Fulminant immune-mediated necrotising myopathy (IMNM) mimicking myocardial infarction with non-obstructive coronary arteries (MINOCA)

2020 ◽  
Vol 13 (11) ◽  
pp. e236603 ◽  
Author(s):  
Sophie Glenn-Cox ◽  
Robert William Foley ◽  
John D Pauling ◽  
Jonathan C L Rodrigues
Keyword(s):  
Myocardial Infarction ◽  
Skeletal Muscle ◽  
Coronary Arteries ◽  
Troponin T ◽  
Shoulder Girdle ◽  
Left Shoulder ◽  
Normal Range ◽  
Coronary Syndrome ◽  
Immune Mediated ◽  
Shoulder Girdle Muscles

A 74-year-old man, with inflammatory arthritis, recently commenced on adalimumab, presented with a 4-week history of left-sided chest pain, malaise and shortness of breath. Admission ECG showed age-indeterminate left bundle branch block. Troponin T was 4444 ng/L (normal range <15 ng/L) and acute coronary syndrome treatment was commenced. Catheter angiogram revealed mild-burden non-obstructive coronary disease. Cardiac magnetic resonance (CMR) was performed to refine the differential diagnosis and demonstrated no myocardial oedema or late gadolinium enhancement. Extracardiac review highlighted oedema and enhancement of the left shoulder girdle muscles consistent with acute myositis. Creatine kinase was subsequently measured and significantly elevated at 7386 IU/L (normal range 30–200 IU/L in men). Electrophoresis clarified that this was of predominantly skeletal muscle origin. Myositis protocol MRI revealed florid skeletal muscle oedema. The MR findings, together with positive anti-Scl-70 antibodies, suggested fulminant immune-mediated necrotising myopathy presenting as a rare mimic of myocardial infarction with non-obstructive coronary arteries, diagnosed by careful extracardiac CMR review.

scholarly journals The role of peak troponin in patients with a working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA)

2021 ◽  
Vol 22 (Supplement_2) ◽  
Author(s):  
MGL Williams ◽  
K Liang ◽  
E De Garate ◽  
L Spagnoli ◽  
E Fiori ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Arteries ◽  
Troponin T ◽  
Diagnostic Yield ◽  
Coronary Syndrome ◽  
Funding Sources ◽  
Tertiary Centre ◽  
St Elevation ◽  
The Mean

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Rosetrees Trust James Tudor Foundation Background 6-10% of patients who present with an acute coronary syndrome have a myocardial infarction with non-obstructive coronary arteries (MINOCA). Troponin T predicts infarct size and outcomes in patients with ST-elevation myocardial infarction. The value of peak troponin T in patients with a working diagnosis of MINOCA is not well understood. Purpose The aim of this study is to investigate the diagnostic and prognostic role of troponin in patients with MINOCA.  Methods Consecutive patients with a working diagnosis of MINOCA (n = 719) from a single tertiary centre who underwent comprehensive cardiovascular magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) were followed prospectively. The primary endpoint was all-cause mortality. Results Peak troponin T ≥211 ng/L and time to CMR of ≤17 days have a positive predictive value of 94% for being able to make a diagnosis on CMR. If the scan was performed in ≤17 days the diagnostic yield was still 75% even in the lowest troponin decile, but this was 59% if performed after 17 days. Each increase in troponin decile increases the mean diagnostic yield of the CMR by 3.7% (p &lt; 0.001, 95% CI 3.4 – 3.9; R2 0.84; Figure 1). There is no overall difference in median troponin in patients who died and those who survived (229 ng/l v. 424 ng/l; p = 0.157), however mortality is significantly lower in the highest two troponin quartiles (11.9% versus 6.9%; p = 0.009, figure 2).  Conclusions Peak troponin T and time to CMR can be used by cardiologists to determine the likelihood of making a diagnosis using CMR. A higher troponin quartile is associated with lower mortality.

