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Maayah M, Grubman S, Allen S, Ye Z, Park DY, Vemmou E, Gokhan I, Sun WW, Possick S, Kwan JM, Gandhi PU, Hu JR. Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing. Diagnostics (Basel) 2024; 14:503. [PMID: 38472975 DOI: 10.3390/diagnostics14050503] [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: 01/01/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 03/14/2024] Open
Abstract
Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.
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Affiliation(s)
- Marah Maayah
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Scott Grubman
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephanie Allen
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Zachary Ye
- Department of Internal Medicine, Temple University Medical Center, Philadelphia, PA 19140, USA
| | - Dae Yong Park
- Department of Internal Medicine, Cook County Hospital, Chicago, IL 60612, USA
| | - Evangelia Vemmou
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Ilhan Gokhan
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Wendy W Sun
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephen Possick
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Parul U Gandhi
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
- Department of Cardiology, Veterans Affairs Connecticut Health Care System, West Haven, CT 06516, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
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Kulkarni SM, Roongta R, Sankar S. Clinical profile of patients and sensitivity of troponin I in patients with and without acute coronary syndrome: An observational study. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:305-309. [PMID: 38759980 DOI: 10.25259/nmji_801_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Background Various clinical conditions can cause troponin elevation in the absence of myocardial ischaemia. Elevated troponin represents the likely occurrence of myocardial necrosis and does not itself provide any indication of the aetiology. Identifying the cause for troponin elevation and its sensitivity and specificity in predicting acute coronary syndrome (ACS) and cardiac mortality is an important step in determining the optimal management for these patients. Methods We retrospectively collected data of inpatients who had troponin I (TnI) testing as part of their clinical assessment, either in the emergency department, medical wards, coronary care unit (CCU) or intensive care unit (ICU) with their final diagnosis. TnI was used as the index test of sensitivity to diagnose ACS and either echocardiography or coronary angiogram in those available as the reference gold standard. They were classified into two groups of normal and elevated TnI, and further divided into those with ACS and no ACS. Data on clinical parameters and aetiology of elevated TnI in patients without ACS were analysed. Results Of the 254 patients studied, 114 patients (45%) had normal TnI and 140 (55%) had elevated TnI. Seventy-eight patients had ACS, 66 (84.6%) of whom had elevated TnI and 12 (15.38%) had normal TnI. Seventy-four (52.85%) of 140 patients with elevated TnI had alternate causes of TnI elevation; the most common being sepsis, acute kidney injury (AKI) and heart failure without ACS. All-cause mortality was significantly higher in patients with elevated TnI with or without ACS. There was no cardiac mortality among patients with ACS with normal TnI. Sensitivity and specificity of TnI for predicting ACS was 84.6% (95% CI 74.7%-91.8%) and 58% (95% CI 50.3%-65.3%), respectively. Conclusion A variety of conditions apart from myocardial infarction can lead to elevated TnI. Hence, caution should be exercised while diagnosing a patient with ACS based on TnI value in the absence of other supporting evidence given its low specificity. Elevated TnI portends a worse prognosis regardless of the aetiology and has a role in predicting all-cause and cardiac mortality.
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Affiliation(s)
- Shruthi M Kulkarni
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
| | - Rashmi Roongta
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
| | - Seena Sankar
- Department of General Medicine, St John's Medical College Hospital, Koramangala, Bengaluru 560034, Karnataka, India
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Hinton J, Mariathas M, Gabara L, Nicholas Z, Allan R, Ramamoorthy S, Mamas MA, Mahmoudi M, Cook P, Curzen N. Distribution of contemporary sensitivity troponin in the emergency department and relationship to 30-day mortality: The CHARIOT-ED substudy. Clin Med (Lond) 2020; 20:528-534. [PMID: 33199315 PMCID: PMC7687347 DOI: 10.7861/clinmed.2020-0267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Contemporary sensitivity troponin (cs-cTn) concentrations above the upper limit of normal (ULN) are seen in a wide range of clinical conditions and evidence is growing that suggests cs-cTn may be a biomarker of future morbidity and mortality. OBJECTIVES Our aim was to test the hypothesis that cs-cTn, measured in the emergency department, may be a biomarker for 30-day mortality, irrespective of the patient's presentation. METHOD In all 5,708 consecutive cases, contemporary sensitivity troponin I (cs-cTnI) was measured either as requested by the clinical team or as part of the study, in which case both the clinical team and the patient were unaware of the result. Basic demographics were available from the original study and 30-day mortality was derived from NHS Digital data. RESULTS In patients whose cs-cTnI test was requested solely as part of the study, 30-day mortality increased with increasing cs-cTnI concentrations (0% with undetectable concentrations to 14.7% with concentrations above the ULN). Multivariable Cox regression analysis showed that log(10)cs-cTnI concentration was independently associated with 30-day mortality. CONCLUSION Increasing cs-cTnI concentrations are associated with higher short-term mortality as well as length of stay. As such, cs-cTnI measurements may provide useful prognostic information.
