High Troponins, No Q-wave

Renee_RN · Oct 20, 2005

Wow! He is an extremely lucky person.

I have never seen a troponin that high (I have heard of massive MI pts with these numbers).

Is the extremely high troponin due to a massive, global ischemic event secondary to the acute blood loss (anemia, lack of adequate oxygenation to the entire heart) affecting so many of the cardiac muscle cells at one time?

Maybe the event was reversed fast enough before a permanent infarction of muscle occurred.

Thanks for sharing!

Renee

papawjohn · Oct 20, 2005

Hey Renee

Still awake!!! I've actually seen numbers that high in chest trauma Pts. But Cardiac trauma (the ones I've seen were unrestrained drivers who smashed into the steering wheel--WEAR YOUR SEATBELT!!!) has arrhythmias (usually heart blocks and bradycardias) and EKG changes (widened QRS). This guy just lucked out---

Amazed....

Papaw John

Editorial Team / Admin · Oct 20, 2005

I Have seen enzymes elevate in critically ill patients without evidence of myocardial injury, MI. They quickly decrease when the "event" subsides...

lifejourney · Oct 21, 2005

Absolutely!

I was taking care of a post-cardiac stent patient one night. About 4AM he develops "classic" cardiac chest pain with diaphoresis, nausea, SOB. Initial EKG is completely normal. We draw enzymes, start NTG gtt, give morphine, and I get on the phone with his MD on-call after absolutely no change in pain level with meds given. MD wants EKG faxed to him and asks for another when he sees the normal EKG. We take another. Again, completely normal. MD is questioning my assessment because of the EKG but I am adamant! I request that the hospitalist in house be sent. Hospitalist calls for an emergent trip to the cath lab. The patients stent is found to be 100% occluded and troponin peaks at 42.

The patient never showed EKG changes at all. It was a great lesson for me. I'm glad I was insistent with the on-call MD. He was hesitant to believe my assessment (which can sometimes make me question myself). Obviously from our experiences it can happen, right!

lifejourney

Dinith88 · Oct 21, 2005

Hey Ever'body!!!!
Thought I'd lay out a little scenario for comment. Guy comes in the ER with history of CABG 15yrs ago, old inferior MI on EKG, stable angina pattern at home (approx 1 NTG SubLing per day). Had bright red rectal bleeding at home. (Typical heart pt--didn't wanna come in. Wife called 911.)
In our ICU for observation til the GI workup to begin the next morning, he gets up to the BSCommode. HUGE melena stool--bradycardia--loss of consciousness!!!
Toss him back into the bed. Get the whole medical community activated. Give blood, FFP, Platelets and about 2 or 3 liters of NSS to keep his BP and H&H up. Waiting for the OR to get into the building, and he has chest pain!!!
I give a couple NTGs, do a 12lead--shows major ST segm't depression at all anterior leads. Cardiologist says give Fentanyl--so I do and that relieves the Chest Pain. Then off to the OR he goes and ends up with total colectomy and ileostomy.
Now, here's the event that leads to this question. Post Op, he has cardiac enzymes and serial EKGs. The Troponines go WAY HIGH. They're up to 63!! But the EKGs return to baseline--no Qwaves, no ST Segm't 'flip'. Post op Echocardiogram not significantly different from PreOp. (Has Eject'nFract'n of 60%!!) Obviously a lucky guy!!! Had transient cardiac ischemia with his GI Bleeding 'crisis' but no MI.
Here's what I thought would be interesting: Has anyone else seen this kind of elevation of enzymes without EKG documentation of MI?
Papaw John
(The Duke of Wellington, who defeated Napoleon at Waterloo, said that the battle of Waterloo was "A DAMNED CLOSE RUN THING." That's my past few days with this guy!!)

Hey papajohn, by "...'old inferior MI' on EKG..." as you state....i'm assuming he already had inferior q-waves???

If so, could be he had another inferior event (on the periphery of old mi) that was just 'hidden' or 'buried' in these old q-waves.

Or...if the event occured elsewhere, it could simply be a matter of a 'non-q-wave MI (non ST-elevation MI). If the infarction isnt transmural (through the entire myocardial wall), then q-waves (or st elevation) wont develope.

Surely enzymes can get all screwed up with surgeries and other non-cardiac stuff...but not troponins. Thats too specific.

My guess is another inferior event (periphery of old inferior mi??), or non-qwave (no st elevation) MI elsewhere. Sucks the guy had a big belly surgery...thinners are out of the question (ouch!!). He's pretty sick.

Editorial Team / Admin · Oct 21, 2005

Troponin levels can be elevated in instances of a non-cardiac nature such as renal dz, sepsis, strenuous prolonged exercise, severely critically ill patient.....

