with acute MI are a subgroup of patients with acute myocardial injury, who present in an ischemic clinical context. Variables defining the clinical criteria of MI include symptoms of ischemia, presumably new electrocardiographic (ECG) changes or imaging evidence of new loss of viable myocardium or regional wall motion abnormalities, or detection of an intracoronary thrombus. In critically ill or mechanically ventilated patients, the diagnosis of MI is challenging due to limitations in history taking, co-existence of comorbidities, overlapping symptoms and equivocal or unspecific ECG changes. This article presents the diagnostic criteria of the Universal MI definition, discusses subtypes of MI and focuses on various differential diagnoses. Furthermore, implications of diagnosis of MI in critically ill patients, especially regarding the use of ECG and troponin assays, are discussed.
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Affiliation(s)
- M Vafaie
- Medizinische Klinik III, Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland.
| | - K M Stoyanov
- Medizinische Klinik III, Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
| | - E Giannitsis
- Medizinische Klinik III, Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
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Kortbaoui R, Allyn J, Guglielminotti J, Bussienne F, Montravers P, Martinet O, Vandroux D, Desmard M, Augustin P, Allou N. Pattern and consequences of cardiologic medications management for patients with elevated troponin I upon admission into an intensive care unit not linked to type 1 acute myocardial infarction: A prospective observational cohort study. ANNALES PHARMACEUTIQUES FRANÇAISES 2017; 75:285-293. [PMID: 28454759 DOI: 10.1016/j.pharma.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES No recommendations are currently available to help the clinician with the pharmacological management of intensive care unit (ICU) patients with elevated cardiac troponin (cTn) not linked to type 1 AMI. The aim of this study was to evaluate the pattern of cardiologic medications for patients with elevated cTnI in ICU not link to type 1 AMI and their effects on in-hospital mortality. MATERIAL AND METHODS A prospective observational cohort study conducted in two ICU units. Patients with increased plasma concentration of cTnI at admission not linked to type 1 AMI were consecutively included. RESULTS One hundred and ninety of the 835 patients admitted (23%) had an increased plasma concentration of cTnI not related to type 1 AMI. Antiplatelet therapy (AT) and statin were prescribed in 56 (29.5%) and 50 (26.3%) of patients, respectively. Others cardiologic medications were prescribed in less than 5% of all cases and were considered as contraindicated in more than 50% of cases. Antiplatelet therapy was the only cardiologic treatment associated with reduction of in-hospital mortality following uni- and multivariate analysis. The death rate was 23% and 40% in these patients treated with and without AT, respectively (aOR=0.39 [95% CI: 0.15-0.97]). CONCLUSIONS Statin and AT were frequently prescribed to patients with a cTnI elevation not linked to type 1 AMI. This study suggests that AT in patients with an increased plasma concentration of cTnI, not related to type 1 AMI in ICU, could reduce in-hospital mortality.
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Affiliation(s)
- R Kortbaoui
- Département d'anesthésie-réanimation, centre hospitalier universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France.
| | - J Allyn
- Réanimation polyvalente, centre hospitalier universitaire Félix-Guyon, Bellepierre, allée des Topazes, 97405 Saint-Denis, Reunion.
| | - J Guglielminotti
- Département d'anesthésie-réanimation, centre hospitalier universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, rue Henri-Huchard, 75018 Paris, France.
| | - F Bussienne
- Réanimation polyvalente, centre hospitalier universitaire Félix-Guyon, Bellepierre, allée des Topazes, 97405 Saint-Denis, Reunion.
| | - P Montravers
- Département d'anesthésie-réanimation, centre hospitalier universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, rue Henri-Huchard, 75018 Paris, France.
| | - O Martinet
- Réanimation polyvalente, centre hospitalier universitaire Félix-Guyon, Bellepierre, allée des Topazes, 97405 Saint-Denis, Reunion.
| | - D Vandroux
- Réanimation polyvalente, centre hospitalier universitaire Félix-Guyon, Bellepierre, allée des Topazes, 97405 Saint-Denis, Reunion.
| | - M Desmard
- Département d'anesthésie-réanimation, centre hospitalier universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France.
| | - P Augustin
- Département d'anesthésie-réanimation, centre hospitalier universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, rue Henri-Huchard, 75018 Paris, France.
| | - N Allou
- Réanimation polyvalente, centre hospitalier universitaire Félix-Guyon, Bellepierre, allée des Topazes, 97405 Saint-Denis, Reunion.