scholarly journals ANALYSIS OF DATA FROM MINOCA PATIENTS BASED ON COMPARISON OF TOTAL REGISTER OF ACUTE CORONARY SYNDROME IN THE KRASNODAR REGION WITH FOREIGN REGISTERS

2019 ◽  
Vol 33 (4) ◽  
pp. 38-43
Author(s):  
S. V. Kruchinova ◽  
E. D. Kosmacheva ◽  
S. A. Raff ◽  
V. A. Porkhanov
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Comparative Analysis ◽  
Coronary Arteries ◽  
Krasnodar Krai ◽  
Coronary Syndrome ◽  
Krasnodar Region

The review presents a comparative analysis of data from patients with myocardial infarction with non-obstructive coronary arteries. Data were obtained from the total register of acute coronary syndrome in the Krasnodar Krai and were compared with data of foreign registers.

A comparison of cardiac troponin T delta change methods and the importance of the clinical context in the assessment of acute coronary syndrome

2019 ◽  
Vol 56 (6) ◽  
pp. 701-707
Author(s):  
Paul Simpson ◽  
Rosy Tirimacco ◽  
Penelope Cowley ◽  
May Siew ◽  
Narelle Berry ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Z Score ◽  
Clinical Context ◽  
Coronary Syndrome ◽  
Delta Change

Background The management of patients presenting with symptoms suggestive of acute coronary syndrome is a significant challenge for clinicians. Guidelines for the diagnosis of acute myocardial infarction require a rise and/or fall of cardiac troponin, along with other criteria. Knowing what constitutes a significant delta change from baseline is still unclear and the literature is varied. Methods We compared three methods for determining cardiac troponin delta changes (relative, absolute and z-scores) for detecting acute myocardial infarction in 806 patients presenting to an emergency department with symptoms suggestive of acute coronary syndrome. Blood specimens were collected at admission and 2, 3, 4 and 6 h postadmission and tested on the Roche Elecsys high-sensitivity troponin T assay. Results A positive diagnosis for acute myocardial infarction was found in 39 (4.8%) patients. ROC AUC showed better performance for the absolute and z-score delta change (0.959–0.988 and 0.956–0.988, respectively) compared with relative delta change (0.921–0.960) at all time points in the diagnosis of acute myocardial infarction. Optimal timing for the second sample was at 4–6 h postadmission. Conclusions Although not statistically significant, the results show a trend of absolute and z-score delta change performing better than relative delta change for the diagnosis of acute myocardial infarction. The z-score approach allows for a single cut-off value across multiple high-sensitivity assays which could be useful in the clinical setting. Our study also highlighted the importance of interpreting cardiac troponin changes in the clinical context with a combination of the patient’s clinical history and electrocardiogram.

P4420Is exercise-induced cardiac troponin release caused by skeletal muscle injury?

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T Paana ◽  
S Jaakkola ◽  
E Tuunainen ◽  
S Wittfooth ◽  
K Bamberg ◽  
...  
Keyword(s):  
Skeletal Muscle ◽  
Cardiac Troponin ◽  
Muscle Injury ◽  
Troponin I ◽  
Troponin T ◽  
Skeletal Muscle Injury ◽  
Coronary Syndrome ◽  
Marathon Race ◽  
Recreational Runners ◽  
Exercise Induced

