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Original Research

Open Access Special Issue

The difficulty in distinguishing the type of occlusive coronary artery disease among patients with sepsis in the emergency department: a multicenter retrospective cohort study

  • Yi-Hsi Chen1
  • Shou-Yen Chen1,2
  • Shi-Ying Gao1
  • Hsiang-Yun Lo1,2
  • Chip-Jin Ng1,2
  • Chung-Hsien Chaou1,2,3

1Department of Emergency Medicine, Chang Gung Memorial Hospital, 244 Linkou, Taiwan

2Chang Gung University College of Medicine, 330 Taoyuan, Taiwan

3Chang-Gung Medical Education Research Centre, Chang Gung Memorial Hospital, 330 Taoyuan Taiwan

DOI: 10.22514/sv.2021.105 Vol.18,Issue 1,January 2022 pp.122-128

Submitted: 09 April 2021 Accepted: 07 May 2021

Published: 08 January 2022

*Corresponding Author(s): Chung-Hsien Chaou E-mail:


Purpose: Distinguishing true obstructive coronary artery disease (OCAD) from myocardial infarction (MI) resulting from a mismatch between oxygen supply and demand (T2MI) in patients with sepsis is difficult. This study aimed to assess the clinical presentation and laboratory biomarkers of OCAD in patients with sepsis in the emergency department.

Materials and Methods: This was a multicenter retrospective cohort study. We included patients diagnosed with sepsis or septic shock in the emergency department between January 2010 and December 2017 and who underwent coronary angiography in the emergency department for suspected concomitant MI. The patients were categorized into the mixed MI group, for those who had significant coronary occlusion superimposed on type 2 MI or the pure type 2 MI (T2MI) group.

Results: A total of 71 patients were included after exclusion. Forty patients (56.3%) had OCAD (mixed MI). Fever (25% vs. 15%) and high scores of quick sequential organ failure assessment (qSOFA score) (35.5% vs. 27.5%) were more frequent in the T2MI group, and the troponin-I level was more elevated in the mixed MI group, but the difference was not significant. The most common focus of infection was pulmonary. Sepsis patients with OCAD tended to have longer admissions in the intensive care unit and ward admission days. However, the proportion of mortality and shock events was similar to T2MI group after percutaneous coronary artery intervention (PCI) treatment.

Conclusions: Differentiating between mixed MI from pure T2MI through clinical presentation or laboratory results in patients with sepsis with suspected myocardial infarctions remains difficult. Lowering the threshold of coronary artery angiography may play a critical role in differentiating OCAD from T2MI.


Sepsis; Obstructive coronary artery disease; Myocardial infarction; Coronary angiogra-phy; Type 2 MI

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Yi-Hsi Chen,Shou-Yen Chen,Shi-Ying Gao,Hsiang-Yun Lo,Chip-Jin Ng,Chung-Hsien Chaou. The difficulty in distinguishing the type of occlusive coronary artery disease among patients with sepsis in the emergency department: a multicenter retrospective cohort study. Signa Vitae. 2022. 18(1);122-128.


[1] Pitts SR, Niska RW, Xu J, Burt CW. National hospital ambulatory medical care survey: 2006 emergency department summary. National Health Statistics Reports. 2008; 6: 1–38.

[2] Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Journal of the American College of Cardiology. 2007; 50: 2173–2195.

[3] Fourth universal definition of myocardial infarction (2018). Revista Española de Cardiología. 2019; 72: 72.

[4] Javed U, Aftab W, Ambrose JA, Wessel RJ, Mouanoutoua M, Huang G, et al. Frequency of elevated troponin i and diagnosis of acute myocardial infarction. American Journal of Cardiology. 2009; 104: 9–13.

[5] Furie N, Israel A, Gilad L, Neuman G, Assad F, Ben-Zvi I, et al. Type 2 myocardial infarction in general medical wards: clinical features, treatment, and prognosis in comparison with type 1 myocardial infarction. Medicine. 2019; 98: e17404.

[6] Stein GY, Herscovici G, Korenfeld R, Matetzky S, Gottlieb S, Alon D, et al. Type-II myocardial infarction—patient characteristics, management and outcomes. PLoS ONE. 2014; 9: e84285.

[7] Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American college of cardiology/American heart association task force on practice guidelines. Journal of the American College of Cardiology. 2014; 64: e139–e228.

[8] Baron T, Hambraeus K, Sundström J, Erlinge D, Jernberg T, Lindahl B. Type 2 myocardial infarction in clinical practice. Heart. 2015; 101: 101–106.

[9] Zochios V, Valchanov K. Raised cardiac troponin in intensive care patients with sepsis, in the absence of angiographically documented coronary artery disease: a systematic review. Journal of the Intensive Care Society. 2015; 16: 52–57.

