Elevated Troponin I Levels in Diabetic Ketoacidosis Without Obstructive Coronary Artery Disease

Troponinemia in Patients With Diabetic Ketoacidosis Without Acute Coronary Syndrome

Ischemic myocardial injury in a diabetes mellitus (DM) patient can be a trigger or a complication of diabetic ketoacidosis (DKA). This case series examines the phenomenon of elevated troponin levels in patients with DKA in the absence of obstructive coronary artery disease. Two out of three cases showed ST-segment elevation on electrocardiogram (EKG). Despite the absence of obstructive coronary artery disease on coronary angiography, all cases exhibited troponinemia (>79 ng/dl). These elevated troponin levels and EKG changes may pose diagnostic challenges for clinicians. Alternatively, troponinemia could be due to myocardial injury caused by acidotic stress and free fatty acid utilization along with increased myocardial oxygen demand and not obstructive coronary artery pathology in every case. However, a better understanding of the complex interplay between DKA and myocardial injury needs further research.

Rapid diagnosis of acute myocardial infarction based on reverse transcription-accelerated strand exchange amplification of miR-208a

Acute myocardial infarction (AMI) is a prevalent cardiovascular disease associated with high morbidity and mortality, posing a significant threat to human health. Therefore, early diagnosis of AMI has become a focal point of research. MiR-208 is specifically expressed in the heart and is involved in the regulation of cardiomyocyte hypertrophy, cardiac fibrosis, and other myocardial gene expressions. It is expected to be applied in the clinical detection of AMI due to its release by damaged myocardial cells within 3 hours of AMI. In this study, we developed a denatured bubble-mediated reverse transcription-accelerated strand exchange amplification (RT-ASEA) method to detect the early biomarker miR-208a of AMI. The novel approach allowed rapid amplification of miR-208a in 15 minutes, with good performance in terms of repeatability (CV < 6%), determination limit (1 × 100 pmol L-1), and linearity (R2 = 0.9690). Based on the analysis of 42 clinical samples, a strong correlation was observed between the Ct value of miR-208a detected by the RT-ASEA method and the cTnI concentration, considered the gold standard for diagnosis of AMI. The research suggested that the RT-ASEA method could be applied to distinguish between AMI and healthy groups. The area under the receiver operating characteristic curve (AUC) was 0.9976, with a sensitivity of 96% and a specificity of 100%. Optimized RT-ASEA is a reliable and efficient method for miRNA detection. Furthermore, this study provides crucial data support for the development of miR-208a as an early biomarker for AMI, which is of great significance in life and health.

Markedly elevated troponin and NT-proBNP and myocardial dysfunction in an adolescent with severe diabetic ketoacidosis: a case report

Severe diabetic ketoacidosis (DKA), rarely, may be associated with elevated troponin and proBNP levels in adults with a history of diabetes. However, few cases have reported this association in children with severe and complicated DKA. We describe a case of severe DKA (pH: 6.89, HCO3: 6.5) in a 14-yr-old female adolescent in which the symptoms of DKA were presented days before the diagnosis. The patient was under the effect of acidosis (Kussmaul respiration) for 12 h before admission to our hospital, where she was admitted in a critical clinical condition. After successful treatment with DKA with intensive intravenous fluid and regular insulin, the patient presented with abnormal cardiac rhythm, disturbance of interventricular septum motility, a mild decrease in left ventricular systolic function, negative T waves in leads III and aVF, and a marked increase in troponin and brain natriuretic peptide (NT-proBNP) levels. All abnormal findings completely resolved within 8 days after the initiation of DKA treatment. The phenomenon in our case was transient, and the patient had a good long-term outcome. However, it represents a challenge for clinicians; therefore, emphasis should be given to cardiac monitoring during the course of severe and prolonged DKA in children and adolescents.

Clinical characteristics and prognostic implications of diabetes and myocardial injury in patients admitted to the emergency room

BACKGROUND

This study aimed to investigate the clinical features and prognosis of diabetes and myocardial injury in patients admitted to the emergency department.

METHODS

We analyzed the clinical data of all consecutive patients admitted to the emergency department during the years 2012 and 2013 with at least 1 cardiac Troponin I (cTnI Ultra Siemens, Advia Centaur) determination, and were classified according to the status of diabetes mellitus (DM) and myocardial injury (MI). Clinical events were evaluated in a 4-year follow-up.

RESULTS

A total of 3622 patients were classified according to the presence of DM (n = 924 (25.55%)) and MI (n = 1049 (28.96%)). The proportion of MI in patients with DM was 40% and 25% in patients without DM. Mortality during follow-up was 10.9% in non-DM patients without MI, 21.3% in DM patients without MI, 40.1% in non-DM patients with MI, and 52.8% in DM patients with MI. A competitive risk model was used to obtain the Hazard Ratio (HR) for readmission for myocardial infarction or heart failure. There was a similar proportion of readmission for myocardial infarction and heart failure at a four-year follow-up in patients with DM or MI, which was much higher when DM was associated with MI, with respect to patients without DM or MI. The HR (95% Coefficient Interval) for myocardial infarction in the DM without MI, non-DM with MI, and DM with MI groups with respect to the non-DM without MI group was 2511 (1592-3960), 2682 (1739-4138), and 5036 (3221-7876), respectively. The HR (95% CI) for the risk of readmission for heart failure in the DM without MI, non-DM with MI, and DM with MI groups with respect to the non-DM without MI group was 2663 (1825-3886), 2562 (1753-3744) and 4292 (2936-6274), respectively.