Abstract Background Cardiac troponins (cTn) are highly sensitive and specific markers for cardiac injury and a key element in the diagnosis of acute coronary syndrome. Strenuous exercise is known to induce increases in cTn, but the causative factors remain ambiguous. It is also equivocal whether exercise induced skeletal muscle injury is associated with cTn elevation. Purpose The aim of this study was to identify independent predictors for the rise in cardiac troponin T (cTnT) and I (cTnI) concentration and to focus on the relationship between skeletal muscle injury measured by skeletal troponin I (skTnI) and cTn elevations after a marathon race in a large group of male recreational runners. Methods A total of 40 recreational runners participating in the marathon in our city were recruited. The study included baseline visit (prerace) and immediate post-race sampling. Results The post-marathon cTnT concentration rose above the reference limit in 38 (95%) participants and the detection limit for cTnI was exceeded in 34 (85%) participants. Similarly, a 10-fold increase in skTnI concentration was observed and elevated post-race values were seen in all participants. There was no significant correlation between the post-race cTnT or cTnT change and post-race skTnI (Spearman's rho = 0.249, p=0.122, rho = 0.285, p=0.074). However, post-race cTnI and change in cTnI were associated with post-race skTnI (rho = 0.404, p=0.01, rho = 0.460, p=0.003) and creatine kinase (r=0.368, p=0.019) concentration. Subjective exertion or self-reported muscle symptoms did not correlate with post-race cTnT, cTnI or skTnI levels. Post-Race cTnT <40 Post-Race cTnT ≥40 p-value n=18 n=22 Age, years 53.3±12.2 44.0±11.9 0.002 Active training, years 12.0 (9.3) 17.0 (15.8) 0.190 Muscle symptoms 7 (38.9) 11 (52.4) 0.523 Creatinine kinase, ug/l 406 (137) 399 (319) 0.163 N-terminal proBNP ng/l 137±168 158±277 0.783 Skeletal Troponin I, ng/ml 28.6 (41) 56.7 (143) 0.199 Figure 1 Conclusions Cardiac troponin became abnormal in almost all runners after marathon race. The exercise-induced rise in cardiac troponin I is related to simultaneous release of skeletal troponin I. The mechanism of this association remains uncertain, but clinicians should be cautious when interpreting post-exercise troponin levels without clinical symptoms and signs of myocardial ischemia.

P6004Safety assessment and results of coronary spasm provocation testing in patients with MINOCA compared to patients with stable angina and unobstructed coronary arteries

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Probst ◽  
A Seitz ◽  
G Pirozzolo ◽  
A Becker ◽  
T Schaeufele ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Risk Factor ◽  
Coronary Arteries ◽  
Stable Angina ◽  
Troponin T ◽  
Coronary Spasm ◽  
St Segment Elevation ◽  
Risk Factor Data ◽  
Provocation Testing ◽  
Factor Data

Abstract Background Approximately 10% of patients with acute myocardial infarction do not have a culprit lesion. Such patients have been labelled as MINOCA (myocardial infarction with non-obstructive coronary arteries) and several pathophysiological etiologies have been described as potential explanations. This includes spontaneous coronary dissection, tako-tsubo-syndrome and coronary spasm. The latter can be diagnosed during invasive provocative testing. The aim of this study was to assess the frequency of coronary spasm and the safety of intracoronary provocation testing using acetylcholine in MINOCA patients compared to patients with stable angina and unobstructed coronary arteries. Methods Between 2007 and 2018 180 consecutive patients with either MINOCA or stable angina and unobstructed coronary arteries were enrolled. MINOCA was defined as acute onset of chest pain with either ST-segment elevation on the ECG or significant high sensitive troponin T elevation but no relevant epicardial stenosis (<50%) according to the current ESC guidelines. All patients underwent intracoronary acetylcholine provocation testing (ACH-test) in search of coronary spasm according to a standardized protocol immediately after diagnostic coronary angiography. Apart from systematic assessment of clinical, demographic and risk factor data, data regarding complications during the ACH-test were meticulously recorded. Results Eighty patients with MINOCA and 100 consecutive patients with stable angina were recruited (52% women, mean age 62±13 years). Overall, 59% had hypertension and 20% had diabetes. Comparison of clinical, demographic and risk factor data did not reveal any statistically significant differences except for a female preponderance in the stable patients (61% vs. 40%, p=0.007). The ACH-test revealed a coronary vasomotor disorder in 68% of cases. In 32% of cases the ACH-test was either inconclusive or negative. Epicardial spasm was found in 31% of patients with a higher prevalence among the MINOCA patients compared to the stable angina patients (41% vs. 23%, p=0.002). Microvascular spasm was found in 37% with a higher prevalence among the stable angina patients compared to the MINOCA cohort (49% vs. 23%, p=0.002). Assessment of complications during the ACH-test revealed that 13 MINOCA patients and 15 stable angina patients had minor complications such as intermittent atrioventricular block, sinusbradycardia, paroxysmal atrial fibrillation, ventricular ectopic beats or transient hypotension. Comparison of minor complications between the two groups did not reveal statistically significant differences (16% vs. 15%, p=0.839). None of the patients experienced any irreversible complications. Conclusion Coronary spasm is a frequent cause for MINOCA. Intracoronary spasm provocation testing using acetylcholine is feasible in such patients. The complication rate during ACH-testing in MINOCA patients is low and comparable to patients with stable angina. Acknowledgement/Funding Berthold-Leibinger-Foundation, Ditzingen, Germany

