Clinical Cases: Elevations of hs-TnT in Non-cardiac Conditions

2 June 2021

Patient presented with non-specific symptoms such as dyspnea and tachycardia. After a prolonged flight, he had swelling of lower limb. He had h/o DVT 3 years back. Laboratory investigations revealed raised inflammatory markers. ECG showed a RBBB. hs TnT kinetic pattern showed a rise and fall within 48hours. Pulmonary imaging showed multiple thromboembolic events. Clinical context needs to be considered before reaching a diagnosis in this case.

It is not always possible to differentiate between acute myocardial infarction (except by definition in STEMI) and other diseases with acute cardiac involvement such as pulmonary embolism and ventricular tachyarrhythmias, which require the work-up of differential diagnoses.¹

Case 5

54-year-old man

Key signs and symptoms

Sudden dyspnoea, breathing-related flank pain, tachycardia

Medical history

Trip to Asia 7 days ago. Deep leg vein thrombosis 3 years ago

Clinical examination

Right lower leg swelling, tachycardia 102/min

Laboratory test results

Results		Reference range
CRP 10 mg/dL		<5 mg/dL
D-dimers 12,2 mg/dL		<0,5 mg/dL
Serum creatinine 0,9 mg/dL		<9 mg/dL
Leukocytes 11,2/nL		4.4 – 11.3/nL
NT-proBNP 750 ng/L		<300 ng/L to rule-out AHF and >900 ng/L HF likely if 50–75 year-old (confirmation with imaging)

ECG

Typical ECG changes with sinus tachycardia, SI-QIII type, right bundle-branch block

Electrocardiogram showing typical changes with sinus tachycardia, SI-QIII type, right bundle-branch block.

Troponin kinetic profile

Pulmonary imaging

Angiographic CT scan (256-slice CT) showing multiple thromboembolic events indicated by red arrows bilaterally.

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Diagnosis

Acute pulmonary embolism

This patient presents the typical clinical features and has an indicative history following a prolonged flight. Typical ECG changes with sinus tachycardia, SI-QIII type, right bundle-branch block are observed. The angiographic CT scan (256-slice CT) shows multiple thromboembolic events (red arrows) bilaterally. The cTnT-hs levels display an acute kinetic profile with a rapid rise followed by a fall. The clinical context is the key element to consider for a differential diagnosis of acute non-STEMI.