1. Hypertroponinaemia Michael Stewart CT1 ACCS

2. Case 1 64 year old male 64 year old male Known history of IHD – 2x NSTEMI, UA Known history of IHD – 2x NSTEMI, UA Two hours of central chest pain, identical to previous MI Two hours of central chest pain, identical to previous MI ECG: Lateral ST depression ECG: Lateral ST depression Trop T 0.07 Trop T 0.07

3. Case 2 72 year old male 72 year old male Presents with three hours central chest pain, onset during dancing Presents with three hours central chest pain, onset during dancing Nausea, mildly dyspnoeic Nausea, mildly dyspnoeic Ex-smoker; hypertensive Ex-smoker; hypertensive Not diabetic, no FH of IHD Not diabetic, no FH of IHD

4. Case 2 ECG shows dynamic inferior ST depression ECG shows dynamic inferior ST depression Pain eased after IV GTN and morphine with resolution of ECG changes Pain eased after IV GTN and morphine with resolution of ECG changes Troponin 0.56 Troponin 0.56

5. Case 3 62 year old female 62 year old female Onset of palpitations and dyspnoea on waking Onset of palpitations and dyspnoea on waking GP found irregular pulse, rate ~160 GP found irregular pulse, rate ~160

6. Case 3 Hypertensive; no other significant co-morbidity Hypertensive; no other significant co-morbidity ECG: Fast AF, rate ~170 ECG: Fast AF, rate ~170 BP 100/60 BP 100/60 Pale, clammy, drowsy Pale, clammy, drowsy DC Cardioversion – SR restored DC Cardioversion – SR restored Troponin 0.13 Troponin 0.13

7. Troponin Component of cardiac and striated muscle Component of cardiac and striated muscle Calcium binding initiates conformational change to permit myosin to bind to actin filament Calcium binding initiates conformational change to permit myosin to bind to actin filament Myosin conformational cycling on actin acts as ‘molecular motor’ for muscle contraction Myosin conformational cycling on actin acts as ‘molecular motor’ for muscle contraction Cardiac Troponins are specific for cardiac myocyte damage Cardiac Troponins are specific for cardiac myocyte damage Troponin is NOT specific for myocardial infarction Troponin is NOT specific for myocardial infarction

8. PICI/SICI/NICI Primary Ischaemic Cardiac Injury Primary Ischaemic Cardiac Injury Secondary Ischaemic Cardiac Injury Secondary Ischaemic Cardiac Injury Non-Ischaemic Cardiac Injury Non-Ischaemic Cardiac Injury

10. PICI Coronary artery occlusion/stenosis by thrombotic disease Coronary artery occlusion/stenosis by thrombotic disease STEMI/NSTEMI STEMI/NSTEMI

11. NSTEMI Any two of: Any two of: Typical chest pain Typical chest pain Typical ECG changes Typical ECG changes Rise in cardiac enzymes Rise in cardiac enzymes New definition!

12. 2007 Universal Definition Troponin > 99 th centile of reference range (Locally agreed at Trop T > 0.1) (Locally agreed at Trop T > 0.1)PLUS: Ischaemic symptoms Ischaemic symptoms ECG changes ECG changes Regional wall motion abnormality Regional wall motion abnormality Loss of viable myocardium on imaging Loss of viable myocardium on imaging

14. SICI Secondary cause of coronary artery obstruction Secondary cause of coronary artery obstruction Embolic disease; during PCI; during CABG Embolic disease; during PCI; during CABG Coronary vasospasm or inflammation Coronary vasospasm or inflammation Primary; vasculitides; SLE Primary; vasculitides; SLE Increased myocardial oxygen demand Increased myocardial oxygen demand Tachyarrythmias; prolonged exercise; sympathomimetic drugs; heart failure; PE Tachyarrythmias; prolonged exercise; sympathomimetic drugs; heart failure; PE

16. NICI Direct trauma Direct trauma Penetrating; blunt; surgical Penetrating; blunt; surgical Myocarditis Myocarditis Infectious; auto-immune; drug/alcohol; inflammatory Infectious; auto-immune; drug/alcohol; inflammatory Metabolic Metabolic Renal failure; multiple organ failure; sepsis Renal failure; multiple organ failure; sepsis

17. Cases Case 1: Typical chest pain, Trop T 0.07 Case 1: Typical chest pain, Trop T 0.07 PICI, not criteria for NSTEMI PICI, not criteria for NSTEMI Case 2: Typical chest pain, Trop T 0.56 Case 2: Typical chest pain, Trop T 0.56 NSTEMI NSTEMI Case 3: Fast AF, no pain, Trop T 0.13 Case 3: Fast AF, no pain, Trop T 0.13 SICI ( + NICI ) SICI ( + NICI )

18. Questions?

19. Summary Troponins are a sensitive marker of cardiac myocyte damage Troponins are a sensitive marker of cardiac myocyte damage Not all cardiac myocyte damage represents acute myocardial infarction Not all cardiac myocyte damage represents acute myocardial infarction Primary, secondary, and non-ischaemic causes exist Primary, secondary, and non-ischaemic causes exist

20. References Thygesen, Kristian, Alpert, Joseph S., White, Harvey D., on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction, Universal Definition of Myocardial Infarction Thygesen, Kristian, Alpert, Joseph S., White, Harvey D., on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction, Universal Definition of Myocardial Infarction J Am Coll Cardiol 2007 50: 2173-2195 Collinson, P O, Stubbs, P J Are troponins confusing? Heart 2003 89: 1285-1287 Collinson, P O, Stubbs, P J Are troponins confusing? Heart 2003 89: 1285-1287 http://www.trauma.org http://www.trauma.org