MYOCARDIAL INFARCTION DIAGNOSIS AND CARDIAC TROPONINS

Abstract

Acute myocardial infarction is a condition that develops due to the blockage of blood flow to the heart. Serial electrocardiog- raphy follow-up should be performed in patients with suspected acute myocardial infarction, serum cardiac troponin levels should be measured, and this measurement should be repeated at regular intervals. Cardiac troponins are the main markers for the diagnosis of acute myocardial infarction, as they are sensitive and specific biochemical markers of myocardial cell necrosis. Elevated levels of cardiac troponins indicate cardiac damage, but it does not explain the cause of the damage. Increases in cardiac troponin levels can be observed in many different disease states and do not necessarily indicate acute myocardial infarction. It is necessary to check cardiac troponin levels in a patient admitted to the hospital in order to exclude other diseases before establishing the diagnosis of myocardial infarction. The one-hour “rule-in” and “rule-out” algorithms are used in the tests per- formed on patients who come to the emergency department with non-ST elevation myocardial infarction. In addition, there are point-of-care cardiac troponin tests that can be used in emergency services and ambulances. However, while using point-of-care cardiac troponin tests for the diagnosis of myocardial infarction, it should be kept in mind that these tests are less sensitive and more costly than tests performed in central laboratories

Keywords

• Myocardial infarction
• acute coronary syndrome
• troponin

References

1. 1. Racek J, Rajdl D, editors. Clinical Biochemistry. 1st ed. Prague: Karolinum Press; 2016.p.296-8.
2. 2. Duygu E, Kahraman N, Pehlivanoğlu S et al. Akut koroner sen- drom dışı olaylarda kardiyak troponin yüksekliğinin klinik önemi. Türk Kardiyoloji Dem Arş 2004;32:571-80.
3. 3. Peela JR, Jarari AM, Hai A et al. Cardiac biomarkers: the tro- ponins and CK-MB. Ibnosina Journal of Medicine and Biomedical Sciences 2010;2(5):190-7.
4. 4. Topol EJ. Chapter 13. In: Topol EJ, editor. Acute Coronary Syn- dromes. 3rd ed. Florida: CRC Press;2004.p.329-65.
5. 5. Agewall S, Giannitsis E, Jernberg T et al. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J 2011;32(4):404-11.
6. 6. Alpert JS, Thygesen K, Antman E et al. Myocardial infarction redefined-a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the re- definition of myocardial infarction. J Am Coll Cardiol 2000;36:959- 69.
7. 7. Kavsak PA, MacRae AR, Lustig et al. The impact of the ESC/ACC redefinition of myocardial infarction and new sensitive troponin assays on the frequency of acute myocardial infarction. Am Heart J 2006;152:118-25.
8. 8. Braunwald E, Antman EM, Beasley JW et al. ACC/AHA 2002 guideline update for the management of patients with unstable an- gina and non-ST-segment elevation myocardial infarction-summa- ry article: a report of the American College of Cardiology/Ameri- can Heart Association task force on practice guidelines (committee on the management of patients with unstable angina). J Am Coll Cardiol 2002;40:1366-74.