scholarly journals P181 An uncommon mechanism of severe mitral regurgitation due to infective endocarditis mimicking acute myocardial infarction

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
A Collevecchio ◽  
G Simeti ◽  
M Previtero ◽  
S Iliceto ◽  
D Muraru ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Infective Endocarditis ◽  
Mitral Regurgitation ◽  
Coronary Arteries ◽  
Papillary Muscle ◽  
Distal Part ◽  
Troponin I ◽  
Blood Cultures ◽  
Coronary Syndrome

Abstract A 53-year-old man, smoker, with diabetes mellitus, presented to the Emergency Department because of intense chest and abdominal pain, accompanied by dyspnea and high fever (39.5 °C) in the previous 4 days. Physical examination revealed an apical holosystolic murmur, with no signs of peripheral or pulmonary edema. An ECG showed sinus rhythm (90 bpm), complete right bundle branch block and minimal ST elevation in the inferior leads. A transthoracic echocardiography showed a mild reduction in left ventricle ejection fraction (EF 44%) due to akinesia of the infero-lateral wall, and mild mitral regurgitation (MR) due to mitral valve prolapse. An abdominal ultrasound ruled out signs of acute cholecystitis. Blood cultures were collected, and an empirical antibiotic therapy was started. Urgent blood exam showed high Troponin I (72000 ng/L) and high C-reactive protein (290 mg/L). An acute coronary syndrome was suspected based on clinical, ECG and echocardiography exam, and the patient underwent coronary angiography (Figure 1, Panel A) that showed no significant coronary stenosis, except for two small filling defects in the very distal part of both the left anterior descendent and the circumflex coronary arteries suspected for coronary emboli. The patient was then admitted in the coronary care unit, but after just a few hours his clinical and hemodynamic condition deteriorated. A transesophageal echocardiography was performed to rule out mechanical complications related to the acute myocardial infarction and revealed severe MR (Panel D), elongated, hyperechogenic and dysfunctioning antero-lateral papillary muscle (ALPM) with an abnormal mobility suggestive for myocardial abscess, and a mobile mass attached on the aortic valve suggestive for vegetation (Panel B and C). Due to the worsening hemodynamic status, the patient underwent urgent cardiac surgery. Histological analysis confirmed the presence of an abscess of the ALPM due to Staphylococcus Aureus. The patient died after a week because of cerebral hemorrhage. Autopsy reported multiple lungs, renal and cerebral embolic septic infarctions. Learning points coronary artery embolization and papillary muscle abscess are very rare and often fatal consequences of infective endocarditis (IE). High (otherwise unexplained) fever and signs of embolism are minor Duke modified criteria for IE that should lead the physician to look for major criteria, such as positive blood cultures or echocardiography suggestive for IE. Emboli seen in the very distal part of the coronary arteries might have caused the ALPM abscess. Abstract P181 Figure

scholarly journals Elevated Heart-Type Fatty Acid-Binding Protein Predicts Early Myocardial Injury and Aids in the Diagnosis of Non-St Elevation Myocardial Infarction