[10] Putot A, Jeanmichel M, Chague F, Manckoundia P, Cottin Y, Zeller M. Type 2 myocardial infarction: a geriatric population-based model of pathogenesis. Aging and Disease. 2020; 11: 108–117.

[11] Allou N, Brulliard C, Valance D, Esteve JB, Martinet O, Corradi L, et al. Obstructive coronary artery disease in patients hospitalized for severe sepsis or septic shock with concomitant acute myocardial infarction. Journal of Critical Care. 2016; 32: 159–164.

[12] Long B, Long DA, Tannenbaum L, Koyfman A. An emergency medicine approach to troponin elevation due to causes other than occlusion myocardial infarction. American Journal of Emergency Medicine. 2020; 38: 998–1006.

[13] Lippi G, Sanchis-Gomar F, Cervellin G. Chest pain, dyspnea and other symptoms in patients with type 1 and 2 myocardial infarction. A literature review. International Journal of Cardiology. 2016; 215: 20–22.

[14] Lippi G, Sanchis-Gomar F, Cervellin G. Cardiac troponins and mortality in type 1 and 2 myocardial infarction. Clinical Chemistry and Laboratory Medicine. 2017; 55: 181–188.

[15] Smilowitz NR, Naoulou B, Sedlis SP. Diagnosis and management of type II myocardial infarction: increased demand for a limited supply of evidence. Current Atherosclerosis Reports. 2015; 17: 478.

[16] López-Cuenca A, Gómez-Molina M, Flores-Blanco PJ, Sánchez-Martínez M, García-Narbon A, De Las Heras-Gómez I, et al. Comparison between type-2 and type-1 myocardial infarction: clinical features, treatment strategies and outcomes. Journal of Geriatric Cardiology. 2016; 13: 15–22.

[17] Sandoval Y, Smith SW, Schulz KM, Murakami MM, Love SA, Nicholson J, et al. Diagnosis of type 1 and type 2 myocardial infarction using a high-sensitivity cardiac troponin I assay with sex-specific 99th percentiles based on the third universal definition of myocardial infarction classification system. Clinical Chemistry. 2015; 61: 657–663.

[18] Shah ASV, McAllister DA, Mills R, Lee KK, Churchhouse AMD, Fleming KM, et al. Sensitive troponin assay and the classification of myocardial infarction. American Journal of Medicine. 2015; 128: 493–501. e3.

[19] Saaby L, Poulsen TS, Diederichsen ACP, Hosbond S, Larsen TB, Schmidt H, et al. Mortality rate in type 2 myocardial infarction: observations from an unselected hospital cohort. American Journal of Medicine. 2014; 127: 295–302.

[20] Hanson I, Kahn J, Dixon S, Goldstein J. Angiographic and clinical characteristics of type 1 versus type 2 perioperative myocardial infarction. Catheterization and Cardiovascular Interventions. 2013; 82: 622–628.

[21] Boeckel J, Palapies L, Klotsche J, Zeller T, von Jeinsen B, Perret MF, et al. Adjusted troponin I for improved evaluation of patients with chest pain. Scientific Reports. 2018; 8: 8087.

[22] Wassef AWA, Hiebert B, Saeed MF, Tam JW. Novel high-sensitivity troponin assay requires higher cut-off value to separate acute myocardial infarction from non-acute myocardial infarction in a high-risk population. Canadian Journal of Physiology and Pharmacology. 2015; 93: 873–877.

[23] Alpert JS. The fourth edition of the universal definition of myocardial infarction. American Journal of Medicine. 2018; 131: 1265–1266.

[24] Gupta S, Vaidya SR, Arora S, Bahekar A, Devarapally SR. Type 2 versus type 1 myocardial infarction: a comparison of clinical characteristics and outcomes with a meta-analysis of observational studies. Cardiovascular Diagnosis and Therapy. 2017; 7: 348–358.

[25] Turner A, Tsamitros M, Bellomo R. Myocardial cell injury in septic shock. Critical Care Medicine. 1999; 27: 1775–1780.

[26] Dahhan A. Type 2 myocardial infarction. Journal of Cardiovascular Medicine. 2019; 20: 510–517.

[27] Ambrose JA, Loures-Vale A, Javed U, Buhari CF, Aftab W. Angiographic correlates in type 1 and 2 MI by the universal definition. JACC: Cardiovascular Imaging. 2012; 5: 463–464.

[28] Roongsritong C, Warraich I, Bradley C. Common causes of troponin elevations in the absence of acute myocardial infarction. Chest. 2004; 125: 1877–1884.

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