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Affiliation(s)
- Jonathan Hinton
- University Hospital Southampton NHS Foundation Trust, Southampton, UK and University of Southampton, Southampton, UK
| | - Mark Mariathas
- University Hospital Southampton NHS Foundation Trust, Southampton, UK and University of Southampton, Southampton, UK
| | - Lavinia Gabara
- University Hospital Southampton NHS Foundation Trust, Southampton, UK and University of Southampton, Southampton, UK
| | - Zoe Nicholas
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rick Allan
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Mamas A Mamas
- Keele University, Stoke on Trent, UK and Jefferson University, Philadelphia, USA
| | - Michael Mahmoudi
- University Hospital Southampton NHS Foundation Trust, Southampton, UK and University of Southampton, Southampton, UK
| | - Paul Cook
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nick Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK and University of Southampton, Southampton, UK
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4
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McCarthy CP, Raber I, Chapman AR, Sandoval Y, Apple FS, Mills NL, Januzzi JL. Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays: A Practical Approach for Clinicians. JAMA Cardiol 2020; 4:1034-1042. [PMID: 31389986 DOI: 10.1001/jamacardio.2019.2724] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Traditionally, elevated troponin concentrations were synonymous with myocardial infarction. But with improvements in troponin assays, elevated concentrations without overt myocardial ischemia are now more common; this is referred to as myocardial injury. Physicians may be falsely reassured by the absence of myocardial ischemia; however, recent evidence suggests that myocardial injury is associated with even more detrimental outcomes. Accordingly, this article reviews the definition, epidemiology, differential diagnosis, diagnostic evaluation, and management of myocardial injury. Observations Current epidemiological evidence suggests that myocardial injury without overt ischemia represents about 60% of cases of abnormal troponin concentrations when obtained for clinical indications, and 1 in 8 patients presenting to the hospital will have evidence of myocardial injury. Myocardial injury is a concerning prognosis; the 5-year mortality rate is approximately 70%, with a major adverse cardiovascular event rate of 30% in the same period. The differential diagnosis is broad and can be divided into acute and chronic precipitants. The initial workup involves an assessment for myocardial ischemia. If infarction is ruled out, further evaluation includes a detailed history, physical examination, laboratory testing, a 12-lead electrocardiogram, and (if there is no known history of structural or valvular heart disease) an echocardiogram. Unfortunately, no consensus exists on routine management of patients with myocardial injury. Identifying and treating the underlying precipitant is the most practical approach. Conclusion and Relevance Myocardial injury is the most common cause of abnormal troponin results, and its incidence will likely increase with an aging population, increasing prevalence of cardiovascular comorbidities, and greater sensitivity of troponin assays. Myocardial injury represents a challenge to clinicians; however, given its serious prognosis, it warrants a thorough evaluation of its underlying precipitant. Future strategies to prevent and/or manage myocardial injury are needed.
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Affiliation(s)
- Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andrew R Chapman
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston.,Baim Institute for Clinical Research, Boston, Massachusetts
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Long B, Long DA, Tannenbaum L, Koyfman A. An emergency medicine approach to troponin elevation due to causes other than occlusion myocardial infarction. Am J Emerg Med 2020; 38:998-1006. [DOI: 10.1016/j.ajem.2019.12.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/18/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023] Open
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Okyay K, Sadıç BÖ, Şahinarslan A, Durakoğlugil ME, Karabay CY, Eryüksel SE, Gülbahar Ö, Tekin A, Yıldırır A, Görenek B, Yavuzgil O, Fak AS. Turkish Society of Cardiology consensus paper on the rational use of cardiac troponins in daily practice. Anatol J Cardiol 2019; 21:331-344. [PMID: 31073114 PMCID: PMC6683230 DOI: 10.14744/anatoljcardiol.2019.42247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2019] [Indexed: 01/23/2023] Open
Affiliation(s)
- Kaan Okyay
- Department of Cardiology, Faculty of Medicine, Başkent University; Ankara-Turkey.