2009 ◽  
Vol 16 (3) ◽  
pp. 141-147 ◽  
Author(s):  
GY Naroo ◽  
S Mohamed Ali ◽  
V Butros ◽  
A Al Haj ◽  
I Mohammed ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Fatty Acid ◽  
Chest Pain ◽  
Fatty Acid Binding Protein ◽  
Troponin T ◽  
Binding Protein ◽  
Fatty Acid Binding ◽  
Coronary Syndrome ◽  
Acid Binding Protein

Background Biomarkers play an important role in the early diagnosis, risk stratification and management of patients with the acute coronary syndrome. Objective The objective of this study was to evaluate the clinical reliability of heart-type fatty acid-binding protein (h-FABP) in identifying patients with the acute coronary syndrome in the early hours of chest pain. Methods Creatine kinase (CK-MB) (in laboratory), troponin T (in laboratory) and h-FABP (with point-of-care test CardioDetect®) were performed on 791 patients who presented with chest pain with duration since onset ranging from 20 minutes to 12 hours. Results Data of the 791 patients were analysed. h-FABP had a higher sensitivity of 75.76% and a specificity of 96.97% compared with 58.59% and 98.84% for troponin T and 68.69% and 97.54% for CK-MB respectively (in the first 6 hours). Conclusion: h-FABP was found to be a better biomarker of cardiac necrosis in the early hours in the diagnosis of non-conclusive ECG in patients with acute myocardial infarction. (Hong Kong j.emerg.med. 2009;16:141–147)

scholarly journals Early Dynamic Change in High-Sensitivity Cardiac Troponin T in the Investigation of Acute Myocardial Infarction

2011 ◽  
Vol 57 (8) ◽  
pp. 1154-1160 ◽  
Author(s):  
Sally J Aldous ◽  
A Mark Richards ◽  
Louise Cullen ◽  
Martin P Than
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Adverse Events ◽  
Troponin T ◽  
Dynamic Change ◽  
High Sensitivity ◽  
Hazard Ratio ◽  
Diagnostic Sensitivity ◽  
Diagnostic Specificity ◽  
Coronary Syndrome

BACKGROUND The definition of acute myocardial infarction (AMI) requires a rise and/or fall in troponin with 1 or more results ≥99th percentile of the reference range. How much troponin must change has not been specified. We ascertained whether dynamic changes (δ) in high-sensitivity troponin T (hs-TnT) improved diagnostic and prognostic test performance in the emergency department. METHODS We recruited 939 patients with symptoms suggestive of acute coronary syndrome (without ST elevation). hs-cTnT was measured at 0 h and 2 h after presentation. End-points were admission diagnosis of AMI and 1-year adverse events (composite of death, AMI, revascularization). RESULTS Diagnostic specificity of 0–2-h hs-cTnT for AMI (incurred by 200 patients) improved from 79.8% (78.8%–80.5%) by using the 99th percentile alone to 94.2% (92.9%–95.4%) when we also included a δ ≥20%, but diagnostic sensitivity decreased from 94.5% (90.7%–96.9%) to 49.5% (44.6%–53.9%). With the inclusion of those patients with a δ ≥20% when 0–2-h hs-cTnT was &lt;99th percentile, in addition to any with concentrations ≥99th percentile, diagnostic sensitivity increased to 97.5% (94.4%–98.9%). hs-cTnT ≥99th percentile predicted adverse events (incurred by 111 patients), adjusted hazard ratio 1.9 (1.2–2.8), whereas a δ ≥20% did not, hazard ratio 1.1 (0.7–1.7). CONCLUSIONS Diagnostic specificity of hs-cTnT improved with the use of a δ ≥20% in those patients with concentrations ≥99th percentile, but at a cost of a large reduction in sensitivity. Diagnostic sensitivity improved with the use of a δ ≥20% in patients with 0–2-h concentrations &lt;99th percentile. Both approaches may be required for optimum rule-in and rule-out strategies, respectively. The δ criteria seem to be less useful for medium-term risk stratification.

scholarly journals Predictive Value of a 6-Hour Ecg/Troponin Protocol in Patients with Chest Pain

