Cardiac Troponin I elevation after epileptic seizure

Neuroprotective Effects of Milrinone on Acute Traumatic Brain Injury

BACKGROUND

Traumatic brain injury is still an important health problem worldwide. Traumatic brain injury not only causes direct mechanical damage to the brain but also induces biochemical changes that lead to secondary nerve cell loss. In this study, we investigated the neuroprotective effect of milrinone after traumatic brain injury (TBI) in a rat model.

METHODS

Forty male Wistar albino rats, were used. Rats were divided into 4 groups: 1) sham, 2) TBI, 3) TBI + Ringers, and 4) TBI + Milrinone. In group 1 (sham), only craniotomy was performed. In group 2 (TBI), TBI was performed after craniotomy. In group 3 (TBI + Ringer), TBI was performed after craniotomy and intraperitoneal Ringers solution was given immediately afterward. Group 4 (TBI + Milrinone), TBI was performed after craniotomy, and milrinone was given 1.0 mg/kg milrinone intraperitoneally directly (0.5 mg/kg milrinone intraperitoneally again 24 hours, 48 hours, and 72 hours after trauma). Tests were performed for neurological and neurobehavioral functions. Immunohistochemistry and histopathology studies were performed.

RESULTS

In group 4 compared with group 2 and group 3 groups, tests for neurological functions and neurobehavioral functions were significantly better. In the milrinone treatment used in group 4, plasma and brain tissue tumor necrosis factor, 8-OH 2-deoxyguanosine , and interleukin 6 levels were significantly decreased, and increased plasma and tissue IL-10 levels were detected. Histopathological spinal cord injury and apoptotic index increased in groups 2 and 3, while significantly decreasing in group 4.

CONCLUSIONS

This study shows for the first time that the anti-inflammatory, antioxidant and antiapoptotic properties of milrinone may be neuroprotective after TBI.

Troponin I New Biomarker in Traumatic Brain Injury

Mortality in traumatic brain injury (TBI) is thought to be pathology in the heart-brain axis but its effect on the prognosis of traumatic brain injury remains unclear. Our study aimed to investigate the relationship between cardiac troponin I (cTnI) level and prognosis in TBI patients. Between January 2017 and May 2021, 480 patients diagnosed with TBI, who applied to the emergency department, were retrospectively included in this multicentric study. The databases of the hospitals were examined comprehensively and the demographic, clinical, laboratory, radiological, and therapeutic data and results of the patients were obtained. The severity of trauma and clinical status was evaluated with AIS, Injury Severity Score (ISS), ASA physical status, and Glasgow Coma Scale (GCS). The severity of the trauma was evaluated with the ISS. The modified Rankin Scale (mRS) and the Glasgow Outcome Scale (GOS) at discharge were used to evaluate in-hospital clinical outcomes. cTnI levels were classified into three categories: normal (< 0.05 ng/ml), mildly elevated (0.05–0.99 ng/ml), and severely elevated (≥ 1 ng/ml). The mean age of the patients was 41.7 and 75.4% of them were men. It was observed that mortality among patients over 65 years (13.9%) increased. High cTnI was detected in 284 (59.1%) patients. Although it was not statistically significant regarding the elevation of cTnI in patients under 65 years of age (P = 0.62), the difference was significant for cTnI in patients over 65 years of age (P < 0.001). The relationship between cTnI elevation was found to be statistically significant (P < 0.001) as the severity of the trauma increased and when severe additional traumas (thoracic, abdominal, or pelvic) occurred. A high cTnI level is associated with poor prognosis in TBI patients. cTnI measurement is a useful tool for early risk stratification and accelerated care; however, further prospective studies are needed.