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Sarkisian L, Saaby L, Poulsen TS, Gerke O, Hosbond S, Jangaard N, Diederichsen ACP, Thygesen K, Mickley H. Prognostic Impact of Myocardial Injury Related to Various Cardiac and Noncardiac Conditions. Am J Med 2016; 129:506-514.e1. [PMID: 26763756 DOI: 10.1016/j.amjmed.2015.12.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Elevated cardiac troponins in clinical conditions other than myocardial infarction are well known. For such occurrences, the term "myocardial injury" has been proposed. The long-term outcome in patients with myocardial injury related to various cardiac and noncardiac clinical disorders is unknown. METHODS During January 2010 to January 2011, we prospectively studied hospitalized patients who had cardiac troponin I measured on clinical indication. Patients with cardiac troponin I values >30 ng/L and no evidence of myocardial ischemia were diagnosed as having myocardial injury. Patients were classified into 5 categories of plausible related conditions: cardiac ischemic, cardiac nonischemic, noncardiac, multifactorial, or indeterminate. Follow-up was a minimum of 3 years, with all-cause mortality as the single end-point. RESULTS A total of 3762 patients were considered, of whom 1089 (29%) had myocardial injury. The most common associated conditions were noncardiac (n = 346) or multifactorial (n = 359). Cardiac ischemic (n = 183) and cardiac nonischemic (n = 134) conditions occurred less frequently. After a median of 3.2 years, 645 patients (59%) had died. A multivariate Cox regression analysis showed no difference in mortality between patients with cardiac ischemic and cardiac nonischemic conditions (hazard ratio [HR] 0.75; 95% confidence interval [CI], 0.50-1.13; P = .2). Patients with noncardiac or multifactorial disorders, however, had significantly higher mortality than those with associated cardiac ischemic conditions (HR 1.39; 95% CI, 1.06-1.80; P = .02, and HR 1.94; 95% CI, 1.50-2.51; P <.001), respectively. CONCLUSIONS In patients with myocardial injury, the most common associated conditions were noncardiac or multifactorial. Of notice, these patients had significantly higher long-term mortality when compared with those with associated cardiac conditions.
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Affiliation(s)
- Laura Sarkisian
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Lotte Saaby
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Tina S Poulsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark; Centre of Health Economics Research, University of Southern Denmark, Odense, Denmark
| | - Susanne Hosbond
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Nikolaj Jangaard
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, Denmark.
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8
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Harvell B, Henrie N, Ernst AA, Weiss SJ, Oglesbee S, Sarangarm D, Hernandez L. The meaning of elevated troponin I levels: not always acute coronary syndromes. Am J Emerg Med 2016; 34:145-8. [DOI: 10.1016/j.ajem.2015.09.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/27/2015] [Accepted: 09/26/2015] [Indexed: 10/23/2022] Open
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Significance of an Indeterminate Troponin I in Patients Evaluated for Chest Pain in an Emergency Department Observation Unit. Crit Pathw Cardiol 2015; 14:146-9. [PMID: 26569654 DOI: 10.1097/hpc.0000000000000054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have suggested that patients with an indeterminate troponin I (TnI) in the emergency department (ED) are significantly more likely to be diagnosed with acute myocardial infarction (MI). The role of the ED observation unit (EDOU) in the evaluation of these patients is unclear. OBJECTIVE We sought to determine the risk of MI and revascularization in chest pain patients with an indeterminate TnI in the ED, who were placed in an EDOU. METHODS We performed a prospective evaluation with 30-day follow-up for all chest pain patients placed in the University of Utah EDOU between June 1, 2009 and May 31, 2012. The EDOU excludes patients with a positive TnI, significant electrocardiogram changes, or active chest pain; however, the EDOU is utilized for further evaluation of patients who have an initial indeterminate TnI (0.06 ng/mL-0.49 ng/mL) with serial TnI measurements, cardiology consult, and potential provocative testing. We identified all patients who had an indeterminate TnI on initial testing in the ED. Primary outcomes were MI, revascularization with cardiac stent or coronary artery bypass graft, and death. RESULTS We evaluated 1276 chest pain patients in the EDOU over the 3-year study period (average age: 54.1 years, 54% female). Fifty-eight patients (4.5%) had an initial indeterminate TnI. There were no deaths or adverse outcomes in the EDOU among those with an indeterminate TnI, and none of these patients developed a positive TnI during their hospital stay or 30-day follow-up. Patients with an indeterminate TnI had a higher rate of inpatient admission from the EDOU (24.1% vs. 10.3%; P=0.001). Among those with an indeterminate TnI, 8.6% underwent revascularization, while the rate of revascularization or MI was 2.9% among those who did not have an initial indeterminate TnI (P=0.032). CONCLUSION Patients evaluated in our EDOU for chest pain with an initial indeterminate TnI did not develop subsequent MI. However, these patients had an increased rate of revascularization and inpatient admission compared with controls. While our experience suggests that patients with an indeterminate TnI may be safely evaluated in an observation setting, EDOUs which treat only low-risk chest pain patients may wish to recommend inpatient admission for this patient group.
