Use of the peak troponin value to differentiate myocardial infarction from reversible neurogenic left ventricular dysfunction associated with aneurysmal subarachnoid hemorrhage

2003 ◽  
Vol 98 (3) ◽  
pp. 524-528 ◽  
Author(s):  
Ketan R. Bulsara ◽  
Matthew J. McGirt ◽  
Lawrence Liao ◽  
Alan T. Villavicencio ◽  
Cecil Borel ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Output ◽  
Subarachnoid Hemorrhage ◽  
Left Ventricular Dysfunction ◽  
Ventricular Dysfunction ◽  
Surgical Intervention ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Left Ventricular ◽  
Content Type ◽  
Fine Print

Object. Differentiating myocardial infarction (MI) from reversible neurogenic left ventricular dysfunction (stunned myocardium [SM]) associated with aneurysmal subarachnoid hemorrhage (SAH) is critical for early surgical intervention. The authors hypothesized that the cardiac troponin (cTn) trend and/or echocardiogram could be used to differentiate between the two entities. Methods. A retrospective study was conducted for the period between 1995 and 2000. All patients included in the study met the following criteria: 1) no history of cardiac problems; 2) new onset of abnormal cardiac function (ejection fraction [EF] < 40% on echocardiograms); 3) serial cardiac markers (cTn and creatine kinase MB isoform [CK-MB]); 4) surgical intervention for their aneurysm; and 5) cardiac output monitoring either by repeated echocardiograms or invasive hemodynamic monitoring during the first 4 days post-SAH when the patients were euvolemic. Of the 350 patients with SAH, 10 (2.9%) had severe cardiac dysfunction. Of those 10, six were women and four were men. The patients' mean age was 53.5 years (range 29–75 years) and their SAH was classified as Hunt and Hess Grade III or IV. Aneurysm distribution was as follows: basilar artery tip (four); anterior communicating artery (two); middle cerebral artery (one); posterior communicating artery (two); and posterior inferior cerebellar artery (one). The mean EF at onset was 33%. The changes on echocardiograms in these patients did not match the findings on electrocardiograms (EKGs). Within 4.5 days, dramatic improvement was seen in cardiac output (from 4.93 ± 1.16 L/minute to 7.74 ± 0.88 L/minute). Compared with historical controls in whom there were similar levels of left ventricular dysfunction after MI, there was no difference in peak CK-MB. A 10-fold difference, however, was noted in cTn values (0.22 ± 0.25 ng/ml; control 2.8 ng/ml; p < 0.001). Conclusions. The authors determined the following: 1) that the CK-MB trend does not allow differentiation between SM and MI; 2) that echocardiograms revealing significant inconsistencies with EKGs are indicative of SM; and 3) that cTn values less than 2.8 ng/ml in patients with EFs less than 40% are consistent with SM.

Clinical significance of elevated troponin I levels in patients with nontraumatic subarachnoid hemorrhage

2003 ◽  
Vol 98 (4) ◽  
pp. 741-746 ◽  
Author(s):  
Ellen Deibert ◽  
Benico Barzilai ◽  
Alan C. Braverman ◽  
Dorothy Farrar Edwards ◽  
Venkatesh Aiyagari ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Sensitivity And Specificity ◽  
Left Ventricular Dysfunction ◽  
Ventricular Dysfunction ◽  
Troponin I ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Left Ventricular ◽  
Content Type ◽  
Creatine Kinase Mb ◽  
Fine Print

Object. Aneurysmal subarachnoid hemorrhage (SAH) is associated with electrocardiographic abnormalities, regional or focal wall-motion abnormalities on echocardiograms, and/or increased creatine kinase MB isoenzyme (CK-MB) or cardiac troponin I (cTnI). The goal of this prospective study was to compare the sensitivity and specificity of cTnI with those of CK-MB in the prediction of left ventricular dysfunction on echocardiograms in patients with nontraumatic SAH. In addition, those patients with abnormal findings on their echocardiograms and elevated cTnI levels were further evaluated for the presence of coronary artery disease (CAD) by a cardiologist and to determine whether any left ventricular dysfunction that had been detected was reversible. Methods. The authors obtained electrocardiograms and echocardiograms, and measured serial levels of cardiac enzymes (CK-MB and cTnI) in 43 patients with nontraumatic SAH. Patients with known CAD were excluded. Those patients found to have elevated enzyme levels and abnormal findings on their echocardiograms underwent additional evaluation for CAD. The sensitivity and specificity of both cTnI and CK-MB for detecting left ventricular function were determined. Twenty-eight percent of patients with SAH in the study had elevated cTnI levels within the first 24 hours after hemorrhage. Seven of the 12 patients had evidence of left ventricular dysfunction on echocardiograms. In all these patients a return to baseline function was found during follow-up examinations. The authors found that cTnI is much more sensitive than CK-MB (100% compared with 29%) in the detection of left ventricular dysfunction in patients with SAH. Conclusions. An elevated level of cTnI is a good indicator of left ventricular dysfunction in patients with SAH. In this study cardiac dysfunction was reversible and should not necessarily preclude these patients from undergoing operative interventions or becoming heart donors. Clinical management may require more aggressive hemodynamic monitoring until cardiac function returns to normal.

Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage

1988 ◽  
Vol 69 (3) ◽  
pp. 326-331 ◽  
Author(s):  
Douglas Chyatte ◽  
Nicolee C. Fode ◽  
Thoralf M. Sundt
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Intracranial Aneurysm ◽  
Surgical Intervention ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Direct Result ◽  
Aneurysm Surgery ◽  
Content Type ◽  
Surgical Group ◽  
Fine Print

✓ The management results in 244 patients admitted to one institution within 3 days of aneurysmal subarachnoid hemorrhage (SAH) from January, 1979, to December, 1985, were analyzed with respect to the timing of surgical intervention. Twenty-six patients died prior to surgery. Patients surviving to surgery were divided into three groups according to the interval between preadmission SAH and surgery: 0 to 3 days (85 cases), 4 to 9 days (83 cases), and 10 or more days (50 cases). Of the patients who were categorized neurologically into Botterell Grades 1 and 2 (Hunt and Hess Grades I to III) on admission, 87% had an excellent or good result on follow-up evaluation. Patients undergoing surgery 0 to 3 days after SAH had a statistically significant increase in the incidence of postoperative ischemic symptoms (p < 0.005), which was balanced by similar complications preoperatively in the 10-day post-SAH surgical group. Most rebleeds occurred before admission but delaying surgery did increase the risk of rebleeding in the hospital (p < 0.0005). Management morbidity and mortality occurred primarily as a direct result of a severe initial hemorrhage; thus, the measured benefits of early surgery were less than might have been predicted.

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