Significance of serum cardiac troponin I levels in pulmonary embolism

Echocardiography as a Useful Tool for Differentiating Acute Pulmonary Embolism From Acute Coronary Syndrome: A Case Report

Both acute coronary syndrome (ACS) and pulmonary embolism (PE) are life-threatening medical emergencies with overlapping symptoms and laboratory findings. Differentiating these two emergencies and initiating proper treatment are of paramount importance for good outcomes. In this report, we present the case of a 60-year-old male with a history of seizure disorder and hyperlipidemia, who presented to the emergency department (ED) after a syncopal episode preceded by three days of brief episodes of chest pain. In the ED, the initial electrocardiogram (EKG) showed normal sinus rhythm with T wave inversions in the anterior leads, and elevated high-sensitivity troponin levels peaked at 58 ng/mL before declining to 38 ng/mL. Elevated lactic acid and anion gap suggested a seizure, and the patient was discharged after lab tests and clinical status normalized. The patient returned the next day with recurrent syncope, and this time troponin levels were significantly elevated to 151 ng/mL, with a pro-BNP (brain natriuretic peptide) of 1,705 pg/mL. The patient was admitted with an initial diagnosis of ACS. The initial evaluation, including chest X-ray and EKG, was unremarkable. However, echocardiography revealed an interesting finding of right ventricular free wall akinesia with sparing of the apex-McConnell's sign-suggestive of PE, which significantly changed the diagnostic approach. PE was later confirmed by computed tomography angiography. This case highlights the critical role of echocardiography in distinguishing PE from ACS, especially in emergency care settings in patients with atypical and rare presentations.

The Role of Troponin in the Diagnosis and Treatment of Acute Pulmonary Embolism: Mechanisms of Elevation, Prognostic Evaluation, and Clinical Decision-Making

Acute pulmonary embolism (APE) is a cardiovascular disease with severe consequences, wherein cardiac troponin (Tn) plays a pivotal role in diagnosis and treatment. This article reviews the various roles of Tn in managing APE. It looks at how Tn levels increase, their importance in predicting outcomes, and their use in making clinical decisions. Studies indicate that an elevation in Tn is primarily associated with right ventricular overload, ischemia, and necrosis, changes that directly reflect the extent of right ventricular dysfunction and myocardial injury. Elevated levels of Tn are significantly correlated with both short-term and long-term mortality risks in patients with APE, serving as crucial indicators for prognostic assessment and guiding therapeutic strategies. International guidelines recommend integrating Tn testing with clinical scoring and echocardiography to optimize treatment decisions in patients with APE. Despite the significant value of Tn determination in the management of APE, further research is needed to standardize its application. This paper emphasizes future research directions, including exploring the application of Tn in different patient subgroups with APE and its potential combined use with other biomarkers.

Integrating Cardiac Biomarkers and Electrocardiogram in Pulmonary Embolism Prognosis

Pulmonary embolism (PE) represents a significant clinical challenge that substantially impacts healthcare systems. This case report focuses on the nuances of risk stratification in PE, highlighted through the presentation of a 64-year-old female patient. The uniqueness of this case lies in the patient's atypical presentation, where decreased exercise tolerance was the sole symptom leading to the diagnosis of PE. The patient was found to have new-onset atrial fibrillation, elevated levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), and signs of right ventricular strain on imaging. This scenario underscores the necessity for a comprehensive assessment in PE cases, particularly when classic symptoms (e.g., tachycardia, shortness of breath, chest pain) are absent. We explore the incidence of PE in patients diagnosed with deep vein thrombosis, examining the critical role of cardiac biomarkers, including B-type natriuretic peptide, NT-proBNP, and troponins, in prognostication and their potential use in risk assessment tools for PE patients. Additionally, the significance of electrocardiogram evaluation in these patients and its role in risk stratification is thoroughly assessed.

What is the real incidence of right ventricular affection in patients with acute pulmonary embolism?

BACKGROUND

Echocardiographic markers of right ventricular dysfunction or pressure overload (RVd/PO) have been used in risk assessment of patients with acute pulmonary embolism (APE). Nevertheless, the role of echocardiography in these patients is incompletely determined. We evaluated the right ventricular function using 'non-conventional' markers of RVd/PO in patients with APE.