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Stress cardiomyopathy of the critically ill: Spectrum of secondary, global, probable and subclinical forms. Indian Heart J 2017; 70:177-184. [PMID: 29455775 PMCID: PMC5903071 DOI: 10.1016/j.ihj.2017.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/05/2017] [Indexed: 02/06/2023] Open
Abstract
Stress cardiomyopathy (SC) typically presents as potential acute coronary syndrome (ACS) in previously healthy people. While there may be physical or mental stressors, the initial symptom is usually chest pain. This form conforms to the published Mayo diagnostic criteria, is well reported and as the presentation is initially cardiac, is considered primary SC. Increasingly we see SC develop several days into the hospitalization secondary to medical or surgical critical illness. This condition is more complex, presents atypically, is not easy to recognize and carries a much worse prognosis. Label of Secondary SC is appropriate as it manifests in sicker hospitalized patients with numerous comorbidities. We review the limited but provocative literature pertinent to SC in the critically ill and describe important clues to identify global, subclinical and probable forms of SC. We illustrate the several unique clinical features, demographic differences and propose a diagnostic algorithm to optimize cardiac care in the critically ill.
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Rafiq A, Sklyar E, Bella JN. Cardiac Evaluation and Monitoring of Patients Undergoing Noncardiac Surgery. Health Serv Insights 2017; 9:1178632916686074. [PMID: 28469459 PMCID: PMC5398290 DOI: 10.1177/1178632916686074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/24/2016] [Indexed: 12/25/2022] Open
Abstract
Surgical management of disease has a tremendous impact on our health system. Millions of people worldwide undergo surgeries every year. Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient's medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks. Different risk assessment tools and calculators have also been developed to aid in this process, each with their own advantages and limitations. After such a comprehensive evaluation, a physician will be able to provide a risk assessment or it may all lead to further testing if it is believed that a change in management after such testing will help to reduce perioperative morbidity and mortality. There is extensive literature on the significance of multiple perioperative testing modalities and how they can change management. The purpose of our review is to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.
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Affiliation(s)
- Arsalan Rafiq
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eduard Sklyar
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan N Bella
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Carroll I, Mount T, Atkinson D. Myocardial infarction in intensive care units: A systematic review of diagnosis and treatment. J Intensive Care Soc 2016; 17:314-325. [PMID: 28979516 PMCID: PMC5624468 DOI: 10.1177/1751143716656642] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Patients in the intensive care unit are vulnerable to myocardial injury from a variety of causes, both ischaemic and non-ischaemic. It is challenging for ICU clinicians to apply the conventional guidance concerning diagnosis and treatment. We conducted this review to examine the evidence concerning diagnosis and treatment of myocardial infarction in the ICU. METHODS A systematic review was performed to identify relevant studies. RESULTS 19 studies concerning use of ECG, cardiac enzymes, echocardiography and angiography were identified. 4 studies considered treatment of myocardial infarction. CONCLUSIONS Regular 12 lead ECG or 12 lead ECG monitoring is more sensitive than 2 lead monitoring, regular measurement of cardiac enzymes is more sensitive than when provoked by symptoms. Coronary angiography rarely identifies treatable lesions, without regional wall motion abnormality on echocardiography. Evidence relating to treatment was limited. A potential strategy to diagnose myocardial infarctions in the ICU is proposed.
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Affiliation(s)
- Iain Carroll
- Adult Critical Care Unit, Royal London Hospital, London, UK
| | - Thomas Mount
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Dougal Atkinson
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Allou N, Brulliard C, Valance D, Esteve JB, Martinet O, Corradi L, Cordier C, Bouchet B, Allyn J. Obstructive coronary artery disease in patients hospitalized for severe sepsis or septic shock with concomitant acute myocardial infarction. J Crit Care 2016; 32:159-64. [PMID: 26922236 DOI: 10.1016/j.jcrc.2015.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/09/2015] [Accepted: 12/24/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE It is difficult to differentiate type 1 acute myocardial infarction (AMI) with obstructive coronary artery disease (OCAD) from type 2 AMI in patients admitted for severe sepsis. The aims of this study were to assess the risk factors and prognosis of OCAD in patients admitted to the intensive care unit for severe sepsis with concomitant AMI. MATERIALS AND METHODS This is a single-center retrospective cohort study including all consecutive patients who were hospitalized for severe sepsis or septic shock between March 2006 and September 2014 and who underwent coronary angiography in the intensive care unit to identify AMI. RESULTS Overall, 78 (5.5%) of 1418 patients hospitalized for severe sepsis underwent coronary angiography to identify concomitant AMI. Thirty-two patients (41%) had OCAD. Following multivariate analysis, the risk factors of OCAD were peripheral vascular disease (odds ratio [OR] =5.7; 95% confidence interval [CI], 1.1-30.4; P = .042) and at least 2 cardiovascular risk factors (OR = 6.7; 95% CI, 1.9-23.8; P = .003). Obstructive coronary artery disease was associated with a significant mortality increase at 60 days (OR = 8.1; 95% CI, 1.9-30.2; P = .004). CONCLUSIONS Obstructive coronary artery disease is a poor prognosis factor in patients hospitalized for severe sepsis with concomitant AMI. In this setting, medical treatment should be considered for patients with peripheral vascular disease or with at least 2 cardiovascular risk factors; the need to perform coronary angiography should be considered carefully.
