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      Prognostic implications of troponin I elevation in emergency department patients with tachyarrhythmia

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          Abstract

          Background

          Tachyarrhythmias are very common in emergency medicine, and little is known about the long‐term prognostic implications of troponin I levels in these patients.

          Hypothesis

          This study aimed to investigate the correlation of cardiac troponin I (cTnI) levels and long‐term prognosis in patients admitted to the emergency department (ED) with a primary diagnosis of tachyarrhythmia.

          Methods

          A retrospective cohort study was conducted between January 2012 and December 2013, enrolling patients admitted to the ED with a primary diagnosis of tachyarrhythmia and having documented cTnI measurements. Clinical characteristics and 5‐year all‐cause mortality were analyzed.

          Results

          Of a total of 222 subjects with a primary diagnosis of tachyarrhythmia, 73 patients had elevated levels of cTnI (32.9%). Patients with elevated cTnI levels were older and presented significantly more cardiovascular risk factors. At the 5‐year follow‐up, mortality was higher among patients with elevated cTnI levels (log‐rank test P < 0.001). In the multivariable Cox regression analysis, elevated cTnI was an independent predictor of all‐cause death (hazard ratio, 1.95, 95% confidence interval: 1.08‐3.50, P = 0.026), in addition to age and prior heart failure.

          Conclusion

          Patients admitted to the ED with a primary diagnosis of tachyarrhythmia and high cTnI levels have higher long‐term mortality rates than patients with low cTnI levels. cTnI is thus a biomarker with predictive capacity for mortality in late follow‐up, conferring utility in the risk stratification of this population.

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          Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality.

          John Canto, William J Rogers, Robert J. Goldberg … (2012)
          Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality. To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI. Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men). We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality. The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P < .001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P < .001). In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.
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            Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.

            John Canto (2000)
            Although chest pain is widely considered a key symptom in the diagnosis of myocardial infarction (MI), not all patients with MI present with chest pain. The extent to which this phenomenon occurs is largely unknown. To determine the frequency with which patients with MI present without chest pain and to examine their subsequent management and outcome. Prospective observational study. A total of 434,877 patients with confirmed MI enrolled June 1994 to March 1998 in the National Registry of Myocardial Infarction 2, which includes 1674 hospitals in the United States. Prevalence of presentation without chest pain; clinical characteristics, treatment, and mortality among MI patients without chest pain vs those with chest pain. Of all patients diagnosed as having MI, 142,445 (33%) did not have chest pain on presentation to the hospital. This group of MI patients was, on average, 7 years older than those with chest pain (74.2 vs 66.9 years), with a higher proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6% vs 25. 4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3 hours), were less likely to be diagnosed as having confirmed MI at the time of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), beta-blockers (28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients without chest pain had a 23.3% in-hospital mortality rate compared with 9.3% among patients with chest pain (adjusted odds ratio for mortality, 2. 21 [95% confidence interval, 2.17-2.26]). Our results suggest that patients without chest pain on presentation represent a large segment of the MI population and are at increased risk for delays in seeking medical attention, less aggressive treatments, and in-hospital mortality. JAMA. 2000;283:3223-3229
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              Classification of myocardial infarction: frequency and features of type 2 myocardial infarction.

              Axel C. P. Diederichsen, Lotte Saaby, Kristian Thygesen … (2013)
              The classification of myocardial infarction into 5 types was introduced in 2007 as an important component of the universal definition. In contrast to the plaque rupture-related type 1 myocardial infarction, type 2 myocardial infarction is considered to be caused by an imbalance between demand and supply of oxygen in the myocardium. However, no specific criteria for type 2 myocardial infarction have been established. We prospectively studied unselected hospital patients who had cardiac troponin I measured on clinical indication. The diagnosis and classification of myocardial infarction were established, and the frequency and features of type 2 myocardial infarction were investigated by use of novel developed criteria. From January 2010 to January 2011, a total of 7230 consecutive patients who had cardiac troponin I measured were evaluated, and 4499 patients qualified for inclusion. The diagnosis of myocardial infarction was established in 553 patients, of whom 386 (72%) had a type 1 myocardial infarction and 144 (26%) had a type 2 myocardial infarction. Patients in the group with type 2 myocardial infarction were older and more likely to be female, and had more comorbidities. The proportion of patients without significant coronary artery disease was higher in those with type 2 myocardial infarction (45%) than in those with type 1 myocardial infarction (12%) (P < .001). Tachyarrhythmias, anemia, and respiratory failure were the most prevalent mechanisms causing type 2 myocardial infarction. In a cohort of patients with myocardial infarction who were admitted consecutively through 1 year, the category of type 2 myocardial infarction comprised one fourth when diagnosed by the use of newly developed criteria. Approximately half of patients with type 2 myocardial infarction had no significant coronary artery disease. Copyright © 2013 Elsevier Inc. All rights reserved.
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                Author and article information

                Contributors
                Alfredo Bardají:
                ORCID: https://orcid.org/0000-0003-1900-6974
                abardaji.hj23.ics@gencat.cat , abardaji@comt.es
                Journal
                Journal ID (nlm-ta): Clin Cardiol
                Journal ID (iso-abbrev): Clin Cardiol
                Journal ID (doi): 10.1002/(ISSN)1932-8737
                Journal ID (publisher-id): CLC
                Title: Clinical Cardiology
                Publisher: Wiley Periodicals, Inc. (New York )
                ISSN (Print): 0160-9289
                ISSN (Electronic): 1932-8737
                Publication date (Electronic): 26 March 2019
                Publication date Collection: May 2019
                Volume: 42
                Issue: 5 ( doiID: 10.1002/clc.2019.42.issue-5 )
                Pages: 546-552
                Affiliations
                [ 1 ] Cardiology Department University Hospital of Tarragona Joan XXIII, IISPV, Rovira i Virgili University Tarragona Spain
                [ 2 ] Cardiology Department University Hospital Germans Trias Pujol Badalona Spain
                [ 3 ] Emergency Service Department University Hospital of Tarragona Joan XXIII, IISPV, Rovira i Virgili University Tarragona Spain
                [ 4 ] Clinical Analysis Service University Hospital of Tarragona Joan XXIII, IISPV, Rovira i Virgili University Tarragona Spain
                Author notes
                [*] [* ] Correspondence

                Alfredo Bardají. Cardiology Department, University Hospital of Tarragona Joan XXIII, IISPV, Rovira i Virgili University, Tarragona, Spain, Calle Dr Mallafré Guash 4. 43007. Tarragona, Spain.

                Email: abardaji.hj23.ics@ 123456gencat.cat ; abardaji@ 123456comt.es ;

                Author information
                https://orcid.org/0000-0003-0587-050X
                https://orcid.org/0000-0001-9667-7507
                https://orcid.org/0000-0003-1900-6974
                Article
                Publisher ID: CLC23175
                DOI: 10.1002/clc.23175
                PMC ID: 6523000
                PubMed ID: 30895632
                SO-VID: 43b8f6a8-eb8b-41a6-a069-94e1da065476
                Copyright © © 2019 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 09 January 2019
                Date revision received : 06 March 2019
                Date accepted : 14 March 2019
                Page count
                Figures: 2, Tables: 3, Pages: 7, Words: 5067
                Categories
                Subject: Clinical Investigations
                Subject: Clinical Investigations
                Custom metadata
                source-schema-version-number 2.0
                component-id clc23175
                cover-date May 2019
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.3 mode:remove_FC converted:16.05.2019

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: arrhythmia,cardiac troponin,emergency department
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: arrhythmia, cardiac troponin, emergency department

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