Reverse Takotsubo cardiomyopathy associated with tonic clonic seizure: a rare form of Takotsubo cardiomyopathy

A woman in her 30s presented with generalised tonic clonic seizure secondary to known pilocytic astrocytoma. This seizure activity resolved spontaneously after 5 min. On clinical assessment, she was neurologically stable and further neurological investigations did not reveal progression of previously recognised pilocytic astrocytoma. Incidentally, she was found to have an elevated troponin, which significantly increased on serial assessment. ECG was unremarkable and echocardiography revealed regional wall motion abnormalities involving basal segments of the left ventricle with apical sparing. She underwent cardiac MRI, which confirmed the presence of regional wall motion abnormalities seen on echocardiography; however, there was no evidence of myocardial oedema or late gadolinium enhancement. Subsequently, she had an invasive coronary angiogram with intravascular ultrasound which ruled out acute coronary plaque event and coronary dissection. In view of the above, a diagnosis of reverse Takotsubo cardiomyopathy was made. This is a relatively rare entity characterised by the presence of akinesia/hypokinesia in the basal segments with preserved apical contractility; often seen in younger patients.

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.

Value of the high-sensitivity troponin T assay for diagnosis of acute myocardial infarction in patients with and without renal insufficiency

BACKGROUND

Cardiac troponins are important markers for diagnosis of acute myocardial infarction (AMI) in general population; however, chronically-elevated troponins levels are often seen in patients with renal insufficiency, which reduce their diagnostic accuracy. The aim of our study was to access the diagnostic values of initial high-sensitive cardiac troponin T (hs-cTnT) and relative change of hs-cTnT for AMI in patients with and without renal insufficiency.

METHODS

Cardiac care unit patients with elevated hs-cTnT levels in 2017-2018 were enrolled. Receiver operating characteristic (ROC) curves were used to evaluate initial hs-cTnT levels and relative changes after 3 h of enrollment for diagnosis of AMI in patients with estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² (low), and eGFR ≥ 60 mL/min/1.73 m² (normal).

RESULTS

Of 359 patients, 240 patients had low eGFR, and 119 patients had normal eGFR. The area under the ROC curve (AUC) for the initial hs-cTnT levels was 0.58 (95% CI, 0.5-0.65, p = 0.053) among patients with low eGFR and 0.54 (95% CI, 0.4-0.67, p = 0.612) among patients with normal eGFR. AUCs for relative changes of hs-cTnT were 0.82 (95% CI, 0.76-0.88, p < 0.001) in patients with low eGFR and 0.82 (95% CI, 0.71-0.91, p < 0.001) in patients with normal eGFR. Optimal cutoff values for the relative changes in hs-cTnT were 16% and 12% in patients with low eGFR and normal eGFR, respectively.

CONCLUSIONS

Relative changes in hs-cTnT levels had better diagnostic accuracy than initial hs-cTnT levels.

Cardiovascular complications of epileptic seizures

Seizure disorders are associated with multisystem complications. Cardiovascular complications account for a significant proportion of morbidity and mortality in these patients. As such, particular attention must be paid to the incidence of cardiovascular complications especially in populations at increased risk. The background for cardiac dysfunction lies in the interplay of genetic/molecular, autonomic, and iatrogenic factors that contribute to its onset. The purpose of this review was to summarize the state of literature in the last decade with regard to cardiac complications of epileptic seizures in order to increase awareness of short- and long-term debilitating cardiac complications as well as facilitate informed clinical decision-making. Taken together, the evidence provided in this review suggests that cardiac dysfunction following seizures should not be viewed as a separate entity but as an important complication of epileptic seizures. Appropriate cardiac therapy should be instituted in the postictal medical management of epileptic seizures. In acute states, postictal cardiac troponinemia (elevated cTn) should be worked up. Longer-term, monitoring for the development of cardiac structural and functional abnormalities is prudent.

cTnI, BNP and CRP profiling after seizures in patients with drug-resistant epilepsy

PURPOSE

To profile serum levels of high sensitivity Troponin I (hs-cTnI), B-Type Natriuretic Peptide (BNP), and high sensitivity C Reactive Protein (hs-CRP), after epileptic seizures in patients with focal drug-resistant epilepsy, relating the results to the revised SUDEP-7 inventory.

METHODS

We prospectively evaluated patients admitted to our Epilepsy Monitoring Unit. hs-cTnI, BNP, and hs-CRP were measured at admission and after the first seizure. The revised SUDEP-7 Risk Inventory was calculated. The statistical significance level was set at 0.05.