METHODS

This was a prospective, single-arm, single-centre study. Consecutive adult patients hospitalised for APE were included. The RV free wall longitudinal strain (RV-FWLS), the fractional area change (FAC), the ratio tricuspid annular plane systolic excursion (TAPSE)/pulmonary arterial systolic pressure (PASP), and the pulmonary vascular resistance (PVR) were evaluated.

RESULTS

One hundred patients (mean age 70.0 ± 13.9 years, female 48%) were screened and 73 had adequate RV-FWLS images. The most common abnormal echocardiographic marker was RV-FWLS (44/73; p < 0.001, for all other echocardiographic indices). Thirty-one patients had either PASP ≥ 36 mmHg or PVR > 2 WU (49.2% of the patients with both indices available). There were significant correlations between RV-FWLS, TAPSE/PASP and PVR with both D-Dimers and B-type natriuretic peptide (BNP), and between FAC and BNP. RF-FWLS differed significantly between patients with a simplified pulmonary embolism severity index (sPESI) score 0 and those with a score ≥1 (p < 0.001).

CONCLUSIONS

RVd/PO coexists with APE in a large proportion of patients. RV-FWLS is the most abnormal echocardiographic sign and is related to clinical and biochemical prognostic indices.

Risk factors for hospital outcomes in pulmonary embolism: A retrospective cohort study

Background

Pulmonary embolism (PE) is not only a life-threatening disease but also a public health issue with significant economic burden. The aim of the study was to identify factors-including the role of primary care-that predict length of hospital stay (LOHS), mortality and re-hospitalization within 6 months of patients admitted for PE.

Method

A retrospective cohort study was conducted with patients presenting to a Swiss public hospital with PE diagnosed at the hospital between November 2018 and October 2020. Multivariable logistic and zero-truncated negative binomial regression analyses were performed to assess risk factors for mortality, re-hospitalization and LOHS. Primary care variables encompassed whether patients were sent by their general practitioner (GP) to the emergency department and whether a GP follow-up assessment after discharge was recommended. Further analyzed variables were pulmonary embolism severity index (PESI) score, laboratory values, comorbidities, and medical history.

Results

A total of 248 patients were analyzed (median 73 years and 51.6% females). On average patients were hospitalized for 5 days (IQR 3-8). Altogether, 5.6% of these patients died in hospital, and 1.6% died within 30 days (all-cause mortality), 21.8% were re-hospitalized within 6 months. In addition to high PESI scores, we detected that, patients with an elevated serum troponin, as well as with diabetes had a significantly longer hospital stay. Significant risk factors for mortality were elevated NT-proBNP and PESI scores. Further, high PESI score and LOHS were associated with re-hospitalization within 6 months. PE patients who were sent to the emergency department by their GPs did not show improved outcomes. Follow-up with GPs did not have a significant effect on re-hospitalization.

Conclusion

Defining the factors that are associated with LOHS in patients with PE has clinical implications and may help clinicians to allocate adequate resources in the management of these patients. Serum troponin and diabetes in addition to PESI score might be of prognostic use for LOHS. In this single-center cohort study, PESI score was not only a valid predictive tool for mortality but also for long-term outcomes such as re-hospitalization within 6 months.

Interpretation of Cardiac and Non-Cardiac Causes of Elevated Troponin T Levels in Non-Acute Coronary Syndrome Patients in the Emergency Department

The definition of myocardial infarction was updated in 2000 to include an elevation of cardiac troponin T or I (cTnT or xTnI) alongside clinical evidence of myocardial infarction. The redefinition was jointly done by the American College of Cardiology Committee and the European Society of Cardiology. Since then, cardiac troponin T and I have assumed the position as the primary biochemical markers for diagnosing myocardial infarction. The high sensitivity of cardiac troponin for myocardial necrosis influenced the decision to include cardiac troponins (cTn) in the diagnostic pathway. An elevated cTn level indicates the presence of myocardial injury. However, it does not give the underlying reason for the damage. Apart from acute myocardial infarction (AMI), a range of potential diseases feature troponin release, including heart failure, acute pulmonary embolism, end-stage renal disease, and myocarditis. However, regardless of the mechanism that triggers the release from cardiac myocytes, elevated cTnI and cTnT typically implies a poor prognosis. This review attempts to explain both the cardiac and non-cardiac causes of increased cTnT in emergency department patients.