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10
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Cartwright JA, Gow DJ, Gow AG, Handel I, Reed N, Brown AJ, Cash R, Foote A, Mackenzie D, Bell R, Mellanby RJ. Serum cardiac troponin I concentrations decrease following treatment of primary immune-mediated haemolytic anaemia. J Small Anim Pract 2015; 56:516-20. [PMID: 26134761 DOI: 10.1111/jsap.12379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 04/27/2015] [Accepted: 04/30/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The measurement of serum cardiac troponin I concentrations in dogs with a range of non-primary cardiac illnesses suggests that cardiac myocyte damage is commonplace. Dogs with primary immune-mediated haemolytic anaemia have increased serum cardiac troponin I concentrations at the time of diagnosis. However, it is unclear whether biochemical evidence of cardiac myocyte damage improves following successful treatment of anaemia. METHODS A haematology profile was performed and serum cardiac troponin I concentrations were measured in 19 dogs with primary immune-mediated haemolytic anaemia before and after treatment. RESULTS The haematocrit increased significantly (P = 0 · 0001) following treatment of primary IMHA (median pre: 0 · 13 L/L, median post: 0 · 33 L/L). The serum cardiac troponin I concentrations decreased significantly (P < 0 · 05) after treatment (median pre: 0 · 26 ng/mL, median post: 0 · 16 ng/mL). CLINICAL SIGNIFICANCE Serum cardiac troponin I concentration decreases following successful treatment of primary immune-mediated haemolytic anaemia. The clinical and prognostic significance of serum cardiac troponin I concentrations before and after treatment in dogs with primary immune-mediated haemolytic anaemia merits further investigation.
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Affiliation(s)
- J A Cartwright
- Division of Veterinary Clinical Studies, Royal (Dick) School of Veterinary Studies, The Roslin Institute, The University of Edinburgh, Hospital for Small Animals, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG
| | - D J Gow
- Division of Veterinary Clinical Studies, Royal (Dick) School of Veterinary Studies, The Roslin Institute, The University of Edinburgh, Hospital for Small Animals, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG
| | - A G Gow
- Division of Veterinary Clinical Studies, Royal (Dick) School of Veterinary Studies, The Roslin Institute, The University of Edinburgh, Hospital for Small Animals, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG
| | - I Handel
- Division of Veterinary Clinical Studies, Royal (Dick) School of Veterinary Studies, The Roslin Institute, The University of Edinburgh, Hospital for Small Animals, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG
| | - N Reed
- Division of Veterinary Clinical Studies, Royal (Dick) School of Veterinary Studies, The Roslin Institute, The University of Edinburgh, Hospital for Small Animals, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG
| | - A J Brown
- Division of Veterinary Clinical Studies, Royal (Dick) School of Veterinary Studies, The Roslin Institute, The University of Edinburgh, Hospital for Small Animals, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG
| | - R Cash
- Rossdale & Partners, Beaufort Cottage Laboratories, Suffolk CB8 8JS
| | - A Foote
- Rossdale & Partners, Beaufort Cottage Laboratories, Suffolk CB8 8JS
| | | | - R Bell
- Dick White Referrals, Station Farm, Cambridge CB8 0UH
| | - R J Mellanby
- Division of Veterinary Clinical Studies, Royal (Dick) School of Veterinary Studies, The Roslin Institute, The University of Edinburgh, Hospital for Small Animals, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG
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Rahman A, Broadley SA. Review article: elevated troponin: diagnostic gold or fool's gold? Emerg Med Australas 2015; 26:125-30. [PMID: 24708000 DOI: 10.1111/1742-6723.12203] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2014] [Indexed: 11/30/2022]
Abstract
Troponin is a highly sensitive biomarker of myocardial injury and has been used extensively in everyday clinical practice in the community as well as in hospitals for the diagnosis of acute myocardial infarction (AMI) and for risk stratification of patients with acute coronary symptoms. Dynamic elevations in biomarkers (troponin) are considered fundamental to the diagnosis of AMI. Unfortunately, many clinical conditions can cause troponin elevation in the absence of myocardial ischaemia, and elevated levels sometimes pose a diagnostic dilemma. In some cases, inappropriate diagnosis of 'AMI' based primarily on a raised troponin can have a deleterious impact on an individual, including on driving, insurance and other medicolegal matters. An incorrect diagnosis of myocardial infarction can also lead to the oversight of serious life-threatening alternative causes of troponin elevation (e.g. pulmonary embolism). This article discusses the role of troponin in our everyday clinical practice in the ED.