RESULTS

Fifty-eight patients were included (53.4 % female). The index seizure was a focal to bilateral tonic-clonic seizure (FBTCS) in 25.9 % of the patients, and 17.5 % had post-ictal generalized EEG suppression (PGES). After the seizure, 25.9 % had a significant (above 50 %) increase in hs-cTnI, 23.3 % in BNP, and 4.3 % in hs-CRP. About 40 % had cardiovascular risk factors (CRF), without known cardiac disease. The elevation of one biomarker did not compel the elevation of another. hs-cTnI increase was associated with FBTCS, PGES, longer seizures, maximal ictal heart rate, and HR change. Increases in BNP were associated with CRF. hs-CRP increase was associated with PGES. We found no significant association between SUDEP-7 and any biomarker increase.

SIGNIFICANCE

Several patients had increases in biomarkers of myocardial necrosis/dysfunction after seizures, without significant association with the SUDEP-7 inventory. Different patterns of biomarkers' elevations point to multifactorial pathophysiologies hypothetically associated with incipient myocardial lesions. A larger cohort with follow-up data could help to clarify the clinical relevance of these findings.

Cardiac stress after electroconvulsive therapy and spontaneous generalized convulsive seizures: A prospective echocardiographic and blood biomarker study

AIM

Knowledge about cardiac stress related to seizures in electroconvulsive therapy (ECT) and spontaneously occurring generalized convulsive seizures (GCS) is limited. The aim of the present study was to analyze cardiac function and circulating markers of cardiac stress in the early postictal period after ECT and GCS.

METHODS

Patients undergoing ECT in the Department of Psychiatry, Psychotherapy and Psychosomatics and patients undergoing diagnostic video-EEG monitoring (VEM) in the Department of Neurology were prospectively enrolled between November 2017 and November 2018. Cardiac function was examined twice using transthoracic echocardiography within 60 min and >4 h after ECT or GCS. Established blood markers (troponin T high-sensitive, N-terminal pro brain natriuretic peptide) of cardiac stress or injury were collected within 30 min, 4 to 6 h, and 24 h after ECT or GCS. In the ECT group, the troponin T values were also correlated with periprocedural heart rate and blood pressure values. Because of organizational or technical reasons, the measurement was not performed in all patients.

RESULTS

Twenty patients undergoing ECT and 6 patients with epilepsy with a GCS during VEM were included. Postictal echocardiography showed no wall motion disorders and no change in left ventricular and right ventricular functions. Four of 17 patients displayed a transient increase in high-sensitive cardiac troponin T 4-6 h after the seizure (3 patients with ECT-induced seizure). None of these 4 patients had signs of an acute cardiac event, and periprocedural blood pressure or heart rate peaks during ECT did not significantly differ in patients with and without troponin T elevation.

CONCLUSIONS

Signs of mild cardiac stress can occur in some patients following ECT or GCS without clinical complications, probably related to excessive catecholamine release during the seizure.

Heartbreakers-Cardiac Stress After Uncomplicated Generalized Convulsive Seizures

Blood Markers of Cardiac Stress After Generalized Convulsive Seizures. Nass RD, Motloch LJ, Paar V, Lichtenauer M, Baumann J, Zur B, Hoppe UC, Holdenrieder S, Elger CE, Surges R. Epilepsia. 2019;60(2):201-210. doi:10.1111/epi.14637. Epub 2019 Jan 15. PMID: 30645779 Objective: Generalized convulsive seizures (GCS) are associated with high demands on the cardiovascular system, thereby facilitating cardiac complications. To investigate occurrence, influencing factors, and extent of cardiac stress or injury, the alterations and time course of the latest generation of cardiac blood markers were investigated after documented GCS.

METHODS

Adult patients with refractory epilepsy who underwent video-electroencephalography monitoring along with simultaneous one-lead electrocardiography recordings were included. Cardiac biomarkers (cardiac troponin I [cTNI]; high-sensitivity troponin T [hsTNT]; N-terminal prohormone of brain natriuretic peptide; copeptin; suppression of tumorigenicity-2 [SST-2]; growth differentiation factor 15, [GDF-15]; soluble urokinase plasminogen activator receptor [suPAR]; and heart-type fatty acid binding protein [HFABP]) and catecholamines were measured at inclusion and at different time points after GCS. Peri-ictal cardiac properties were assessed by analyzing heart rate (HR), HR variability (HRV), and corrected QT intervals (QTc).