9. 9. Bassand JP, Hamm CW, Ardissino D et al. Guidelines for the di- agnosis and treatment of non-ST-segment elevation acute coronary syndromes. Task Force for Diagnosis and Treatment of Non-ST- Segment Elevation Acute Coronary Syndromes of European Soci- ety of Cardiology. Eur Heart J 2007;28:1598-660.
10. 10. Celebi OO, Diker E, Aydogdu S. Kardiyak troponinlerin klinik önemi. Turk Kardiyol Dern Ars 2008 Jun;36(4):269-77.
11. 11. Sheehan P, Vasikaran SD. The evolving clinical role of cardiac troponins and new acute myocardial infarction guidelines: implica- tions for the clinical laboratory. Clin Bichemist Rev 2001;23:52–65.
12. 12. Wu AHB. Increased troponin in patients with sepsis and septic shock: myocardial necrosis or reversible myocardial depression? Intensive Care Med 2001;27:959-61.
13. 13. Morrow DA, Rifai N, Tanasijevic MJ et al. Clinical efficacy of three assays for cardiac troponin I for risk stratification in acute coronary syndromes: a Thrombolysis In Myocardial Infarction (TIMI) 11B Substudy. Clin Chem 2000 Apr;46(4):453-60.
14. 14. Šimić S, Svaguša T, Prkačin I et al. Relationship between he- moglobin A1c and serum troponin in patients with diabetes and cardiovascular events. Journal of Diabetes and Metabolic Disorders 2019;18(2):693-704.
15. 15. Akwe J, Halford B, Kim E et al. A review of cardiac and non-car- diac causes of troponin elevation and clinical relevance part I: car- diac causes. J Cardiol Curr Res 2017;10(2):00360.
16. 16. Mayo Clinic. Heart attack. (serial online) (cited 2020 May 29). Available from: URL:https://www.mayoclinic.org/diseases-condi- tions/heart-attack/symptoms-causes/syc-20373106.
17. 17. T.C. Sağlık Bakanlığı Halk Sağlığı Genel Müdürlüğü Kro- nik Hastalıklar ve Yaşlı Sağlığı Dairesi Başkanlığı. Kalp damar hastalıkları kalp krizi (serial online) (cited 2020 May 29). Available from:URL: https://hsgm.saglik.gov.tr/tr/kalp-damar-hastaliklari/ liste/kalp-damar-hastal%C4%B1klar%C4%B1-kalp-krizi.html.
18. 18. Aykut K, Güzeloğlu M, Albayrak G et al. Akut koroner sendromun cerrahi tedavisi. Turkiye Klinikleri J Cardiol-Special Topics 2013;6(6):42-4.
19. 19. Kekeç Z. Tüm yönleriyle acil tıp (tanı, tedavi ve uygulama ki- tabı). 3rd ed. Ankara: Akademisyen Tıp Kitabevi; 2013.p.69-88.
20. 20. Thygesen K, Alpert JS, Jaffe AS et al. Third universal definition of myocardial infarction. J Am Coll Cardiol 2012;60:1581-98.
21. 21. Suzuki K, Komukai K, Nakata K et al. The usefulness and limita- tions of point-of-care cardiac troponin measurement in the emer- gency department. Intern Med 2018;57(12):1673‐80.
22. 22. Thygesen K, Alpert JS, Jaffe AS et al. Third universal definition of myocardial infarction. Eur Heart J 2012;33(20):2551‐67.
23. 23. Upasham S, Tanak A, Prasad S. Cardiac troponin biosensors: where are we now? Advanced Health Care Technologies 2018;4:1- 13.
24. 24. Shah AS, Anand A, Sandoval Y et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coro- nary syndrome: a cohort study. Lancet 2015;386(10012):2481–8.
25. 25. Christenson RH, Azzazy HME. Cardiac point of care testing: a focused review of current National Academy of Clinical Bio- chemistry guidelines and measurement platforms. Clin Biochem 2009;42(3):150–7.
26. 26. Bertsch T, Bleuel H, Deschl U et al. A new sensitive cardiac tro- ponin T rapid test (TROPT®) for the detection of experimental acute myocardial damage in rats. Exp Toxicol Pathol 1999;51(6):565–9.
27. 27. Avcıküçük M, Bakır F, Topçuoğlu C et al. Akut koroner sen- dromda troponin T ve troponin I. Turk Hij Den Biyol Derg 2011;68(3):127-34.
28. 28. Pagani F, Bonetti G, Panteghini M. Comparative study of cardi- ac troponin I and T measurements in a routine extra-cardiological clinical setting. J Clin Lab Analy 2001;15:210-4.
29. 29. Elmalı E, Karaören Z, Özdöl C et al. Akut koroner sendromlu hastalarda kardiyak troponin T ve troponin I’nın karşılaştırılması. Turk J Biochem 2005;30(3):212-5.
30. 30. Ross G, Bever FN, Uddin Z et al. Troponin I sensitivity and specificity for the diagnosis of acute myocardial infarction. J Am Osteopath Assoc 2000;100(1):29-32.
31. 31. Kalyon S. Yanlış troponin pozitifliği. Dirim Tıp Gazetesi 2010;85:29-31.
32. 32. Meyer T, Binder L, Hruska N et al. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol 2000;36(5):1632-6.
33. 33. Lum G, Solarz DE, Farney L. False positive cardiac troponin results in patients without acute myocardial infarction. Laboratory Medicine 2006;37(9):546-50.
34. 34. Bohner J, von Pape KW, Hannes W et al. False-negative immu- noassay results for cardiac troponin I probably due to circulating troponin I autoantibodies. Clin Chem 1996;42(12):2046.
35. 35. Garg P, Morris P, Fazlanie AL et al. Cardiac biomarkers of acute coronary syndrome: from history to high-sensitivity cardiac tropo- nin. Intern Emerg Med 2017;12(2):147-55.