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Affiliation(s)
- Atifur Rahman
- School of Medicine, Gold Coast Campus, Griffith University, Gold Coast, Queensland, Australia; Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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12
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Hickman PE, Lindahl B, Cullen L, Koerbin G, Tate J, Potter JM. Decision limits and the reporting of cardiac troponin: Meeting the needs of both the cardiologist and the ED physician. Crit Rev Clin Lab Sci 2014; 52:28-44. [PMID: 25397345 DOI: 10.3109/10408363.2014.972497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiac troponin is the preferred biomarker for defining the acute coronary syndrome and acute myocardial infarction. Currently, the only decision limit formally endorsed with regard to the cardiac troponins is the 99th percentile. This is a "rule-in" criterion, intended to ensure that only persons with the acute coronary syndrome are reviewed. The 99th percentile is an arbitrary cut point and there are many problems associated with its application, including defining a truly healthy population, the difficulty of standardisation of cardiac troponin assays, especially but not only cardiac troponin I, and the effects of age and sex on this parameter. The Emergency Department (ED) screens many more persons for possible acute coronary syndromes than actually have the condition and their needs are best met by a "rule-out" test that enables them to clear their busy departments of the many persons who do not actually have the condition. The needs of the ED are not optimally met using the 99th percentile. The index of individuality for the cardiac troponins is small and significant changes consistent with an acute coronary syndrome can occur without the 99th percentile being exceeded. It appears that the ED may be better served by use of delta troponin changes rather than the 99th percentile, but there are problems with this approach, particularly in persons who present late when troponin release has plateaued. In addition, there are many non-acute coronary syndrome causes for cardiac troponin release. The needs of the cardiologist and the ED physician are so different that it may be inappropriate for both groups to use the same diagnostic criteria for cardiac troponin, and it is of great importance that cardiac troponin measurement be used as only one part of the assessment of the person presenting with possible acute coronary syndrome.
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13
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Elevated troponin in septic patients in the emergency department: frequency, causes, and prognostic implications. Clin Res Cardiol 2014; 103:561-7. [DOI: 10.1007/s00392-014-0684-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 01/29/2014] [Indexed: 10/25/2022]
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Illmann A, Riemer T, Erbel R, Giannitsis E, Hamm C, Haude M, Heusch G, Maier LS, Münzel T, Schmitt C, Schumacher B, Senges J, Voigtländer T, Mudra H. Disease distribution and outcome in troponin-positive patients with or without revascularization in a chest pain unit: results of the German CPU-Registry. Clin Res Cardiol 2013; 103:29-40. [DOI: 10.1007/s00392-013-0619-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 09/11/2013] [Indexed: 10/26/2022]
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15
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Langhorn R, Oyama MA, King LG, Machen MC, Trafny DJ, Thawley V, Willesen JL, Tarnow I, Kjelgaard-Hansen M. Prognostic importance of myocardial injury in critically ill dogs with systemic inflammation. J Vet Intern Med 2013; 27:895-903. [PMID: 23678990 DOI: 10.1111/jvim.12105] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 02/19/2013] [Accepted: 04/08/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In noncardiac critical disease in humans, myocardial injury as detected by cardiac troponin I and T (cTnI and cTnT) has been linked to high intensive care unit (ICU) death independent of prognostic composite scoring. HYPOTHESIS Presence of myocardial injury predicts short-term death in critically ill dogs with systemic inflammation and provides additional prognostic information when combined with established canine prognostic composite scores. ANIMALS Forty-two dogs admitted to the ICU with evidence of systemic inflammation and no primary cardiac disease. METHODS Prospective cohort study. Blood samples were obtained at ICU admission for the measurement of cTnI and cTnT, C-reactive protein, and several cytokines. The acute patient physiologic and laboratory evaluation (APPLE) score and the survival prediction index were calculated within the first 24 hours of admission. Receiver operating characteristic (ROC) curves were used to examine the prognostic capacity of each biomarker and severity score. Multiple logistic regression analysis was performed to evaluate whether cardiac markers significantly contributed to severity scores. RESULTS Twenty-eight day case fatality rate was 26% (11/42 dogs). cTnI concentrations were (median [range]) 0.416 [0.004-141.5] ng/mL and cTnT concentrations were 13.5 [<13-3,744] ng/L. cTnI, cTnT, and the APPLE score were all significant prognosticators with areas under the ROC curves [95% CI] of 0.801 [0.649; 0.907], 0.790 [0.637; 0.900], and 0.776 [0.621; 0.889], respectively. cTnI significantly contributed to the APPLE score in providing additional prognostic specificity (P = .025). CONCLUSIONS AND CLINICAL IMPORTANCE Markers of myocardial injury predict short-term death in dogs with systemic inflammation and cTnI significantly contributes to the APPLE score.
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Affiliation(s)
- R Langhorn
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, Frederksberg C, Denmark.