RESULTS

Thirty-six GCS (6 generalized-onset tonic-clonic seizures and 30 focal to bilateral tonic-clonic seizures) were recorded in 30 patients without a history of cardiac or renal disease. Postictal catecholamine levels were elevated more than 2-fold. A concomitant increase in HR and QTc, as well as a decrease in HRV, was observed. Elevations of cTNI and hsTNT were found in 3 (10%) of 30 patients and 6 (26%) of 23 patients, respectively, which were associated with higher dopamine levels. Copeptin was increased considerably after most GCS, whereas SST-2, HFABP, and GDF-15 displayed only subtle variations, and suPAR was unaltered in the postictal period. Cardiac symptoms did not occur in any patient.

SIGNIFICANCE

The use of more sensitive biomarkers such as hsTNT suggests that signs of cardiac stress occur in about 25% of the patients with GCS without apparent clinical symptoms. Soluble urokinase plasminogen activator receptor may indicate clinically relevant troponin elevations. Copeptin could help to diagnose GCS but specificity needs to be tested.

Postictal syndrome: The forgotten continent. An overview of the clinical, biochemical and imaging features

Postictal syndrome (PIS) encompasses the clinical, biological, electroencephalographic (EEG) and magnetic resonance imaging (MRI) signs that follow the termination of a seizure. These signs occur as soon as the epileptic discharge ends, but might remain for a substantially long period of time, making them amenable to clinical observation. As a direct consequence, neurologists and intensivists are more frequently attending patients with PIS than during their seizure. Moreover, careful PIS documentation may help physicians to diagnose epileptic seizure from other non-epileptic disorders. Careful analysis of PIS could also be helpful to better characterize the seizure (seizure subtypes, and to some extent, the localization and/or lateralization of the seizure). This article aims to review the main clinical, biological, EEG and MRI components of PIS, discuss differential diagnoses and propose a general clinical attitude, based on the acronym "WAITTT": W for "Watch", to monitor and investigate PIS in order to provide relevant information on seizure, AIT for "Avoid Inappropriate Treatment", to underscore the risk carrying out unnecessary drug injections and intensive care procedures in the setting of a self-limited symptomatology, and TT for "Take Time", to keep in mind that time remains the clinician's best ally for treating patients with PIS.

Significance of Cardiac Troponin I Elevation in Traumatic Brain Injury Patients

Background

Myocardial dysfunction is frequently described as an underlying cause of mortality in traumatic brain injury (TBI) known as brain-cardiac link. However the impact on prognosis of a disease remains uncertain.

Objectives

The current study aimed at investigating the correlation between TBI and cardiac troponin I (cTnI) rise and in-hospital mortality rate among patients with TBI.

Methods

In the current prospective study TBI patients with abbreviated injury scale score (AIS) > 3 and Glasgow coma scale (GCS) score ≤ 8 with cTnI measurement within the first 24 hours of admission were evaluated. Chi-square, Kruskal-Wallis, Mann-Whitney U and Logistic Regression tests were used for data analysis.

Results

A total of 166 eligible patients were studied .The mean age of the cases was 37.64 ± 17.21 years, largely under 65 (93.4%) and male (86.7%).The most common injuries were cerebral contusion (35.1%), while motor vehicle crash (MVC) was the most common cause of injuries (83.73%); 59 % of the patients showed detectable cTnI concentrations within 24 hours of admission; 65.7% of the patients expired; they showed higher levels of cTnI compared to survivors that showed lower levels, 0.148 ± 0.074 vs 0.057 ± 0.055, respectively (P < 0.001). Moreover, a significant association was observed between mortality rate and lower admission GCS 3.49 ± 1.08 vs 6.79 ± 1.66, respectively (P < 0.001).

Conclusions

Increased cTnI levels could be a predictor of mortality among patients with TBI. Its measurement and investigation for therapeutic strategies could lead to better management of these cases.

Closed-loop Neuropharmacology for Epilepsy: Distant Dream or Future Reality?