36. 36. Sherwood MW, Kristin Newby L. High-sensitivity troponin as- says: evidence, indications, and reasonable use. J Am Heart Assoc 2014;3(1):e000403.
37. 37. Roffi M, Patrono C, Collet JP et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: ask force for the manage- ment of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardi- ology (ESC). Eur Heart J 2016;37:267-315.
38. 38. Tanindi A, Cemri M. Troponin elevation in conditions oth- er than acute coronary syndromes. Vasc Health Risk Manag2011;7:597-603.
39. 39. Neukamm AM, Høiseth AD, Hagve TA et al. High-sensitivi- ty cardiac troponin T levels are increased in stable COPD. Heart 2013;99(6):382-7.
40. 40. Brekke PH, Omland T, Holmedal SH et al. Determinants of car- diac troponin T elevation in COPD exacerbation - a cross-sectional study. BMC Pulm Med 2009:19;9-35.
41. 41. Gresslien T, Agewall S. Troponin and exercise. Int J Cardiol 2016;221:609-21.
42. 42. Shave R, Baggish A, George K et al. Exercise-induced cardiac troponin elevation: evidence, mechanisms, and implications. J Am Coll Cardiol 2010;56(3):169-76.
43. 43. Harvard Health Publishing. Takotsubo cardiomyopathy (bro- ken-heart syndrome). (serial online) (cited 2020 May 29). Available from: URL:https://www.health.harvard.edu/heart-health/takotsu- bo-cardiomyopathy-broken-heart-syndrome.
44. 44. Ramaraj R, Sorrell VL, Movahed MR. Levels of troponin release can aid in the early exclusion of stress-induced (takotsubo) cardio- myopathy. Exp Clin Cardiol 2009;14(1):6-8.
45. 45. Spies C, Haude V, Fitzner R et al. Serum cardiac troponin T as a prognostic marker in early sepsis. Chest 1998;113(4):1055-63.
46. 46. Su WL, Shui HA, Lan CC et al. Cardiovascular parameters asso- ciated with troponin I as indicators for 14-day mortality in patients with septic shock. Am J Med Sci 2018;356(3):244-53.
47. 47. Marshall WJ, Lapsey M, Day A et al. Lipids, lipoproteins and cardiovascular disease. Clinical Chemistry. 9th ed. St Louis: Else- vier; 2020.p.318-9.
48. 48. Ulakoğlu Zengin E. Kardiyak acillerde biyokimya laboratuvarı. Hastalıkların Tanı ve İzlenmesinde Biyokimya Laboratuvarı Sem- pozyum Dizisi;81:49-66.
49. 49. Danese E, Montagnana M. An historical approach to the diag- nostic biomarkers of acute coronary syndrome. Ann Transl Med 2016;4(10):194.
50. 50. Crook MA. Cardiovascular disease. In: Crook MA, editor. Clin- ical Biochemistry and Metabolic Medicine. London: CRC Press; 2012.p.326-8.
51. 51. Dasgupta A, Wahed A. Cardiac Biomarkers. In: Dasgupta A, Wahed A, editors. Clinical Chemistry, Immunology and Laborato- ry Quality Control. St Louis: Elsevier; 2014.p.138-9.
52. 52. Weinberger I, Rotenberg Z, Sagie A et al. "Flipped" lactic de- hydrogenase pattern in acute coronary insufficiency. Clin Cardiol 1986;9(12):597-9.
53. 53. Pant S, Deshmukh A, Neupane P et al. Cardiac biomarkers. Nov- el Strategies in Ischemic Heart Disease. IntechOpen (serial online) 2011 May-Sep (cited 2020 June). Available from: URL:https://www. intechopen.com/books/novel-strategies-in-ischemic-heart-dis- ease/biomarkers-in-ischemic-heart-disease.
54. 54. de Winter RJ, Lijmer JG, Koster RW et al. Diagnostic accuracy of myoglobin concentration for the early diagnosis of acute myo- cardial infarction. Ann Emerg Med 2000;35(2):113-20.
55. 55. Babuin L, Jaffe AS. Troponin: the biomarker of choice for the detection of cardiac injury CMAJ 2005;173(10):1191-1202.
56. 56. Raffel CO, White HD. Acute coronary syndromes. In: Sideboth- am D, McKee A, Gillham M, editors. Cardiothoracic Critical Care. Oxford: Butterworth-Heinemann; 2007.p.257-77.
57. 57. Habif S. Kardiyak troponinler. Türkiye Klinikleri J Med Sci 2003;23(1):74-80.
58. 58. The American Association for Clinical Chemistry. Labora- tory medicine practice guidelines: biomarkers of acute coronary syndromes and heart failure. (serial online) (cited 2020 May 21). Available from: URL:https://www.aacc.org/-/media/Files/Sci- ence-and-Practice/Practice-Guidelines/ACS-and-Heart-Failure/ACS_PDF_online.pdf ?la=en&hash=735F26B3C58FD8539A2E- C6A8A45351E9890FFFD3.
59. 59. Neumann F, Kastrati A, Pogatsa-Murray G et al. Evaluation of rolonged antithrombotic pretreatment ("Cooling-Off " Strategy) be- fore intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA 2003;290(12):1593–9.
60. 60. Bingisser R, Cairns C, Christ M et al. Cardiac troponin: a critical review of the case for point-of-care testing in the ED. Am J Emerg Med 2012;30(8):1639‐49.
61. 61. Ho C, Cimon K, Weeks L et al. Point-of-care troponin testing in patients with symptoms suggestive of acute coronary syndrome: a health technology assessment. Canadian Agency for Drugs and Technologies in Health (serial online) 2016 Mar (cited 2020 May 21). Available from: URL:https://www.ncbi.nlm.nih.gov/books/ NBK362842/.