Dinith88 · Oct 21, 2005

Troponin levels can be elevated in instances of a non-cardiac nature such as renal dz, sepsis, strenuous prolonged exercise, severely critically ill patient.....

It's unlikely (wrong) that the troponin of 63 was caused by a non-cardiac event in the face of the ekg changes john mentions. ...

Also, i think you may be confusing Troponin with CPK. Srenuous excercise and being critically ill wont bump your troponin (unless of course you injure your heart in the process!) . And renal disease surely wont bump your troponin to such an extent. (it's usually a marginal elevation if at all).

In any event, after re-reading johns post, i'd have to change my answer. The changes he saw were in anterior leads...so my best guess is anterior NQWMI. (if these anterior changes were reciprocal from an inferior event, then elevation would/could be seen inferiorly).

Or...another poster mentioned a global event r/t pt's anemia. Thats surely a possibility but i wonder if the troponin could get that high with that???

Editorial Team / Admin · Oct 21, 2005

It's unlikely (wrong) that the troponin of 63 was caused by a non-cardiac event in the face of the ekg changes john mentions. ...
Also, i think you may be confusing Troponin with CPK. Srenuous excercise and being critically ill wont bump your troponin (unless of course you injure your heart in the process!) . And renal disease surely wont bump your troponin to such an extent. (it's usually a marginal elevation if at all).
In any event, after re-reading johns post, i'd have to change my answer. The changes he saw were in anterior leads...so my best guess is anterior NQWMI. (if these anterior changes were reciprocal from an inferior event, then elevation would/could be seen inferiorly).
Or...another poster mentioned a global event r/t pt's anemia. Thats surely a possibility but i wonder if the troponin could get that high with that???

http://www.chestjournal.org/cgi/content/full/125/5/1877

Granted the Troponin elevation in this scenerio is more than likely cardiac related.

Dinith88 · Oct 22, 2005

http://www.chestjournal.org/cgi/content/full/125/5/1877
Granted the Troponin elevation in this scenerio is more than likely cardiac related.

Nice. Please re-read the introduction. It states that troponin is an indicator of myocardial injury (we all know this). It's also stating that other 'mechanisms' can cause myocardial injury (than just coronary disease). So...the study you're quoting doesnt support your previous post. You were attempting to sAy that Troponin can be elevated even when the myocardium is not injured... which is wrong. This study clearly states that troponin measures myocardial injury....it just points out that CAD may not be the sole reason for the troponin bump/heart injury. A non-cardiogenic rise in troponin (that you were inferring) is not mentioned, supported, or mentioned in this study.

papawjohn · Oct 22, 2005

Hey Y'all

Thanx for all the input/conversation....

Our guy had no renal impairment. (Post op Bun and Cr totally normal with some variation that had to do with normal fuctuations in CVP and because the Pulmonologist/Intensivist gave him a one-time 'hit' of lasix/albumin/KCl). I'm not at work at present but by memory--the last Bun ~ 10, Creat ~ 0.8).

His PreOp EKG had an interesting little 'delta' behind the QRS and Q's (moderate size) in the inferior leads. I specifically remember noticing that the pre-op and post-op Qwave in II were unchanged. I did both EKGs with my own hands, so particularly paid attention. Really the EKG had NO INDICATION of myocardial damage, I promise. And the Troponines seemed remarkably high. Thought that was interesting.

The troponins did not 'peak' and subside quickly like they tend to do post MI. I don't have documentation for this but don't they become normal about 36hrs post MI? This guy still had very high trops 36hrs post op.

He had a post op echo-cardiogram. It showed the very same mild valvular problems (slight mitral regurg is all I remember--because I have a particular vanity about hearing murmurs) and essentially the same EF (60%) as a pre-op echo done in the office of his Primary that was added to the chart a couple of days post op.

Interesting business we're in.

Thanx again everybody....

Papaw John

BTW--great work Lifejourney!! I love working with nurses that stick to their guns and stand up for the Pt like you did on the event you mentioned!!!

P- J-

chadash · Oct 30, 2005

This may help:"Traditionally patients with suspected myocardial ischaemia are admitted for "screening" tests to exclude myocardial infarction, largely based on serial measurements of markers for myocardial necrosis. Historically, the markers used were non-specific enzymes released from myocardial cells and other tissues such as skeletal muscle and liver. Recently, however, extremely sensitive and specific markers have become widely availablethe cardiac troponins.

Cardiac troponin I and troponin T are components of the myocardial contractile apparatus. They are encoded by distinct genes, allowing the development of highly specific immunoassays. Unlike other cardiac markers, the troponins are undetectable in healthy subjects, so that even minor increases indicate myocardial damage. "