Epilepsy is considered the most frequent severe neurological condition but most patients treated with medication become seizure free. The management of treatment, however, is highly empirical, mainly relying on observation. A closed-loop therapy for epilepsy would be very valuable for more efficient treatment regimens. Here we discuss monitoring treatment (therapeutic drug monitoring) and the potential developments in this field, as well as providing a review of potential biomarkers that could be used to monitor the disease activity. Finally, we consider the pharmacogenetic input in epilepsy treatment.

Brain-Heart Interactions in Traumatic Brain Injury

The cardiovascular manifestations associated with nontraumatic head disorders are commonly known. Similar manifestations have been reported in patients with traumatic brain injury (TBI); however, the underlying mechanisms and impact on the patient's clinical outcomes are not well explored. The neurocardiac axis theory and neurogenic stunned myocardium phenomenon could partly explain the brain-heart link and interactions and can thus pave the way to a better understanding and management of TBI. Several observational retrospective studies have shown a promising role for beta-adrenergic blockers in patients with TBI in reducing the overall TBI-related mortality. However, several questions remain to be answered in clinical randomized-controlled trials, including population selection, beta blocker type, dosage, timing, and duration of therapy, while maintaining the optimal mean arterial pressure and cerebral perfusion pressure in patients with TBI.

Sudden death: Neurogenic causes, prediction and prevention

Sudden death is a major health problem all over the world. The most common causes of sudden death are cardiac but there are also other causes such as neurological conditions (stroke, epileptic attacks and brain trauma), drugs, catecholamine toxicity, etc. A common feature of all these diverse pathologies underlying sudden death is the imbalance of the autonomic nervous system control of the cardiovascular system. This paper reviews different pathologies underlying sudden death with emphasis on the autonomic nervous system contribution, possibilities of early diagnosis and prognosis of sudden death using various clinical markers including autonomic markers (heart rate variability and baroreflex sensitivity), present possibilities of management and promising prevention by electrical neuromodulation.

Laboratory markers of cardiac and metabolic complications after generalized tonic-clonic seizures

Background

Generalized tonic-clonic seizures (GTCS) frequently lead to emergency inpatient referrals. Laboratory blood values are routinely performed on admission to detect underlying causes and metabolic or cardiac complications. Our goal was to assess the nature and frequency of complications occurring in association with GTCS.

Methods

We retrospectively extracted data from emergency protocols and discharge letters of adult patients admitted to the Department of Epileptology between 01/2010 and 06/2015. Inclusion criteria were diagnosis of GTCS and admission via emergency services. Exclusion criteria were status epilepticus prior to admission to hospital and non-generalized seizures.

Results

A total of 223 patients (of 986 screened cases) were included. Overall, 1.8% required intubation while 1.3% had less severe respiratory problems. In 5.6% of patients, a transient hypoxemia was measured. Hypertensive urgencies affected 7.8% of the patients, sinus tachycardia occurred in 41.2%. Troponin I (cTNI) was determined in 75 patients and was increased in 12% of these cases. Occurrence of elevated cTNI levels was significantly correlated with patient’s age. Four patients were diagnosed with NSTEMI and one patient with STEMI. Creatine kinase (CK) was increased in 59.4% of the patients, with <5-fold increases in 47%, <10-fold in 5.8% and >10-fold increases in 4.3%. Rhabdomyolysis with an >50 fold increase in CK was detected in 1.9% of patients. Prolonged disturbances of consciousness affected 5% of cases while agitation, delirium, and psychotic episodes occurred in 6.3%. Minor traumatic injuries affected 45.7% of patients.

Conclusions

Troponin elevations in association with GTCS are one of the more common complications after emergency admissions especially in older patients. In our selected patient population, serious complications such as intracranial hemorrhage, myocardial infarction and acute renal failure occurred in <1% of GTCS only.

Study of young patients with myocardial infarction: Design and rationale of the YOUNG-MI Registry

The YOUNG-MI registry is a retrospective study examining a cohort of young adults age ≤ 50 years with a first-time myocardial infarction. The study will use the robust electronic health records of 2 large academic medical centers, as well as detailed chart review of all patients, to generate high-quality longitudinal data regarding the clinical characteristics, management, and outcomes of patients who experience a myocardial infarction at a young age. Our findings will provide important insights regarding prevention, risk stratification, treatment, and outcomes of cardiovascular disease in this understudied population, as well as identify disparities which, if addressed, can lead to further improvement in patient outcomes.