2003 ◽  
Vol 10 (3) ◽  
pp. 146-152 ◽  
Author(s):  
CY Man ◽  
PA Cameron ◽  
WL Cheung
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Troponin T ◽  
Low Risk ◽  
Chinese Patients ◽  
Initial Assessment ◽  
Coronary Syndrome ◽  
Pain Patients

Introduction Patients presenting with chest pain and considered to be at low risk of acute coronary syndrome (ACS) may still have coronary heart disease. The potential risk of sudden cardiac death due to arrhythmias or progression to acute myocardial infarction still exists. To minimize this risk, we have designed a 6-hour risk stratification protocol for patients with a low risk of acute myocardial infarction on initial assessment in the Accident and Emergency Department (AED). Materials & Methods This was a retrospective observational study with the aim of determining the risk of adverse cardiovascular events in chest pain patients attending an AED. These patients were subject to an ECG and cardiac troponin T tests (cTnT) at 0 hour and at 6 hours (if the two tests were negative at 0 hour), and were put under observation in the AED observation ward during the same period. The main outcome measures were adverse cardiac events at 30 days. Results A total of 371 Chinese patients considered to have low risk of ACS were recruited into the protocol. Troponin T tested positive in 19 patients (5.1%) at 0 hour and 8 patients (2.2%) at 6 hours. Amongst the 332 patients that were discharged directly from the AED, there were no re-admissions for cardiac-related deaths, acute myocardial infarction, arrhythmia or heart failure. Conclusion The 6-hour ECG and troponin T observation protocol is a useful tool to allow safe discharge of chest pain patients who are at low risk of acute coronary syndrome.

scholarly journals Takotsubo cardiomyopathy: case report

2017 ◽  
Vol 95 (7) ◽  
pp. 663-668
Author(s):  
Marina G. Matveeva ◽  
G. E. Gogin ◽  
M. N. Alekhin
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Left Ventricle ◽  
Coronary Arteries ◽  
Takotsubo Cardiomyopathy ◽  
Left Ventricular ◽  
Classical Type ◽  
Coronary Microvascular Dysfunction ◽  
Apical Ballooning Syndrome ◽  
Coronary Syndrome

This article reports a clinical case of Takotsubo cardiomyopathy manifest clinically, biochemicaly, electrocardiographically, and echocardiographicalyas acute myocardial infarction. The diagnosis was based on finding intact coronary arteries and rapid positive dynamics of instrumental and laboratory data. Takotsubo cardiomyopathy (CMP) (stress-associated CMP, apical ballooning syndrome) is a rare reversible disease developing after acute emotional and physical stress. Its prevalence is estimated at 1-2% of all cases of acute myocardial infarction. It most commonly affects postmenopausal women. The clinical picture is similar to that of acute coronary syndrome with transient hypo- and akinesiaof apical and middle segments of the left ventricle (LV) in combination with hyperkinesia of its basal myocardial segment in the absence of stenosis or a spasm of coronary arteries. The precise pathophysiology of the disease is unknown; several hypotheses are proposed including enhancedsympathoadrenal activity, catecholamine multivesselepicardial coronary artery spasm, coronary microvascular dysfunction, catecholamine cardiotoxicity and catecholamine-mediated myocardial stunning. The Mayo Clinic diagnostic criteria are most widely used in clinical practice: transient hypokinesia, akinesia, or dyskinesia of left ventricular mid-segments with or without apical involvement; regional wall motion abnormalities extending beyond the region of blood supply of a single epicardialartery; a stressful event oftenbut not always present in the medical history in the absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; new electrocardiographic abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin 1 level; the absence of pheochromocytoma and myocarditis. Takotsubo cardiomyopathyhas been classified into 3 types based on the involvement of the left ventricle: classical type, reverse type and mid-ventricular type; lesions of right ventricle are also described. Specific treatment of the disease is unavailable, and the main purpose of therapy is normalization of LV systolic function. The prognosis of Takotsubo cardiomyopathyis favorable, complete clinical recovery is observed in 95,5% of the cases, the average time of recovery is between 2 and 3 weeks.

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