Association between troponin level and medium-term mortality in 20 000 hospital patients

INTRODUCTION

Cardiac troponin (cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in hospital patients without a clinical presentation consistent with type 1 myocardial infarction, and the significance of this is uncertain. The aim of this study was to assess the relationship between medium-term mortality and cTn concentration in a large consecutive hospital population, regardless of whether there was a clinical indication for performing the test.

METHOD

This prospective observational study included 20 000 consecutive in-hospital and outpatient patients who had a blood test for any reason at a large teaching hospital, and in whom a hs-cTnI assay was measured, regardless of the original clinical indication. Mortality was obtained via NHS Digital.

RESULTS

A total of 20 000 patients were included in the analysis and 18 282 of these (91.4%) did not have a clinical indication for cardiac troponin I (cTnI) testing. Overall, 2825 (14.1%) patients died at a median of 809 days. The mortality was significantly higher if the cTnI concentration was above the ULN (45.3% vs 12.3% p<0.001 log rank). Multivariable Cox analysis demonstrated that the log10 cTnI concentration was independently associated with mortality (HR 1.76 (95% CI 1.65 to 1.88)). Landmark analysis, excluding deaths within 30 days, showed the relationship between cTnI concentration and mortality persisted.

CONCLUSION

In a large, unselected hospital population, in 91.4% of whom there was no clinical indication for testing, cTnI concentration was independently associated with medium-term cardiovascular and non-cardiovascular mortality in the statistical model tested.

Cardiogenic shock due to acute severe ischemic mitral regurgitation

The reduction in patients presenting with ST-elevation myocardial infarction (STEMI) during the COVID19 crisis could have resulted from fears about developing COVID-19 infection in hospital. Patients who delay presenting with STEMI are more likely to develop mechanical complications, including acute ischemic mitral regurgitation (MR). We present a 69-year-old women with an inferior STEMI and cardiogenic shock due to acute ischemic MR who delayed presenting to hospital due to the fear of COVID-19. Early identification of this mechanical complication using transthoracic echocardiography in the Emergency Department enabled the team to target her optimisation. Ultimately these patients require urgent surgery to repair the mitral valve and revascularize the myocardium but they are often too unwell to undergo surgery and even when it is feasible the outcomes are poor.

Pregnancies in adolescents: fetal, neonatal and maternal outcome

We studied the perinatal morbidity and mortality among adolescent pregnancies in the semi-urban population of Gorakhpur. The number of eligible couples (females 15-44 yrs) were 24,000. Out of 430 adolescent married girls, 242 (56.3%) became pregnant during the study period. Nineteen (7.8%) of adolescent pregnancies were in the maternal age group less than 15 years and 110 (45.5%) and 113 (46.7%) pregnancies were in the age group 15-17 yrs and 17-19 yrs, respectively. The incidence of low birth weight babies was 67.3% of all live births. Infections during neonatal period, congenital anomalies and birth injuries were seen in 21.6, 8.6 and 13.1% newborns, respectively. Neonatal mortality rate was 136.2/1000 live births. Three adolescent mothers died during pregnancy or puerperium due to causes related to pregnancy. The incidence of LBW, neonatal and maternal morbidity and mortality associated with adolescent pregnancies were significantly higher.

JE virus encephalitis: 1988 epidemic at Gorakhpur

Gorakhpur region experienced the most serious outbreak of Japanese encephalitis (JE) in 1988 in which 875 children were admitted in the Department of Pediatrics, BRD Medical College, Gorakhpur. Children between 7-10 years age group constituted half (49.3%) of these cases, convulsions (83.8%), altered sensorium (78.2%), headache (68.8%) and hypertonia (77.0%) were the main presenting features. IgM against JE virus was demonstrated in 18/25 CSF and 27/53 sera collected from these children. Significant titres of HI antibodies against JE were present in 498/670 patients. Patients were managed symptomatically. Dexamethasone and dopamine were given to only 137 (15.7%) children admitted with shock and peripheral circulatory failure. Almost a third (31.8%) of the patients expired, 51.4% recovered completely and 10.7% recovered partially. Corticosteroids did not improve the outcome. Twenty four patients had recurrence of symptoms after excellent recovery from acute attack of whom two died and 5 developed neurological deficits.