What does elevated high-sensitive troponin I in stroke patients mean: concomitant acute myocardial infarction or a
B Anders1, A Alonso, D Artemis
1Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, Germany.
Insights
High-sensitive troponin I (hs-TNI) was elevated in 20.6% of acute ischemic stroke patients. Serial hs-TNI measurements and expert cardiological evaluation are crucial for diagnosing acute coronary syndrome (ACS) in these high-risk individuals.
Area of Science:
- Cardiology and Neurology
- Biomarker Discovery and Validation
- Acute Cardiovascular and Cerebrovascular Events
Background:
- Acute ischemic stroke patients frequently present with concomitant acute coronary syndrome (ACS).
- High-sensitive cardiac troponin (hs-TNI) assays are increasingly used to detect ACS in stroke patients, often revealing elevated levels.
- The clinical significance of elevated hs-TNI in stroke patients without overt ACS symptoms remains unclear.
Purpose of the Study:
- To investigate the incidence and clinical relevance of elevated hs-TNI levels in acute ischemic stroke patients.
- To differentiate between constant and dynamic hs-TNI changes and their association with ACS.
- To emphasize the importance of serial measurements and cardiological assessment for accurate ACS diagnosis in stroke patients.
Main Methods:
- Prospective examination of hs-TNI values in 834 consecutive acute ischemic stroke patients over one year.
- hs-TNI measurement upon admission and 3 hours later if initial levels exceeded the 99th percentile (>0.045 ng/ml).
- Classification of elevated hs-TNI into constant or dynamic (≥30% change within 3 hours) groups; comprehensive stroke unit monitoring and cardiological evaluation for ACS.
Main Results:
- Elevated hs-TNI levels were observed in 20.6% (172/834) of patients upon admission.
- Patients with elevated hs-TNI showed significantly higher rates of hypertension, prior stroke, coronary artery disease, myocardial infarction, heart failure, and atrial fibrillation.
- Of 136 patients with elevated hs-TNI, 54 had dynamic changes, including 29 diagnosed with myocardial infarction (STEMI or NSTEMI).
Conclusions:
- Elevated hs-TNI is common in acute ischemic stroke patients, but therapeutically relevant ACS is primarily identified in those with dynamic hs-TNI changes.
- Non-dynamic hs-TNI elevations may occur in stroke patients without ACS due to cardiac stress.
- hs-TNI is a sensitive marker for identifying high-risk stroke patients, but serial measurements and expert cardiological workup are essential for accurate ACS diagnosis and management.
Background:
Acute ischemic stroke patients may occasionally suffer from concomitant acute coronary syndrome (ACS). Troponin I and T are established biomarkers to detect ACS. Recently introduced high-sensitive cardiac troponin (hs-TNI and hs-TNT) assays are increasingly used to identify ACS in stroke patients even without signs or symptoms of ACS. These new test systems very often detect elevated values of hs-troponin, although clinical relevance and consequences of elevated hs-TNI values in these patients are unclear so far.
Patients And Methods:
We examined hs-TNI values in 834 consecutive ischemic stroke patients admitted to our Comprehensive Stroke Center during a 1-year period. hs-TNI was measured immediately after admission and after 3 h if initial hs-TNI was elevated above the 99th percentile of normal values (>0.045 ng/ml). Patients with elevated values were divided into two groups: (1) constant and (2) dynamic hs-TNI values. The dynamic approach was defined as a 30% rise or fall of the hs-TNI value above the critical value within 3 h. All patients received stroke diagnostic and continuous monitoring according to international stroke unit standards, including a 12-lead ECG, blood pressure, body temperature and continuous ECG monitoring, as well as regular 6-hourly neurological and general physical examination (including NIHSS scores). The cardiologists - as members of the Stroke Unit team - evaluated clinical symptoms/examination, as well as laboratory, echocardiographic and ECG findings for the diagnosis of ACS.
Results:
172/834 (20.6%) patients showed elevated hs-TNI levels on admission. Patients with elevated hs-TNI values exhibited a significantly (p < 0.001) increased rate of hypertension (89 vs. 77.2%), history of stroke (24.4 vs. 14.8%), history of coronary artery disease (65.7 vs. 34.1%), history of myocardial infarction (22.1 vs. 7.6%), heart failure (12.8 vs. 5.7%) and atrial fibrillation (44.2 vs. 23.6%). 82/136 patients showed constant and 54/136 patients dynamic hs-TNI values: among the latter, 5 patients were diagnosed with ST segment elevation myocardial infarction (STEMI) and 24 with non-STEMI (NSTEMI).
Conclusion:
Our data demonstrate that hs-TNI was elevated in about 20.6% of acute ischemic stroke patients but therapeutically relevant ACS was diagnosed only in the dynamic group. hs-TNI elevations without dynamic changes may occur in stroke patients without ACS due to different reasons that stress the heart. Therefore, we suppose that hs-TNI is a sensitive marker to detect high-risk patients but serial measurements are mandatory and expert cardiological workup is essential for best medical treatment and to accurately diagnose ACS in acute ischemic stroke patients.
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