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Affiliation(s)
- Nicolas Allou
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint Denis, France.
| | - Caroline Brulliard
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint Denis, France.
| | - Dorothée Valance
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint Denis, France.
| | | | - Olivier Martinet
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint Denis, France.
| | - Laure Corradi
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint Denis, France.
| | - Charlotte Cordier
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint Denis, France.
| | - Bruno Bouchet
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint Denis, France.
| | - Jérôme Allyn
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint Denis, France.
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77-137. [PMID: 25091544 DOI: 10.1016/j.jacc.2014.07.944] [Citation(s) in RCA: 813] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e278-333. [PMID: 25085961 DOI: 10.1161/cir.0000000000000106] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
PURPOSE OF REVIEW Cardiac troponins in serum have become the biomarkers of choice for the diagnosis of myocardial infarction. Yet, troponin can also be elevated by a multitude of causes in the absence of overt myocardial ischemia. Such nonspecific elevations are particularly common in the critically ill. This article aims to provide information on the significance of troponin elevations in unselected critically ill patients and in patients with sepsis or septic shock. RECENT FINDINGS Recent studies reconsider the possible association of troponin elevations with myocardial infarction in unselected critically ill patients. There are also more data on the prognostic significance of troponin in this population. In patients with sepsis, recent studies suggest that troponin may be a reliable index of sepsis-induced myocardial dysfunction, although the implications of this finding in the management of sepsis remain unclear for the time being. Troponin also appears to be a predictor of short and possibly also long-term outcome in septic patients. The advent of newer assays with even higher sensitivity, may lead to further redefinition of the role of troponin in the ICU. SUMMARY Troponin is frequently elevated in critically ill patients. More research is needed on the diagnostic and prognostic significance and possible clinical applications of troponin measurements in patients with sepsis and critical illness.
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Abstract
OBJECTIVE The reliability of electrocardiogram interpretation to diagnose myocardial ischemia in critically ill patients is unclear. In adults with septic shock, we assessed intra- and inter-rater agreement of electrocardiogram interpretation, and the effect of knowledge of troponin values on these interpretations. DESIGN Prospective substudy of a randomized trial of vasopressin vs. norepinephrine in septic shock. SETTING Nine Canadian intensive care units. PATIENTS Adults with septic shock requiring at least 5 μg/min of norepinephrine for 6 hrs. INTERVENTIONS Twelve-lead electrocardiograms were recorded before study drug, and 6 hrs, 2 days, and 4 days after study drug initiation. MEASUREMENTS Two physician readers, blinded to patient data and group, independently interpreted electrocardiograms on three occasions (first two readings were blinded to patient data; third reading was unblinded to troponin). To calibrate and refine definitions, both readers initially reviewed 25 trial electrocardiograms representing normal to abnormal. Cohen's Kappa and the φ statistic were used to analyze intra- and inter-rater agreement. RESULTS One hundred twenty-one patients (62.2 ± 16.5 yrs, Acute Physiology and Chronic Health Evaluation II 28.6 ± 7.7) had 373 electrocardiograms. Blinded to troponin, readers 1 and 2 interpreted 46.4% and 30.0% of electrocardiograms as normal, and 15.3% and 12.3% as ischemic, respectively. Intrarater agreement was moderate for overall ischemia (κ 0.54 and 0.58), moderate/good for "normal" (κ 0.69 and 0.55), fair to good for specific signs of ischemia (ST elevation, T inversion, and Q waves, reader 1 κ 0.40 to 0.69; reader 2 κ 0.56 to 0.70); and good/very good for atrial arrhythmias (κ 0.84 and 0.79) and bundle branch block (κ 0.88 and 0.79). Inter-rater agreement was fair for ischemia (κ 0.29), moderate for ST elevation (κ 0.48), T inversion (κ 0.52), and Q waves (κ 0.44), good for bundle branch block (κ 0.78), and very good for atrial arrhythmias (κ 0.83). Inter-rater agreement for ischemia improved from fair to moderate (κ 0.52, p = .028) when unblinded to troponin. CONCLUSIONS In patients with septic shock, inter-rater agreement of electrocardiogram interpretation for myocardial ischemia was fair, and improved with troponin knowledge.
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