I had a patient who was admitted under diagnosis of NSTEMI. On the floor the patient had no s/sx of chest pain, SOB, respiratory distress, NSR on the monitor, troponin of 0.3. Upon further labs and urinalysis done, they found that the patient had positive nitrites. So then we did a urine CS and found that the patient has a UTI. The patient had a Cardiologist consult due to the diagnosis of NSTEMI and elevated troponin. Two days later, the patient was then discharged by another nurse with RX for oral antibiotics for the UTI when the sensitivity came back. But I was actually surprised to find out that the patient was also discharged with a troponin of 0.06.
My question is, has anyone discharged a patient with elevated troponin levels? Or specifically a troponin level of 0.06?
I went to the link above which you wanted me to see. And I found out with the readings above regarding this, "Cardiac troponin T and troponin I are cardiac regulatory proteins that control the calcium mediated interaction between actin and myosin."
Would you know what "myosin" is in the body. It is as I "As the most abundant of these proteins myosin plays a structural and enzymatic role in muscle contraction and intracellular motility. Myosin was first discovered in muscle in the 19th century." This is from https://proteopedia.org/wiki/index.php/Myosin
That's why if you read from all the suggestions regarding troponin in this website that nurses sees a lot of cases involving elevated troponin that has nothing to do with cardiac problems or issues.
If you want to diagnose that elevated troponin is really about cardiac related condition, you need more workups like EKG, Echo, vital signs especially BP measurements, physical assessment, history taking and some more to adequately diagnose it as such.
As with other conditions like an increased BUN and creatinine, you cannot just say that it's really a renal condition not unless you do a lot more workup because BUN and creatinine can also increase in dehydration or congestive heart failure.
Therefore, one lab work can mean nothing not unless we investigate or put the pieces of the puzzle together to fully understood the condition. But nevertheless, we nurses is at the core in every hospital course of the patient so we must take as much prudent and inherent intelligence to provide excellent nursing judgement in whatever we do and whatever specialty we are in. We don't need to know everything but we just need to learn what the concept is.
As in the case of being a citizen of a country, we cannot memorize all the criminal law, the civil law, penal law, the labor law of our country but we just have to know the concept that we should not commit any murder to anyone, steal or destroy property of someone and we will be out of trouble.
Just another little tidbit...if you drew the trop with a tourniquet---especially if you left it on "too long"---this can raise the trop level artificially. Saw this happen a gazillion times. If you draw from a peripheral IV, using a band....it's just not ideal. I know it sounds stupid--but it's true.
If you left the torniquet too long, it's probably you injured the muscle around it because troponin is found in all muscles. When you injured the muscle, the troponin seeps in to the blood stream thus increasing it's value and result. It is what is called a false positive reading because you didn't intend to cause but during the process, it went up without any underlying condition except that it was during the drawing of the blood sample.
A troponin test measures the levels of troponin T or troponin I proteins in the blood. These proteins are released when the heart muscle has been damaged, such as occurs with a heart attack. The more damage there is to the heart, the greater the amount of troponin T and I there will be in the blood.
The heart muscle is unique to the heart and troponin labs that we measure to screen for myocardial ischemia are cardiac specific troponins.
I have questioned elevated troponins in renal patients and the MD attributed the elevated trops to "transient demand ischemia"
4 hours ago, magellan said:
If you want to diagnose that elevated troponin is really about cardiac related condition, you need more workups like EKG, Echo, vital signs especially BP measurements, physical assessment, history taking and some more to adequately diagnose it as such.
You are absolutely right that they do a big workup for elevated trop and NSTEMI on EKG. On my floor, they will be on a heparin drip, have serial cardiac troponin labs, have an echo, If they are still symptomatic (eg complain of chest pain when asked), they will go to cath lab for an angiogram and sign consent for stent/angioplasty/other interventions if they are indicated. 9/10 times, they are done with angiogram in 15 minutes because there are no significant blockages of coronary arteries. Heparin drip off, nitro d/c'ed, eat, back on home meds, and discharge because the renal piece is chronic and the EF on echo is low but same as last time they were in (ie the heart and kidneys are tired and failing...)
If you left the torniquet too long, it's probably you injured the muscle around it because troponin is found in all muscles. When you injured the muscle, the troponin seeps in to the blood stream thus increasing it's value and result. It is what is called a false positive reading because you didn't intend to cause but during the process, it went up without any underlying condition except that it was during the drawing of the blood sample.
Thanks, but i wasn't asking for an explanation of why it happens. I know why it happens and my point was to the OP---that the explanation for the elevated trop could be as simple as a tourniquet left on too long.
I would start there before spending $77,456.99 on this whole workup--to find out that your phlebotomist doesn't know how to properly pull a trop....particularly in the absence of other s/s of ACS.
Sometimes the simplest explanation is the correct one. Repeat the trop without a tourniquet (if one was used) and don't draw from a PIV or use an 18g (my favorite way of transferring blood into tubes) to transfer the blood.
If a BP is 250/110 and the patient has no other s/s....you wouldn't repeat the measurement?
