Etiology of Myocardial Injury in Critically Ill Patients with Sepsis: A Cohort Study

Endothelial dysfunction: Pathophysiology and therapeutic targets for sepsis-induced multiple organ dysfunction syndrome

Sepsis and septic shock are critical medical conditions characterized by a systemic inflammatory response to infection, significantly contributing to global mortality rates. The progression to multiple organ dysfunction syndrome (MODS) represents the most severe complication of sepsis and markedly increases clinical mortality. Central to the pathophysiology of sepsis, endothelial cells play a crucial role in regulating microcirculation and maintaining barrier integrity across various organs and tissues. Recent studies have underscored the pivotal role of endothelial function in the development of sepsis-induced MODS. This review aims to provide a comprehensive overview of the pathophysiology of sepsis-induced MODS, with a specific focus on endothelial dysfunction. It also compiles compelling evidence regarding potential small molecules that could attenuate sepsis and subsequent multi-organ damage by modulating endothelial function. Thus, this review serves as an essential resource for clinical practitioners involved in the diagnosing, managing, and providing intensive care for sepsis and associated multi-organ injuries, emphasizing the importance of targeting endothelial cells to enhance outcomes of the patients.

Acute Myocardial Injury Assessed by High-Sensitivity Cardiac Troponin I Levels in Adult Patients with Early Sepsis at a Tertiary Referral Center in Mexico: An Exploratory Study

The objective of the study was to describe the frequency of acute myocardial injury (AMI) assessed by high-sensitivity cardiac troponin I (hs-cTnI) levels and to determine the possible initial risk factors (related to the characteristics of the patient, the disease, and the initial management) in a population of adult patients with early sepsis (within the first 72 h of diagnosis) in a single tertiary hospital center in western Mexico. For the inferential statistics, the proportions of the categorical dichotomous variables were compared using the chi-square test. In all analyses, p values less than 0.05 with a 95% confidence interval were considered significant. We included a total of 64 patients diagnosed with early sepsis, of whom 46 presented elevated hs-cTnI and were classified as having AMI. In our study, the frequency of AMI in patients with early sepsis was 71.87%, and no significant differences were found in all of the characteristics of patients with early sepsis with and without AMI, nor was any significant association found with any of the variables analyzed. In the population of western Mexico, the frequency of AMI in patients with early sepsis, assessed by hs-cTnI levels, is high and similar to that reported in other populations worldwide.

First Sampled High-Sensitive Cardiac Troponin T is Associated With One-Year Mortality in Sepsis Patients and 30- to 365-Day Mortality in Sepsis Survivors

BACKGROUND

Previous studies using cardiac troponin levels to investigate the relationship between myocardial injury and mortality in sepsis patients have been conflicting. Our aim was to investigate the relationship between plasma high-sensitive cardiac troponin T (hs-cTnT) level and 30-day and 1-year mortality in sepsis patients and 30- to 365-day mortality in sepsis survivors.

METHODS

Sepsis patients requiring vasopressor support and admitted to our institution between 2012 and 2021 (n = 586) were included in this retrospective cohort study. Elevated hs-cTnT values (≥15 ng/L) were divided into quartiles (Q): Q1 15-35 ng/L; Q2 36-61 ng/L; Q3 62-125 ng/L; Q4 126-8630 ng/L. Stratified Kaplan-Meier curves and multivariable Cox regression were used for survival analyses.

RESULTS

First sampled hs-cTnT was elevated in 529 (90%) patients. One-year mortality was 45% (n = 264). Increasing level of hs-cTnT was independently associated with higher adjusted hazard ratios (HR) for 1-year mortality compared with normal levels: Q1 HR 2.9 (95% confidence interval [CI], 1.03-8.1); Q2 HR 3.5 (95% CI, 1.2-9.8); Q3 HR 4.8 (95% CI, 1.7-13.4); Q4 HR 5.7 (95% CI, 2.1-16). In acute phase survivors, first sampled hs-cTnT was an independent predictor of 30- to 365-day mortality (HR 1.3; 95% CI, 1.1-1.6 per loge hs-cTnT).

CONCLUSIONS

First sampled plasma hs-cTnT in critically ill sepsis patients was independently associated with 30-day and 1-year mortality. Importantly, first sampled hs-cTnT was associated with mortality during the convalescence phase (30- to 365-day) and could be a feasible marker to identify acute phase survivors at high risk of death.

Variation in Troponin I Measurement and the Cardiovascular Management Approach Following Elevated Troponin I Among Critically Ill Patients With Sepsis

Troponin I is frequently elevated in sepsis, but optimal clinical approaches to diagnosis and management of troponin I during sepsis are unclear.

OBJECTIVES

We aimed to describe the variation in troponin I measurement and the cardiovascular diagnostic and therapeutic approach to elevated troponin I among critically ill adults with sepsis.

DESIGN SETTING AND PARTICIPANTS

Observational cohort study of the hospital-level variation in serial troponin I measurement, trending troponin I to peak, echocardiography, cardiac stress test, cardiac catheterization, antiplatelet agents, therapeutic anticoagulation, beta-blockers, and statins quantified using hospital median odds ratios-the median odds of receiving an intervention at randomly selected higher versus lower rate hospitals-derived from multivariable-adjusted random-effects logistic regression models with hospital site as the random effect. The Premier Healthcare Database was used. Patients were adults aged greater than 18 years admitted to the ICU with sepsis from 2016 to 2020.

MAIN OUTCOMES AND MEASURES

The hospital-level median odds ratios of troponin I measurement as well as cardiovascular diagnostics and therapeutics.

RESULTS

Among 85,830 adults with sepsis, 53,058 (61.8%) had a troponin I measured, with a median odds ratio of troponin measurement across hospitals of 5.30 (95% CI, 4.98-5.67). Among 27,665 adults (32.2%) with sepsis and an elevated troponin I level, 84.8% had serial troponin I measurements, 66.0% had troponin trended to peak level, 66.7% had an echocardiogram, 4.1% had a cardiac stress test, 6.6% underwent cardiac catheterization, 48.3% received antiplatelet agents, 8.3% received therapeutic anticoagulation, 50.5% received beta-blockers, and 38.1% received statins. The median odds ratios between hospitals for cardiovascular diagnostics and therapeutics ranged from 1.28 (95% CI, 1.24-1.32) for use of beta-blockers to 7.58 (95% CI, 6.43-8.77) for use of therapeutic anticoagulation.

CONCLUSIONS AND RELEVANCE

Both troponin I measurement and the approach to an elevated troponin I among critically ill adults with sepsis varied widely across hospitals consistent with disparate practice and care efficiency. Prospective studies are needed to guide an informed approach to troponin I measurement and cardiovascular evaluation in sepsis.