The role of cardiac troponin I in prognostication of patients with isolated severe traumatic brain injury

BACKGROUND

Cardiac dysfunction is frequently observed after severe traumatic brain injury (sTBI); however, its significance is poorly understood. Our study sought to elucidate the association of cardiac troponin I (cTnI) elevation with all-cause in-hospital mortality following isolated sTBI (brain Abbreviated Injury Scale score ≥3 and admission Glasgow Coma Scale score ≤8, no Abbreviated Injury Scale score ≥3 to any other bodily regions).

METHODS

We retrospectively reviewed all adult patients (aged ≥18 years) with isolated sTBI admitted to a Level I trauma center between June 2007 and January 2014. Patients must have cTnI values within 24 hours of admission. Mortality risks were examined by Cox proportional hazard model.

RESULTS

Of 580 patients identified, 30.9% had detectable cTnI in 24 hours of admission. The median survival time was 4.19 days (interquartile range, 1.27-11.69). When adjusted for potential confounders, patients in the highest cTnI category (≥0.21 ng/mL) had a significantly higher risk of in-hospital mortality (hazard ratio, 1.39; 95% confidence interval, 1.04-1.88) compared with patients with undetectable cTnI. Mortality risk increased with higher troponin levels (p < 0.0001). This association was more pronounced in patients aged 65 years or younger (hazard ratio, 2.28; 95% confidence interval, 1.53-3.40; p < 0.0001) while, interestingly, insignificant in those older than 65 years (p = 0.0826).

CONCLUSION

Among patients with sTBI, cTnI elevation is associated with all-cause in-hospital mortality via a nonlinear positive trend. Age modified the effect of cTnI on mortality.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Cardiac Troponin I: A Valuable Biomarker Indicating the Cardiac Involvement in Fabry Disease

Objectives

Assessment of the clinical severity of Fabry disease (FD), an X-linked, rare, progressive disorder based on a genetic defect in alpha-galactosidase is challenging, especially regarding cardiac involvement. The aim of the study was to evaluate the diagnostic value of cardiac troponin I (cTnI) in discriminating FD patients with cardiac involvement in a large FD patient cohort.

Methods

cTnI levels were measured with a contemporary sensitive assay in plasma samples taken routinely from FD patients. The assay was calibrated to measure cTnI levels ≥0.01 ng/ml. Elevated cTnI values (cut-off ≥0.04 ng/ml) were correlated with clinical data.

Results

cTnI was assessed in 62 FD patients (median age: 47 years, males: 36%). Elevated cTnI levels were detected in 23 (37%) patients. Patients with a cTnI elevation were older (median 55 years versus 36 years, p<0.001). Elevated cTnI levels were associated with the presence of a LVH (16/23 versus 1/39; OR 65.81, CI: 6.747–641.859; p<0.001). In almost all patients with a left ventricular hypertrophy (LVH) elevated cTnI levels were detected (16/17, 94%). Absolute cTnI levels in patients with LVH were higher than in those without (median 0.23 ng/ml versus 0.02 ng/ml; p<0.001). A cTnI level <0.04ng/ml had a high negative predictive value regarding the presence of a LVH (38/39, 97%). In a control group of non-FD patients (n = 17) with LVH (due to hypertension) none showed cTnI levels ≥0.01 ng/ml.

Conclusions

Elevated cTnI levels are common in FD patients, reflecting cardiac involvement. FD patients might benefit from a continuous cTnI monitoring.