Diagnostic significance of combining D-dimer with high-sensitivity cardiac troponin I for improving the diagnosis of venous thromboembolism in the emergency department

BACKGROUND

Although cardiac troponins are valuable tools for risk stratification in patients with venous thromboembolism (VTE), their significance remains elusive in diagnosing venous thrombosis.

METHODS

D-dimer (age-adjusted cut-off) and high-sensitivity cardiac troponin I (HS-cTnI; reference limit, <10.5 ng/L in women and <17.8 ng/L in men) were measured in 2199 consecutive patients (1106 women and 1093 men; mean age, 63±20 years), admitted to the Emergency Department of the University Hospital of Parma during a 3-month period. Overall, 53 patients were finally diagnosed with VTE (12 with deep vein thrombosis and 41 with pulmonary embolism).

RESULTS

The diagnostic performance (area under the curve; AUC) of D-dimer and HS-cTnI was 0.70 and 0.71 for all VTE episodes, 0.70 and 0.63 for deep vein thrombosis (DVT), 0.70 and 0.74 for pulmonary embolism (PE), respectively. The combination of positive values of both biomarkers yielded better diagnostic performance than D-dimer values alone for diagnosing PE (AUC, 0.80; p<0.001 vs. D-dimer alone), but not for diagnosing DVT (AUC, 0.73; p=0.458 vs. D-dimer alone). In patients with PE, positive HS-cTnI values in patients with concomitantly positive D-dimer values yielded identical diagnostic sensitivity compared to D-dimer positivity alone (i.e., 1.00), but nearly double diagnostic specificity (i.e., 0.71 vs. 0.40). Positive HS-cTnI values (AUC, 0.68), but not D-dimer positivity (AUC, 0.51), were associated with 30-day hospital readmission of VTE patients.

CONCLUSIONS

The results of this study open intriguing opportunities for combining HS-cTnI and D-dimer in the diagnostic approach of patients with PE.

The Main Causes and Mechanisms of Increase in Cardiac Troponin Concentrations Other Than Acute Myocardial Infarction (Part 1): Physical Exertion, Inflammatory Heart Disease, Pulmonary Embolism, Renal Failure, Sepsis

The causes and mechanisms of increased cardiac troponin T and I (cTnT and cTnI) concentrations are numerous and are not limited to acute myocardial infarction (AMI) (ischemic necrosis of cardiac myocytes). Any type of reversible or irreversible cardiomyocyte injury can result in elevated serum cTnT and cTnI levels. Researchers and practitioners involved in the diagnosis and treatment of cardiovascular disease, including AMI, should know the key causes and mechanisms of elevated serum cTnT and cTnI levels. This will allow to reduce or completely avoid diagnostic errors and help to choose the most correct tactics for further patient management. The purpose of this article is to discuss the main causes and mechanisms of increase in cardiac troponins concentrations in frequently occurring physiological (physical exertion, psycho-emotional stress) and pathological conditions (inflammatory heart disease, pulmonary embolism, chronic renal failure and sepsis (systemic inflammatory response)) not related to myocardial infarction.

Elevation Mechanisms and Diagnostic Consideration of Cardiac Troponins under Conditions Not Associated with Myocardial Infarction. Part 1

Although cardiac troponins are considered the most specific biomarkers for the diagnosis of acute myocardial infarction (AMI), their diagnostic consideration goes far beyond the detection of this dangerous disease. The mechanisms of cardiac troponin elevation are extremely numerous and not limited to ischemic necrosis of cardiac myocytes. Practitioners should be well aware of the underlying pathological and physiological conditions that can lead to elevated serum levels of cardiac troponins to avoid differential diagnostic errors, which will be greatly increased if clinicians rely on laboratory data alone. This article presents a classification of the main causes of an elevation in cardiac troponins and discusses in detail the mechanisms of such elevation and the diagnostic consideration of cardiac troponins in some conditions not associated with AMI, such as physical exertion, inflammatory heart diseases (myocarditis and endocarditis), pulmonary embolism (PE), renal failure, and systemic inflammation (sepsis).

