Article Data

  • Views 1274
  • Dowloads 255

Original Research

Open Access Special Issue

Importance of myocardial ischemia detected with protocol-based measurements of high-sensitivity troponin, ECG and echocardiography in critically ill patients without acute coronary syndrome—a prospective study

  • Gloria Kotnik1
  • Miha Mežnar1
  • Maja Golmajer2
  • Gorazd Voga1
  • Matej Podbregar1,3,*,

1Department of Internal Intensive Care Medicine, General and Teaching Hospital Celje, 3000 Celje, Slovenia

2Department of Surgical Intensive care, General and Teaching Hospital Celje, 3000 Celje, Slovenia

3Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia

DOI: 10.22514/sv.2021.240 Vol.18,Issue 3,May 2022 pp.81-90

Submitted: 13 August 2021 Accepted: 16 September 2021

Published: 08 May 2022

*Corresponding Author(s): Matej Podbregar E-mail: matej.podbregar@guest.arnes.si

Abstract

Elevated cardiac troponin is detected in the majority of critically ill patients. This study aimed to evaluate the prognostic value of protocol-guided detection of myocardial ischemia (MI) (serial 12-lead electrocardiograms (ECG), high-sensitivity troponin T (hsTnT) measurements, and echocardiography) and compare it with a retrospective cohort with only clinically driven detection of MI. In a prospective observational study, 95 patients hospitalized ≥48 hours for reasons other than acute coronary syndrome in medical or surgical intensive-care unit (ICU) were enrolled. A protocol-based approach, with regular 12-lead ECG recordings, hsTnT measurements and admission echocardiography was conducted. All events possibly indicating MI were documented, and ECG, hsTnT, echocardiography were repeated. The protocol-based approach was compared to a retrospective group with only clinically driven detection of MI. In the prospective group, 95.8% of patients had at least one elevated hsTnT value. A hsTnT >70 ng/L was associated with the use of inotropes (OR 3.35 (95% CI: 1.184, 9.472), p = 0.022), left ventricular ejection fraction <30% (OR 9.65 (95% CI: 1.172, 76.620), p = 0.035), regional wall motion abnormalities (OR 3.87 (95% CI: 1.032, 14.533), p = 0.045), ICU mortality (OR 8.38 (95% CI: 1.004, 69.924), p = 0.0495), hospital mortality (OR 3.05 (95% CI: 1.133, 8.230), p = 0.027) and 1-year mortality (OR: 5.43 (95% CI: 2.1099, 13.971), p = 0.005). The incidence of MI was higher in the prospective, as compared to the retrospective group (22.1% vs 5.3%; p = 0.001). MI, compared to the high “hsTnT positive only” group, predicted hospital mortality (OR 3.33 (95% CI: 1.190, 9.329), p = 0.02) and 1-year mortality (OR 4.66 (95% CI: 1.647, 13.222), p = 0.0037). A protocol-based compared to a clinically driven approach for the detection of MI reveals more patients with MI. The majority of critically ill patients have elevated hsTnT levels. Detected MI additionally stratifies patients with elevated hsTnT to higher hospital and 1-year mortality.


Keywords

Critically ill; Troponin; Outcome; Mortality; ECG; Echocardiography


Cite and Share

Gloria Kotnik,Miha Mežnar,Maja Golmajer,Gorazd Voga,Matej Podbregar. Importance of myocardial ischemia detected with protocol-based measurements of high-sensitivity troponin, ECG and echocardiography in critically ill patients without acute coronary syndrome—a prospective study. Signa Vitae. 2022. 18(3);81-90.

References

[1] Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth Universal Definition of Myocardial Infarction (2018). Circulation. 2018; 138: e618–e651.

[2] Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Circulation. 2012; 126: 2020–2035.

[3] Carroll I, Mount T, Atkinson D. Myocardial infarction in intensive care units: A systematic review of diagnosis and treatment. Journal of the Intensive Care Society. 2016; 17: 314–325.

[4] Ostermann M, Lo J, Toolan M, Tuddenham E, Sanderson B, Lei K, et al. A prospective study of the impact of serial troponin measurements on the diagnosis of myocardial infarction and hospital and six-month mortality in patients admitted to ICU with non-cardiac diagnoses. Critical Care. 2014; 18: 1–9.

[5] Lim W, Qushmaq I, Cook DJ, Crowther MA, Heels-Ansdell D, Devereaux PJ. Elevated troponin and myocardial infarction in the intensive care unit: a prospective study. Critical Care. 2005; 9: R636–R644.

[6] Lim W, Holinski P, Devereaux PJ, Tkaczyk A, McDonald E, Clarke F, et al. Detecting myocardial infarction in critical illness using screening troponin measurements and ECG recordings. Critical Care. 2008; 12: R36.

[7] Nates JL, Nunnally M, Kleinpell R, Blosser S, Goldner J, Birriel B, et al. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Critical Care Medicine. 2016; 44: 1553–1602.

[8] Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: an Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography. 2015; 28: 1–39.e14.

[9] Roffi M, Patrono C, Collet J, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal. 2016; 37: 267–315.

[10] Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment eleva-tion: The Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal. 2021; 42: 1289–1367.

[11] Klouche K, Jonquet O, Cristol JP. The diagnostic challenge of myocardial infarction in critically ill patients: do high-sensitivity troponin measurements add more clarity or more confusion? Critical Care. 2014; 18: 148.

[12] Sherwood MW, Kristin Newby L. High‐Sensitivity Troponin Assays: Evidence, Indications, and Reasonable Use. Journal of the American Heart Association. 2014; 3: e000403.