Who to target in sudden unexpected death in epilepsy prevention and how? Risk factors, biomarkers, and intervention study designs

The risk of dying suddenly and unexpectedly is increased 24- to 28-fold among young people with epilepsy compared to the general population, but the incidence of sudden unexpected death in epilepsy (SUDEP) varies markedly depending on the epilepsy population. This article first reviews risk factors and biomarkers for SUDEP with the overall aim of enabling identification of epilepsy populations with different risk levels as a background for a discussion of possible intervention strategies. The by far most important clinical risk factor is frequency of generalized tonic-clonic seizures (GTCS), but nocturnal seizures, early age at onset, and long duration of epilepsy have been identified as additional risk factors. Lack of antiepileptic drug (AED) treatment or, in the context of clinical trials, adjunctive placebo versus active treatment is associated with increased risks. Despite considerable research, reliable electrophysiologic (electrocardiography [ECG] or electroencephalography [EEG]) biomarkers of SUDEP risk remain to be established. This is an important limitation for prevention strategies and intervention studies. There is a lack of biomarkers for SUDEP, and until validated biomarkers are found, the endpoint of interventions to prevent SUDEP must be SUDEP itself. These interventions, be they pharmacologic, seizure-detection devices, or nocturnal supervision, require large numbers. Possible methods for assessing prevention measures include public health community interventions, self-management, and more traditional (and much more expensive) randomized clinical trials.

Systemic complications of status epilepticus--An update

Systemic complications occur at every stage of status epilepticus, involve every organ system, and may worsen outcome. Initially, there is a massive catecholamine release and hyperadrenergic state that may result in neurocardiogenic, pulmonary, and, sometimes, musculoskeletal or renal injury. Further medical complications accompany the various treatments used to abort the seizures including the use of nonanesthetic antiseizure drugs and high-dose anesthetic infusions. Later, sequelae of prolonged immobility and critical illness occur and add to the cumulative morbidity of these patients. Clinicians should follow a protocol to guide screening for early markers of systemic injury, complications of specific pharmacologic and adjunctive treatments, and periodic surveillance for complications related to prolonged immobility. This article is part of a Special Issue entitled "Status Epilepticus".

Determinants of high sensitivity cardiac troponin T elevation in acute ischemic stroke

BACKGROUND

A proportion of patients with acute ischemic stroke have elevated cardiac troponin levels and ECG changes suggestive of cardiac injury, but the etiology is unclear. The aims of this study were to assess the frequency of high sensitivity cardiac troponin T (hs-cTnT) elevation, to identify determinants and ECG changes associated with hs-cTnT elevation, to identify patients with myocardial ischemia and to assess the impact of hs-cTnT elevation on in-hospital mortality.

METHODS

Patients discharged with a diagnosis of acute ischemic stroke during a 1-year period, were included. Patients diagnosed with acute myocardial infarction (MI) within the last 7 days before admission or during hospitalization were excluded.

RESULTS

In all, 156 (54.4%) of 287 patients had elevated hs-cTnT. The factors independently associated with hs-cTnT elevation were age ≥ 76 years (OR 3.71 [95% CI 2.04-6.75]), previous coronary heart disease (CHD) (OR 2.61 [1.23-5.53]), congestive heart failure (OR 4.26 [1.15-15.82]), diabetes mellitus (OR 4.02 [1.50-10.76]) and lower eGFR (OR 0.97 [0.95-0.98]). Of the 182 patients who had two hs-cTnT measurements, 12 (6.6%) had both a rise or fall of hs-cTnT with at least one elevated value, and ECG manifestations of myocardial ischemia, e.g. meeting the criteria of acute MI. Both dynamic relative change (p = 0.026) and absolute change (p = 0.032) in hs-cTnT were significantly associated with higher in-hospital mortality.

CONCLUSIONS

Established CHD and cardiovascular risk factors are associated with hs-cTnT elevation. Acute MI is likely underdiagnosed in acute ischemic stroke patients. Dynamic changes in troponin levels seem to be related to poor short-term prognosis.

Continuous cardiac troponin I release in Fabry disease

BACKGROUND

Fabry disease (FD) is a rare lysosomal storage disorder also affecting the heart. The aims of this study were to determine the frequency of cardiac troponin I (cTNI) elevation, a sensitive parameter reflecting myocardial damage, in a smaller cohort of FD-patients, and to analyze whether persistent cTNI can be a suitable biomarker to assess cardiac dysfunction in FD.

METHODS

cTNI values were determined at least twice per year in 14 FD-patients (6 males and 8 females) regularly followed-up in our centre. The data were related to other parameters of heart function including cardiac magnetic resonance imaging (cMRI).