The Comparison Between Non-High Risk Patients with and Without Cancer Diagnosed with Pulmonary Embolism

Objective

This study aimed to compare the pulmonary embolism (PE) location and clot burden on computed tomography pulmonary angiography (CTPA), the degree of right ventricular dysfunction (RVD), D-dimer, and cardiac troponin I (cTnI) levels, and the presence of a lower extremity deep venous thrombosis (DVT) in patients with and without cancer diagnosed with a non high risk pulmonary embolism (PE).

Method

We calculated Miller score for each patient for clot burden. The location of PE was also evaluated at CTPA. D-dimer and cardiac cTnI levels were measured. Patients had echocardiography for RVD and lower extremity color flow Doppler ultrasonography for DVT.

Results

The study included 71 patients with PE. The patients were divided into two groups according to the presence of cancer. There was no statistically significant difference for D-dimer levels (P=0.15), PE location (p=0.67), clot burden (P=0.34), RVD (P=0.28) and DVT (P=0.33) between groups (P=0.15). Cancer patients diagnosed as PE had statistically significantly higher levels of cTnI than those who were diagnosed as PE without cancer (P=0.03).

Conclusion

There was no significant difference between patients diagnosed as PE with and without cancer in terms of D-dimer levels, clot burden and emboli location, RVD and DVT. cTnI levels were higher in non-high risk PE patients with cancer than these patients without cancer.

D-dimer/troponin ratio in the differential diagnosis of acute pulmonary embolism from non-ST elevation myocardial infarction

BACKGROUND/AIMS

The aim of this study was to investigate useful cardiac biomarkers in the differential diagnosis of acute pulmonary embolism (APE) with troponin elevation from acute non-ST elevation myocardial infarction (NSTEMI).

METHODS

A total of 771 consecutive NSTEMI patients with D-dimer measurements and 90 patients with troponin-I (TnI) elevation out of 233 APE patients were enrolled, and cardiac biomarkers were compared.

RESULTS

D-dimer elevation was noted in 382 patients with NSTEMI (49.5%), and TnI elevation was noted 90 out of 233 APE patients (38.6%). Unnecessary coronary angiography was performed in 10 patients (11.1%) among 90 APE patients with TnI elevation. D-dimer was significantly elevated in APE than in NSTEMI (9.9 ± 11.6 mg/L vs. 1.8 ± 4.3 mg/L, p < 0.001), whereas TnI was significantly elevated in NSTEMI (22.4 ± 41.5 ng/mL vs. 0.7 ± 1.4 ng/mL, p < 0.001). D-dimer/TnI ratio was significantly higher in APE than in NSTEMI (50.6 ± 85.3 vs. 1.6 ± 5.7, p < 0.001). On receiver operation characteristic curve analysis, the optimal cut-off value for differentiating APE from NSTEMI was 1.12 mg/L for D-dimer (sensitivity 81.1%, specificity 70.2%), 0.72 ng/mL for TnI (sensitivity 80.6%, specificity 78.9%), and 1.82 for D-dimer/TnI ratio (sensitivity 93.3%, specificity 86.6%).

CONCLUSION

D-dimer/TnI ratio would be a simple and useful parameter for differentiating APE with cardiac troponin elevation from NSTEMI. Optimal cardiovascular imaging to identify APE should be considered in patients with D-dimer/ TnI ratio > 1.82 before performing coronary angiography to avoid unnecessary invasive procedure.

Retrospective cause analysis of troponin I elevation in non-CAD patients: Special emphasis on sepsis

BACKGROUND

Troponin I is one of the most commonly tested biochemical markers in the emergency room (ER) and in the hospital setting. Besides coronary artery disease (CAD), demand ischemia with underlying tachycardia, anemia, hypertensive emergency, congestive heart failure, kidney disease, sepsis, and pulmonary embolism have also been reported to cause troponin I elevations. Few reports have excluded patients with CAD, and no study has summarized the proportion of these factors relative to an increased troponin I level.