[13] Martinez EA, Kim LJ, Faraday N, Rosenfeld B, Bass EB, Perler BA, et al. Sensitivity of routine intensive care unit surveillance for detecting myocardial ischemia. Critical Care Medicine. 2003; 31: 2302–2308.

[14] Lim W, Qushmaq I, Cook DJ, Devereaux PJ, Heels-Ansdell D, Crowther MA, et al. Reliability of electrocardiogram interpretation in critically ill patients. Critical Care Medicine. 2006; 34: 1338–1343.

[15] Booker KJ, Holm K, Drew BJ, Lanuza DM, Hicks FD, Carrigan T, et al. Frequency and outcomes of transient myocardial ischemia in critically ill adults admitted for noncardiac conditions. American Journal of Critical Care. 2003; 12: 508–517.

[16] Landesberg G, Vesselov Y, Einav S, Goodman S, Sprung CL, Weissman C. Myocardial ischemia, cardiac troponin, and long-term survival of high-cardiac risk critically ill intensive care unit patients. Critical Care Medicine. 2005; 33: 1281–1287.

[17] Lim W, Cook DJ, Griffith LE, Crowther MA, Devereaux PJ. Elevated cardiac troponin levels in critically ill patients: prevalence, incidence, and outcomes. American Journal of Critical Care. 2006; 15: 280–289.

[18] Docherty AB, Alam S, Shah AS, Moss A, Newby DE, Mills NL, et al. Unrecognised myocardial infarction and its relationship to outcome in critically ill patients with cardiovascular disease. Intensive Care Medicine. 2018; 44: 2059–2069.

[19] Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, Villar JC, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. Journal of the American Medical Association. 2012; 307: 2295–2304.

[20] Rothenberg FG, Clay MB, Jamali H, Vandivier-Pletsch RH. Systematic review of β blocker, aspirin, and statin in critically ill patients: importance of severity of illness and cardiac troponin. Journal of Investigative Medicine. 2017; 65: 747–753.

[21] Ammann P, Maggiorini M, Bertel O, Haenseler E, Joller-Jemelka HI, Oechslin E, et al. Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes. Journal of the American College of Cardiology. 2003; 41: 2004–2009.

[22] Lim W, Whitlock R, Khera V, Devereaux PJ, Tkaczyk A, Heels-Ansdell D, et al. Etiology of troponin elevation in critically ill patients. Journal of Critical Care. 2010; 25: 322–328.

[23] Ko Y, Park C, Kim W, Jeong B, Suh GY, Lim SY, et al. Coronary artery disease in patients clinically diagnosed with myocardial infarction in the medical intensive care unit. Journal of Critical Care. 2013; 28: 532.e11–532. e17.

[24] Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald’s heart disease: a textbook of cardiovascular medicine. Elsevier: Philadel-phia. 2012.

[25] Newby LK, Jesse RL, Babb JD, Christenson RH, De Fer TM, Diamond GA, et al. ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. Journal of the American College of Cardiology. 2012; 60: 2427–2463.

[26] Agewall S, Giannitsis E, Jernberg T, Katus H. Troponin elevation in coronary vs. non-coronary disease. European Heart Journal. 2011; 32: 404–411.

[27] Alpert JS, Thygesen KA, White HD, Jaffe AS. Diagnostic and Therapeutic Implications of Type 2 Myocardial Infarction: Review and Commentary. The American Journal of Medicine. 2014; 127: 105–108.

[28] Ostermann M, Ayis S, Tuddenham E, Lo J, Lei K, Smith J, et al. Cardiac Troponin Release is Associated with Biomarkers of Inflammation and Ventricular Dilatation during Critical Illness. Shock. 2017; 47: 702–708.

[29] Wu AH. Increased troponin in patients with sepsis and septic shock: myocardial necrosis or reversible myocardial depression? Intensive Care Medicine. 2001; 27: 959–961.

[30] Jaffe AS, Wu AHB. Troponin release–reversible or irreversible injury?Should we care? Clinical Chemistry. 2012; 58: 148–150.

[31] Hickman PE, Potter JM, Aroney C, Koerbin G, Southcott E, Wu AHB, et al. Cardiac troponin may be released by ischemia alone, without necrosis. Clinica Chimica Acta. 2010; 411: 318–323.

[32] Piper HM, Schwartz P, Spahr R, Hütter JF, Spieckermann PG. Early enzyme release from myocardial cells is not due to irreversible cell damage. Journal of Molecular and Cellular Cardiology. 1984; 16: 385–388.

[33] Sandoval Y, Smith SW, Thordsen SE, Apple FS. Supply/demand type 2 myocardial infarction: should we be paying more attention? Journal of the American College of Cardiology. 2014; 63: 2079–2087.

[34] ver Elst KM, Spapen HD, Nguyen DN, Garbar C, Huyghens LP, Gorus FK. Cardiac Troponins I and T are Biological Markers of Left Ventricular Dysfunction in Septic Shock. Clinical Chemistry. 2000; 46: 650–657.

[35] McLean AS. Echocardiography in shock management. Critical Care. 2016; 20: 275.

[36] Poe S, Vandivier-Pletsch RH, Clay M, Wong HR, Haynes E, Rothenberg FG. Cardiac Troponin Measurement in the Critically Ill: Potential for Guiding Clinical Management. Journal of Investigative Medicine. 2015; 63: 905–915.

[37] Perkins GD, McAuley DF, Davies S, Gao F. Discrepancies between clin-ical and postmortem diagnoses in critically ill patients: an observational study. Critical Care. 2003; 7: R129–R132.


Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

IndexCopernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 0.5(2021) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time

Conferences

Top