CONCLUSIONS

The association of DM and MI in patients treated in an Emergency Service identifies patients at very high risk of mortality and cardiovascular events.

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.

Biomarkers of acute myocardial infarction: diagnostic and prognostic value. Part 1 (literature review)

Morbidity and mortality rates from acute myocardial infarction (AMI) have been growing rapidly in recent years, causing significant socio-economic damage. Cardiac biomarkers play an important role in the diagnosis and prediction of AMI. In our review article, we will summarize information about the main existing cardiac biomarkers and focus on their diagnostic and prognostic value for patients with AMI. In the first part of the review, we consider the diagnostic and prognostic value of biomarkers of necrosis and myocardial ischemia (aspartate aminotransferase; creatine phosphokinase; cardiac troponins; myoglobin, ischemia-modified albumin, fatty acid binding protein) and neuroendocrine AMI biomarkers (natriuretic peptides, adrenomedullin, catestatin, components of the renin-angiotensin-aldosterone system). In the second part of the review, we discuss the diagnostic and prognostic value of inflammatory AMI biomarkers (C-reactive protein, interleukin-6, tumor necrosis factor, myeloperoxidase, matrix metalloproteinases, soluble CD40 ligand form (sCD40L), procalcitonin, placental growth factor (PGF), procalcitonin) and recently discovered new biomarkers (microRNA, stimulating growth factor, expressed by genome 2 (ST2), growth differentiation factor 15 (GDF-15), galectin-3).

Review article: Ketoacidosis in the emergency department

Diabetic ketoacidosis, a life-threatening complication of type 1 diabetes mellitus, is a common cause of presentation to EDs. Two new drug classes have been found to cause ketoacidosis with distinctive presentations. The sodium-glucose transport protein 2 inhibitors used in the management of type 2 diabetes mellitus may present with ketoacidosis with normal glucose levels. Ketoacidosis with these medications may be prolonged and recur after initial resolution. Checkpoint inhibitors may present with fulminant diabetic ketoacidosis in individuals with previously normal glucose tolerance. Ketoacidosis may also occur as a result of starvation and alcohol excess, as well as a number of rare causes. Other causes of metabolic acidosis with both high and normal anion gap need to be considered in the differential diagnosis of ketoacidosis. Diabetic ketoacidosis may also present with biochemical changes suggestive of myocardial ischaemia and pancreatitis in the absence of these pathologies. The present paper reviews ketone body metabolism, ketone testing and the causes and differential diagnosis of ketoacidosis with particular relevance to emergency medicine.

Acute coronary syndrome and diabetic keto acidosis: the chicken or the egg?

We sought to describe two cases of diabetic ketoacidosis (DKA) with elevated troponin. The association of DKA with myocardial infarction (MI) is very frequent. We therefore decide to look deeply in the potential mechanisms behind this strong relationship. We did review the potential role of severe acidosis, intracellular calcium, the counter-regulatory hormones and the potential of the free fatty acid release. Those two conditions can trigger each other and it is often difficult to know which condition appear first. Ultimately, it stands to reason that the message for the clinician should be that a troponin elevation in a DKA patient should always be considered as a coronary abnormality until proven otherwise.

Myocardial dysfunction associated with diabetic ketoacidosis in a 5-year-old girl

In this study, we report a case of a 5-year-old girl with new onset of insulin-dependent diabetes mellitus, who presented with severe diabetic ketoacidosis associated with brain edema and severe myocardial dysfunction, needing intubation and inotropic support. To our knowledge, this is the youngest reported case with severe diabetic ketoacidosis complicated with myocardial dysfunction.

Diagnostic and prognostic value of biomarkers in acute myocardial infarction

The incidence of acute myocardial infarction (AMI) has been increasing rapidly in recent years, seriously endangering human health. Cardiac biomarkers play critical roles in the diagnosis and prognosis of AMI. Troponin is a highly sensitive and specific biomarker for AMI diagnosis and can independently predict adverse cardiac events. Other biomarkers such as N-terminal B-type natriuretic peptide and C reactive protein are also valuable predictors of cardiovascular prognosis. Recently, several novel biomarkers have been identified for the diagnosis and risk assessment in patients with AMI. A multibiomarker approach can potentially enhance the diagnostic accuracy and provide more information for the early risk stratification of AMI. In this review, we will summarise the biomarkers discovered in recent years and focus on their diagnostic and prognostic value for patients with AMI.