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16
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Chang CL, Mills GD, Karalus NC, Jennings LC, Laing R, Murdoch DR, Chambers ST, Vettise D, Tuffery CM, Hancox RJ. Biomarkers of cardiac dysfunction and mortality from community-acquired pneumonia in adults. PLoS One 2013; 8:e62612. [PMID: 23667500 PMCID: PMC3646835 DOI: 10.1371/journal.pone.0062612] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 03/21/2013] [Indexed: 01/08/2023] Open
Abstract
Background Cardiac dysfunction is common in acute respiratory diseases and may influence prognosis. We hypothesised that blood levels of N-terminal B-type natriuretic peptide (NT-proBNP) and high-sensitivity Troponin T would predict mortality in adults with community-acquired pneumonia. Methods and Findings A prospective cohort of 474 consecutive patients admitted with community-acquired pneumonia to two New Zealand hospitals over one year. Blood taken on admission was available for 453 patients and was analysed for NT-proBNP and Troponin T. Elevated levels of NT-proBNP (>220 pmol/L) were present in 148 (33%) and 86 (19%) of these patients respectively. Among the 26 patients who died within 30 days of admission, 23 (89%) had a raised NT-proBNP and 14 (53%) had a raised Troponin T level on admission compared to 125 (29%) and 72 (17%) of the 427 who survived (p values<0.001). Both NT-proBNP and Troponin T predicted 30-day mortality in age-adjusted analysis but after mutual adjustment for the other cardiac biomarker and the Pneumonia Severity Index, a raised N-terminal pro-brain natriuretic peptide remained a predictor of 30-day mortality (OR = 5.3, 95% CI 1.4–19.8, p = 0.013) but Troponin T did not (OR = 1.3, 95% CI 0.5–3.2, p = 0.630). The areas under the receiver-operating curves to predict 30-day mortality were similar for NT-proBNP (0.88) and the Pneumonia Severity Index (0.87). Conclusions Elevated N-terminal B-type natriuretic peptide is a strong predictor of mortality from community-acquired pneumonia independent of clinical prognostic indicators. The pathophysiological basis for this is unknown but suggests that cardiac involvement may be an under-recognised determinant of outcome in pneumonia and may require a different approach to treatment. In the meantime, measurement of B-type natriuretic peptides may help to assess prognosis.
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Affiliation(s)
- Catherina L. Chang
- Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand
| | - Graham D. Mills
- Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand
- Department of General Medicine, Waikato Hospital, Hamilton, New Zealand
| | - Noel C. Karalus
- Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand
| | - Lance C. Jennings
- Canterbury Health Laboratories, Christchurch, New Zealand
- Department of Pathology, University of Otago, Christchurch, New Zealand
| | - Richard Laing
- Canterbury Respiratory Services, Canterbury District Health Board, Christchurch, New Zealand
| | - David R. Murdoch
- Canterbury Health Laboratories, Christchurch, New Zealand
- Department of Pathology, University of Otago, Christchurch, New Zealand
| | | | - Dominic Vettise
- Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand
| | | | - Robert J. Hancox
- Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
- * E-mail:
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17
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Lippi G, Cervellin G. Identification of Troponin Determinants for Improving its Diagnostic Performance in the Emergency Department. J Emerg Med 2012; 43:e487-8. [DOI: 10.1016/j.jemermed.2012.05.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 01/25/2012] [Accepted: 05/06/2012] [Indexed: 11/27/2022]
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18
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Fartashvand M, Nadalian M, Sakha M, Safi S. Elevated Serum Cardiac Troponin I in Cattle with Theileriosis. J Vet Intern Med 2012. [DOI: 10.1111/jvim.12014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- M. Fartashvand
- Department of Clinical Sciences; Faculty of Veterinary Medicine; Tabriz Branch; Islamic Azad University; Tabriz Iran
| | - M.G. Nadalian
- Department of Large Animal Internal Medicine; Faculty of Specialized Veterinary Sciences; Science and Research Branch; Islamic Azad University; Tehran Iran
| | - M. Sakha
- Department of Large Animal Internal Medicine; Faculty of Specialized Veterinary Sciences; Science and Research Branch; Islamic Azad University; Tehran Iran
| | - S. Safi
- Department of Veterinary Clinical Pathology; Faculty of Specialized Veterinary Sciences; Science and Research Branch; Islamic Azad University; Tehran Iran
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19
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A multicentre analysis of troponin use in clinical practice. Ir J Med Sci 2012; 182:185-90. [PMID: 23054475 DOI: 10.1007/s11845-012-0853-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 09/08/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The role of troponin quantification in evaluation of patients with suspected acute coronary syndrome is established, but with cost implications. Emerging high-sensitivity troponin and novel multi-marker assays herald further resource implications. AIMS The objective of this study was to quantify recent trends in troponin usage and costs in a cross-section of hospitals. METHODS A cross-sectional survey seeking data on troponin usage and costs from six tertiary referral, public access teaching hospitals for consecutive years between 2003 and 2009 was carried out. RESULTS A median annual increase in the volume of troponin assays requested was identified in all six hospitals, with an average median annual increase of 6.9 % across hospitals (interquartile range 3.4, 10.1 %). This annual increase was not accompanied by a corresponding increase in volume of patients presenting to the Emergency Department (ED) with chest pain. The majority (44-67 %) of troponin requests originated in the ED of hospitals. The median annual spend on troponins per hospital was <euro>115,612 (interquartile range <euro>80,452, <euro>140,918). An analysis of results of assays performed in one centre found that the majority (91 %) of troponin assays performed were in the normal range. CONCLUSIONS An annual increase in troponin requests without a corresponding increase in patient activity raises the possibility of increasingly indiscriminate troponin testing. The cumulative direct and indirect costs of inappropriate testing are significant. Corrective strategies are necessary to improve patient selection and testing protocols, particularly in the advent of the high-sensitivity troponin assays and novel multi-marker strategies.