RESULTS

Three patients (21%) without specific vascular risk factors other than FD had persistent cTNI-elevations (range 0.05-0.71 ng/ml, normal: <0.01). cMRI disclosed late gadolinium enhancement (LGE) in all three individuals with cTNI values ≥0.01, while none of the 11 patients with cTNI <0.01 showed a pathological enhancement (p<0.01). Two subjects with increased cTNI-values underwent coronary angiography, excluding relevant stenoses. A myocardial biopsy performed in one during this procedure demonstrated substantial accumulation of globotriaosylceramide (Gb3) in cardiomyocytes.

CONCLUSION

Continuous cTNI elevation seems to occur in a substantial proportion of patients with FD. The high accordance with LGE, reflecting cardiac dysfunction, suggests that cTNI-elevation can be a useful laboratory parameter for assessing myocardial damage in FD.

Diagnostic performance of high-sensitive troponin T in patients with renal insufficiency

In the present study, we wanted to (1) evaluate whether high-sensitive troponin T levels correlate with the grade of renal insufficiency and (2) test the accuracy of high-sensitive troponin T determination in patients with renal insufficiency for diagnosis of acute myocardial infarction (AMI). In this cross-sectional analysis, all patients who received serial measurements of high-sensitive troponin T from August 1, 2010, to October 31, 2012, at the Department of Emergency Medicine were included. We analyzed data on baseline characteristics, reason for referral, medication, cardiovascular risk factors, and outcome in terms of presence of AMI along with laboratory data (high-sensitive troponin T, creatinine). A total of 1,514 patients (67% male, aged 65 ± 16 years) were included, of which 382 patients (25%) had moderate to severe renal insufficiency and significantly higher levels of high-sensitive troponin T on admission (0.028 vs 0.009, p <0.0001). In patients without AMI, high-sensitive troponin T correlated inversely with the estimated glomerular filtration rate (R = -0.12, p <0.0001). Overall, sensitivity of an elevated high-sensitive troponin for diagnosis of AMI was 0.64 (0.56 to 0.71) and the specificity was 0.48 (0.45 to 0.51). The area under the curve of the receiver operating characteristic for all patients was 0.613 (standard error [SE] 0.023), whereas it was 0.741 (SE 0.029) for patients with a Modification of Diet in Renal Disease estimated glomerular filtration rate >60 ml/min presenting with acute chest pain or dyspnea and 0.535 (SE 0.056) for patients with moderate to severe renal insufficiency presenting with acute chest pain or dyspnea. In conclusion, the diagnostic accuracy for presence of AMI of a baseline measurement of high-sensitive troponin in patients with renal insufficiency was poor and resembles tossing a coin.

Serum levels of cardiac troponin I in patients with status epilepticus and healthy cardiovascular system

BACKGROUND AND AIMS

Status epilepticus (SE) is accompanied by acute and intense activation of the sympathetic nervous system, which might result in myocyte damage. However, there is insufficient evidence to assess cardiac biomarkers in SE patients. As a highly specific and sensitive biomarker of acute myocardial infarction, serum concentration of cardiac troponin I (cTnI) has been assessed in this study in a sample of SE patients without evidence of previous cardiovascular diseases.

METHODS

In this analytical cross-sectional study, a total number of 30 patients with SE and no history of baseline cardiovascular disorders, aged between 12 and 60 years have been evaluated. Baseline, demographic characteristics and laboratory measurements including cTnI, creatine kinase (CPK) and CPK-MB were recorded for all of patients. cTnI was quantified using ELISA method with the precision of 0.01 ng/mL.

RESULTS

All cases had a cardiac troponin level <0.01 ng/mL except for one 60- year-old female with a history of seizure 3 years prior. The last seizure was 60 days prior and the patient had a reported cTnI level as 0.04 ng/mL, within normal limits. The mean serum levels of CPK and CK-MB were 202.20 (SD = 14.46) μg/l and 14.54 (SD = 1.49) ng/mL, respectively.

CONCLUSIONS

This investigation is one of the few to evaluate serum concentration of cTnI in generalized convulsive SE patients where no detectable elevation was observed in serum concentration of cTnI following SE episode. However, it is very important to take into account that all recruited SE patients included in this study had a healthy cardiovascular system.