Hypertroponinaemia

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Hypertroponinaemia

• Michael Stewart
• CT1 ACCS

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Case 1

• 64 year old male
• Known history of IHD 2x NSTEMI, UA
• Two hours of central chest pain, identical to
  previous MI
• ECG Lateral ST depression
• Trop T 0.07

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Case 2

• 72 year old male
• Presents with three hours central chest pain,
  onset during dancing
• Nausea, mildly dyspnoeic
• Ex-smoker hypertensive
• Not diabetic, no FH of IHD

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Case 2

• ECG shows dynamic inferior ST depression
• Pain eased after IV GTN and morphine with
  resolution of ECG changes
• Troponin 0.56

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Case 3

• 62 year old female
• Onset of palpitations and dyspnoea on waking
• GP found irregular pulse, rate 160

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Case 3

• Hypertensive no other significant co-morbidity
• ECG Fast AF, rate 170
• BP 100/60
• Pale, clammy, drowsy
• DC Cardioversion SR restored
• Troponin 0.13

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Troponin

• Component of cardiac and striated muscle
• Calcium binding initiates conformational change
  to permit myosin to bind to actin filament
• Myosin conformational cycling on actin acts as
  molecular motor for muscle contraction
• Cardiac Troponins are specific for cardiac
  myocyte damage
• Troponin is NOT specific for myocardial infarction

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PICI/SICI/NICI

• Primary Ischaemic Cardiac Injury
• Secondary Ischaemic Cardiac Injury
• Non-Ischaemic Cardiac Injury

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PICI

• Coronary artery occlusion/stenosis by thrombotic
  disease
• STEMI/NSTEMI

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NSTEMI

• Any two of
• Typical chest pain
• Typical ECG changes
• Rise in cardiac enzymes
• New definition!

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2007 Universal Definition

• Troponin gt 99th centile of reference range
• (Locally agreed at Trop T gt 0.1)
• PLUS
• Ischaemic symptoms
• ECG changes
• Regional wall motion abnormality
• Loss of viable myocardium on imaging

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SICI

• Secondary cause of coronary artery obstruction
• Embolic disease during PCI during CABG
• Coronary vasospasm or inflammation
• Primary vasculitides SLE
• Increased myocardial oxygen demand
• Tachyarrythmias prolonged exercise
  sympathomimetic drugs heart failure PE

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NICI

• Direct trauma
• Penetrating blunt surgical
• Myocarditis
• Infectious auto-immune drug/alcohol
  inflammatory
• Metabolic
• Renal failure multiple organ failure sepsis

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Cases

• Case 1 Typical chest pain, Trop T 0.07
• PICI, not criteria for NSTEMI
• Case 2 Typical chest pain, Trop T 0.56
• NSTEMI
• Case 3 Fast AF, no pain, Trop T 0.13
• SICI ( NICI )

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Questions?
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Summary

• Troponins are a sensitive marker of cardiac
  myocyte damage
• Not all cardiac myocyte damage represents acute
  myocardial infarction
• Primary, secondary, and non-ischaemic causes exist

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References

• Thygesen, Kristian, Alpert, Joseph S., White,
  Harvey D., on behalf of the Joint
  ESC/ACCF/AHA/WHF Task Force for the Redefinition
  of Myocardial Infarction, Universal Definition
  of Myocardial Infarction
• J Am Coll Cardiol 2007 50 2173-2195
• Collinson, P O, Stubbs, P JAre troponins
  confusing?Heart 2003 89 1285-1287
• http//www.trauma.org