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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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Stein PD, Janjua M, Matta F, Jaweesh F, Alrifai A, Yaekoub AY, Chughtai HL, Cotant JF. Elevated Cardiac Biomarkers With Normal Right Ventricular Size Indicate an Unlikely Diagnosis of Acute Pulmonary Embolism in Stable Patients. Clin Appl Thromb Hemost 2011; 17:E153-7. [DOI: 10.1177/1076029610392215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The purpose of this investigation is to assess the prevalence of elevated cardiac biomarkers, with or without estimates of right ventricular (RV) size, in stable patients with acute pulmonary embolism (PE). Our hypothesis is that the combination of high levels of cardiac troponin I (cTnI), high creatine kinase isoenzyme MB (CK-MB), and normal size RV are sufficiently uncommon in stable patients with PE to make the diagnosis of PE unlikely. Retrospective review showed a high cTnI plus high CK-MB in 20 (3.4%) of 585 stable patients with acute PE. A high cTnI plus high CK-MB with normal RV size was shown in 5 (1.9%) of 264 patients. In stable patients with such findings, therefore, PE is unlikely and other diagnoses, particularly acute coronary syndrome, should be considered before pursuing a diagnosis of PE.
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Affiliation(s)
- Paul D. Stein
- Departments of Internal Medicine and Research and Advanced Studies Program, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
- Department of Research, St. Mary Mercy Hospital, Livonia, MI, USA
| | - Muhammad Janjua
- Department of Internal Medicine, St. Joseph Mercy Oakland, Pontiac, MI, USA
| | - Fadi Matta
- Departments of Internal Medicine and Research and Advanced Studies Program, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
- Department of Research, St. Mary Mercy Hospital, Livonia, MI, USA
| | - Fadel Jaweesh
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Ahmed Alrifai
- Department of Internal Medicine, St. Joseph Mercy Oakland, Pontiac, MI, USA
| | - Abdo Y. Yaekoub
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, MI, USA
| | - Haroon L. Chughtai
- Department of Internal Medicine, St. Joseph Mercy Oakland, Pontiac, MI, USA
| | - John F. Cotant
- Department of Internal Medicine, St. Joseph Mercy Oakland, Pontiac, MI, USA
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McFalls EO, Larsen G, Johnson GR, Apple FS, Goldman S, Arai A, Nallamothu BK, Jesse R, Holmstrom ST, Sinnott PL. Outcomes of hospitalized patients with non-acute coronary syndrome and elevated cardiac troponin level. Am J Med 2011; 124:630-5. [PMID: 21601821 PMCID: PMC3771399 DOI: 10.1016/j.amjmed.2011.02.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 01/28/2011] [Accepted: 02/02/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Cardiac troponin levels help risk-stratify patients presenting with an acute coronary syndrome. Although cardiac troponin levels may be elevated in patients presenting with non-acute coronary syndrome conditions, specific diagnoses and long-term outcomes within that cohort are unclear. METHODS By using the Veterans Affairs centralized databases, we identified all hospitalized patients in 2006 who had a troponin assay obtained during their initial reference hospitalization. On the basis of the diagnostic codes of the International Classification of Diseases, 9th Revision, primary diagnoses were categorized as acute coronary syndrome or non-acute coronary syndrome conditions. RESULTS Of a total of 21,668 patients with an elevated troponin level who were discharged from the hospital, 12,400 (57.2%) had a non-acute coronary syndrome condition. Among that cohort, the most common diagnostic category involved the cardiovascular system, and congestive heart failure (N=1661) and chronic coronary artery disease (N=1648) accounted for the major classifications. At 1 year after hospital discharge, mortality in patients with a non-acute coronary syndrome condition was 22.8% and was higher than in the acute coronary syndrome cohort (odds ratio 1.39; 95% confidence interval, 1.30-1.49). Despite the high prevalence of cardiovascular diseases in patients with a non-acute coronary syndrome diagnosis, use of cardiac imaging within 90 days of hospitalization was low compared with that in patients with acute coronary syndrome (odds ratio 0.25; 95% confidence interval, 0.23-0.27). CONCLUSIONS Hospitalized patients with an elevated troponin level more often have a primary diagnosis that is not an acute coronary syndrome. Their long-term survival is poor and justifies novel diagnostic or therapeutic strategy-based studies to target the highest risk subsets before hospital discharge.