METHODS

The aim of this retrospective study was to investigate the level of contribution of causative factors in troponin I elevation. Charts of patients tested for troponin I during an ER visit or during hospitalization were collected. Patients with known CAD, abnormal stress tests, cardiac catheterizations, or discharge without an adequate cardiac evaluation were excluded. Logistic regression was used to identify predictors of elevated troponin I levels.

RESULTS

A total of 586 patients were investigated in this study. Age, hemoglobin (Hb), heart rate (HR), glomerularfiltration rate, atrial fibrillation, congestive heart failure (CHF), and sepsis were significant predictors of elevated troponin I by analysis in univariate logistic regression (all P < .001). In multivariate logistic regression, sepsis, CHF, age, Hb, and HR were independent predictors of troponin I (all P < .01). A simple clinical scoring system was generated with 1 score on patients with age ≥ 60, Hb < 10 g/dL, and HR ≥ 100 beats per minute (bpm). The prevalence of elevated troponin I was 4%, 16%, 38%, and 50% for patients with scores of 0, 1, 2, and 3, respectively. In patients without sepsis and CHF, the chances of elevated troponin I were 2%, 11%, 28%, and 43%.

CONCLUSIONS

Sepsis was found to be the strongest independent cause of elevated troponin I levels in non-CAD patients. The scoring system composed of age, hemoglobin (Hb), and heart rate (HR) can assist clinical evaluation of elevated troponin I test in non-CAD patients.

The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: a consensus paper

Electrocardiographic (ECG) abnormalities in the setting of acute pulmonary embolism (PE) are being increasingly characterized and mounting evidence suggests that ECG plays a valuable role in prognostication for PE. We review the historical 21-point ECG prognostic score for the severity of PE and examine the updated evidence surrounding the utility of ECG abnormalities in prognostication for severity of acute PE. We performed a literature search of MEDLINE, EMBASE, and PubMed up to February 2015. Article titles and abstracts were screened, and articles were included if they were observational studies that used a surface 12-lead ECG as the instrument for measurement, a diagnosis of PE was confirmed by imaging, arteriography or autopsy, and analysis of prognostic outcomes was performed. Thirty-six articles met our inclusion criteria. We review the prognostic value of ECG abnormalities included in the 21-point ECG score, including new evidence that has arisen since the time of its publication. We also discuss the potential prognostic value of several ECG abnormalities with newly identified prognostic value in the setting of acute PE.

Evaluation of cardiac biomarkers and right ventricular dysfunction in patients with acute pulmonary embolism

OBJECTIVE

Right ventricular dysfunction (RVD) with myocardial damage may lead to fatal complications in patients with acute pulmonary embolism (PE). Cytoplasmic heart-type fatty acid-binding protein (HFABP) and the N-terminal fragment of its prohormone (NT-proBNP) are sensitive and specific biomarkers of myocardial damage. We evaluated RVD and cardiac biomarkers for myocardial damage and short-term mortality in patients with acute PE.

METHODS

We analyzed 41 patients (24 females, 17 males) with confirmed acute PE prospective. Three groups (massive, submassive, and non-massive) of patients were defined, based on systemic systolic blood pressure measured on admission and RVD by transthoracic echocardiography (TTE). Also, systolic (s) and mean (m) pulmonary artery pressures (PAPs) were recorded by TTE, and plasma concentrations of cardiac troponin T (cTn-T), NT-proBNP, and HFABP were evaluated 6 month follow-up.

RESULTS

Seventeen (41.5%) patients experienced a complicated clinical course in the 6-month follow-up for the combined end-point, including at least one of the following: death (n=12, 29.3%; 3 PE-related), chronic PE (n=4, 9.8%), pulmonary hypertension (n=2, 4.9%), and recurrent PE (n=1, 2.4%). Multivariate hazard ratio analysis revealed HFABP, NT-proBNP, and PAPs as the 6-month mortality predictors (HR 1.02, 95% CI 1.01-1.05; HR 1.01, 95% CI 1.01-1.04; and HR 1.02, 95% CI 1.02-1.05, respectively).

CONCLUSION

HFABP, NT-proBNP, and PAPs measured on admission may be useful for short-term risk stratification and in the prediction of 6-month PE-related mortality in patients with acute PE.