Thanks, but i wasn't asking for an explanation of why it happens. I know why it happens and my point was to the OP---that the explanation for the elevated trop could be as simple as a tourniquet left on too long.
I would start there before spending $77,456.99 on this whole workup--to find out that your phlebotomist doesn't know how to properly pull a trop....particularly in the absence of other s/s of ACS.
Sometimes the simplest explanation is the correct one. Repeat the trop without a tourniquet (if one was used) and don't draw from a PIV or use an 18g (my favorite way of transferring blood into tubes) to transfer the blood.
If a BP is 250/110 and the patient has no other s/s....you wouldn't repeat the measurement?
That's a good sounding nursing judgement because, as a bedside nurse, we should know how to intervene properly or else money, time and effort will be wasted and yet the patient will still be suffering. Don't just follow hospital protocols because it will make the situation as if one size fits for all. All of the patient's case or situation are unique from each other so make it appropriate with them in regards to your nursing judgement. They have their own finger print when they come to the hospital. It will never be the same for all patients so your nursing interventions and judgement will be unique to each and every one depending on your utilization of nursing process.
Going from 0.3 to 0.06 at discharge is a good thing. If the pt was discharged with elevated troponins and no other possible causes or cardiac interventions, then I would be worried.
Going from 0.3 to 0.06 at discharge is a good thing. If the pt was discharged with elevated troponins and no other possible causes or cardiac interventions, then I would be worried.
holy canoli. GREAT CATCH ? i love how the mind fills in things when it wants to see something. 6 is a larger number than 3...ergo...higher. but not.
Tourniquets don't effect cardiac-myocyte-specific troponin levels, I think you might be thinking of lactate levels, which are often suggested to be drawn without a tourniquet even though there is no evidence to support that and studies comparing lactates drawn with and without a tourniquet show no difference between the two.
Patient was brought in due to ALOC and low blood sugar, but in the ER patient was diagnosed with NSTEMI.
In the ER, the patient refused lovenox because the patient verbalized that they do not like lovenox due to fear of bleeding out and do not like injection shots. Patient is also allergic to aspirin. The patient was never on heparin drip. So no cardiac medication interventions were really done, but patient was on some BP meds just to maintain BP due to history of HTN and atorvastatin as ordered by cardiologist. EKG was done and rhythm shows NSR and she was NSR throughout her stay. Patient was on SCD's.
Patient was able to tolerate activity without SOB, respiratory distress, and chest pain. Throughout the time I had the patient for less than 2 days, the patient was asymptomatic and denied SOB, respiratory distress, chest pain, or in general pain anywhere.
And, it is a good point that the patient was possibly given that initial diagnosis NSTEMI just due to the elevated initial troponin. With further work up of labs and what not, troponin did indeed trend down without any cardiac interventions and it was found that patient had positive nitrites for UTI.
However, I'd like to know how long should the patient remain in the hospital to monitor the troponin to trend down or how many trends does it take haha (if there is such a thing)? I suppose my concern is that the patient went from 0.3 down to 0.06, and then up to 0.08, then back down to 0.06 for three consecutive results and got discharged so quick!
Thank you for your replies everyone.
Keep in mind that the finding of a positive troponin level, and the diagnosis of NSTEMI that is often incorrectly documented as a result of a positive troponin, has little meaning clinically. For instance, studies of marathon runners have found that more than half of marathoners will have a troponin level above the diagnostic cutoff, which means they've had NSTEMIs according to commonly used criteria, that doesn't mean they all need to be admitted to a hospital.
Also, even once the myocardial myocytes have stopped releasing above-normal levels of Tropnin I due to stress or ischemia the troponin will continue to circulate and therefore be detectable for many days.
Tourniquets don't effect cardiac-myocyte-specific troponin levels, I think you might be thinking of lactate levels, which are often suggested to be drawn without a tourniquet even though there is no evidence to support that and studies comparing lactates drawn with and without a tourniquet show no difference between the two.
Hmmm. This is thought provoking...so....to the library I went.
Yes, yes I was thinking lactate as well. But it's also shown in this study that prolonged tourniquet use effects troponins. Pulling trops from PIVs increases hemolysis as well.
Something else I came across--and I feel like such a stupid for not knowing all of this---but it's an interesting read nonetheless:
magellan
84 Posts
I went to the link above which you wanted me to see. And I found out with the readings above regarding this, "Cardiac troponin T and troponin I are cardiac regulatory proteins that control the calcium mediated interaction between actin and myosin."
Would you know what "myosin" is in the body. It is as I "As the most abundant of these proteins myosin plays a structural and enzymatic role in muscle contraction and intracellular motility. Myosin was first discovered in muscle in the 19th century." This is from https://proteopedia.org/wiki/index.php/Myosin
That's why if you read from all the suggestions regarding troponin in this website that nurses sees a lot of cases involving elevated troponin that has nothing to do with cardiac problems or issues.
If you want to diagnose that elevated troponin is really about cardiac related condition, you need more workups like EKG, Echo, vital signs especially BP measurements, physical assessment, history taking and some more to adequately diagnose it as such.