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Affiliation(s)
- Edward O McFalls
- Cardiology Section, Veterans Affairs Medical Center, Minneapolis, Minn. 55417, USA.
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Carlberg DJ, Tsuchitani S, Barlotta KS, Brady WJ. Serum troponin testing in patients with paroxysmal supraventricular tachycardia: outcome after ED care. Am J Emerg Med 2011; 29:545-8. [DOI: 10.1016/j.ajem.2010.01.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 01/28/2010] [Accepted: 01/28/2010] [Indexed: 10/19/2022] Open
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Gow DJ, Gow AG, Bell R, Spratt D, Cash R, Ricketts S, Archer J, Mellanby RJ. Serum cardiac troponin I in dogs with primary immune-mediated haemolytic anaemia. J Small Anim Pract 2011; 52:259-64. [DOI: 10.1111/j.1748-5827.2011.01061.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Stein PD, Janjua M, Matta F, Pathak PK, Jaweesh F, Alrifai A, Chughtai HL. Prognosis based on creatine kinase isoenzyme MB, cardiac troponin I, and right ventricular size in stable patients with acute pulmonary embolism. Am J Cardiol 2011; 107:774-7. [PMID: 21247522 DOI: 10.1016/j.amjcard.2010.10.061] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 10/19/2010] [Accepted: 10/19/2010] [Indexed: 01/04/2023]
Abstract
Prognosis of stable patients with acute pulmonary embolism (PE) has been assessed with cardiac troponin I (cTnI) and right ventricular (RV) function or size. Whether creatine kinase-MB isoenzyme (CK-MB) would add to the prognostic assessment is uncertain. We retrospectively assessed in-hospital mortality from PE in 392 stable patients to test the hypothesis that CK-MB would be of greater prognostic value than cTnI or RV size and we assessed whether combinations would increase prognostic value. CK-MB was high in 29 patients (7.4%); cTnI was high in 76 patients (19%) and intermediate in 78 patients (20%). The right ventricle was dilated in 128 patients (33%). Trends showed highest in-hospital mortality from PE in 4 of 29 (14%) with high CK-MB compared to 6 of 76 (7.9%) with high cTnI and 8 of 128 (6.3%) with RV dilatation (differences NS). High CK-MB and high cTnI provided added prognostic information only in patients with RV dilatation. Mortality with high CK-MB plus RV dilatation (4 of 19, 21%) tended to exceed mortality with high cTnI plus RV dilatation (5 of 39, 13%, NS). When CK-MB and cTnI were high and the right ventricle was dilated, PE mortality tended to be highest (4 of 14, 29%, NS). In conclusion, cardiac biomarkers contributed to prognosis only in patients with RV dilatation. CK-MB was the strongest predictor of death from PE but its prevalence was low, thus limiting its value as a single prognostic indicator. The combination of high CK-MB, high cTnI, and RV dilatation tended to indicate the highest mortality.
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Validation of a prediction score model to distinguish acute coronary syndromes from other conditions causing raised cardiac troponin T levels. Coron Artery Dis 2010; 21:363-8. [DOI: 10.1097/mca.0b013e32833d18d8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Stein PD, Matta F, Janjua M, Yaekoub AY, Jaweesh F, Alrifai A. Outcome in stable patients with acute pulmonary embolism who had right ventricular enlargement and/or elevated levels of troponin I. Am J Cardiol 2010; 106:558-63. [PMID: 20691316 DOI: 10.1016/j.amjcard.2010.03.071] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 03/30/2010] [Accepted: 03/30/2010] [Indexed: 10/19/2022]
Abstract
Normotensive patients with acute pulmonary embolism (PE) who have increased troponin levels and right ventricular (RV) dysfunction are thought to be at high risk of death, but the level of risk is unclear. We retrospectively evaluated outcome in 1,273 stable patients with PE who had echocardiographic evaluations of RV size and/or measurement of cardiac troponin I (cTnI). In-hospital all-cause mortality was higher in those with RV enlargement (8.0%, 19 of 237, vs 3.3%, 22 of 663, p = 0.003). With an increased cTnI, irrespective of RV enlargement, all-cause mortality was 8.0% (28 of 330) versus 1.9% (15 of 835) in patients with a normal cTnI (p <0.0001). In patients with an increased cTnI combined with an enlarged right ventricle, all-cause mortality was 10.2% (12 of 118) compared to 1.9% (8 of 421) in patients who had neither (p <0.0001). These data show that increased levels of cTnI and RV enlargement are associated with an adverse outcome in stable patients with acute PE. In conclusion, increased levels of cTnI in combination with RV enlargement might indicate a group who would benefit from intense monitoring and aggressive treatment if subsequently indicated. The outcomes, however, were not extreme enough to warrant routine thrombolytic therapy.
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