Dr Lee 임상 사례: hs-TnT 만성 상승 non-AMI-AMI 케이스들

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Case Study: 70-year old womanCase Study: 13-year male adolescentCase Study: 82-year woman

Case   70-year old woman

Key signs and symptoms   Progressive orthopnea and exertional dyspnea for 4 days, associated with chest tightness and palpitation.

Medical history/ Clinical examination   Medical history: Congestive heart failure, valvular heart disease, and third degree atrioventricular block, status post permanent pacemaker implantation. Clinical examination: BP 106/69mmHg, HR 106 BPM, RR 26BPM, temperature 36.7C, oxygen saturation 97%, Glasgow coma scale 15.

Laboratory test results   Test   Value   Reference range WBC (x103/μL)   6.05   3.54 – 9.06 Hemoglobin (g/dL)   12.1   10.8 – 14.9 NT-proBNP (pg/mL)   3319   Rule out of acute heart failure (AHF): <300 pg/mL Rule in AHF: < 50 years: >450 pg/mL 50 – 75 years: >900 pg/mL >75 years: >1800 pg/mL

ECG Atrial fibrillation with rapid ventricular response; nonspecific ST and T wave abnormality

Troponin kinetic profile

Chest X-ray

9 Prof Lee's Clinical Case - 6 What is the diagnosis of this case? Takotsubo syndrome Pulmonary embolism Acute Decompensated Heart Failure Tachyarrhythmias

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Diagnosis

1. Acute decompensated heart failure

2. Chronic heart failure

3. Atrial fibrillation with rapid ventricular

The reason to rule out MI:

• Although the hs-cTnT level was higher than the 99th percentile cutoff (14 ng/L), serial measurement did not disclose an significant kinetic change higher than 20%, acute myocardial infarction can be excluded

Author’s opinion

• Acute heart failure is a common cause for troponin elevation. Serial measurement with an significant kinetic change would help rule in or rule out MI.

• In addition, measurement of troponin is recommended as an initial laboratory test in patients presenting with suspected acute heart failure to investigate the trigger of acute heart failure. Potential trigger include: ACS (acute coronary syndrome), hypertension, atrial fibrillation, mechanical reasons such as aortic valve stenosis, pneumonia or pulmonary embolism. Highly elevated cTnT-hs or relevant rising values increase the probability for myocardial ischemia/NSTEMI as the relevant trigger.

Case   13-year male adolescent

Key signs and symptoms   Chest pain located at the central chest. The pain was diffuse and persistent for 2-3 hours without radiation.

Medical history/ Clinical examination   Medical history: Past history of chest pain and asthma. Clinical examination: BP 129/87mmHg, HR 81 BPM, RR 20 BPM, temperature 36C, oxygen saturation 97%, Glasgow coma scale 15.

Laboratory test results   Test   Value   Reference range WBC (x103 /μL)   12.65   3.54 – 9.06 Segmented neutrophil (%)   83.2   50 – 70 Hemoglobin (g/dL)   14.1   10.8 – 14.9 CRP (mg/dL)   11.27   <1 Creatinine clearance (ml/min)   143   90 – 139

ECG at admission Concave ST elevation at lead II, III, aVF

Subsequent ECG Evolutionary changes with normalisation of ST elevation and diffuse T-wave inversion

Troponin kinetic profile

Chest X-ray

Echocardiography

Normal LV size and function; no pericardial effusion

1 Prof Lee's Clinical Case - 8 What is the diagnosis of this case? Unstable Angina STEMI Non Cardiac Chest pain Acute perimyocarditis

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Diagnosis

Suspected acute perimyocarditis

• First ECG showed concave ST elevation at lead II, III, aVF. Subsequent ECG showed evolutionary changes with normalisation of ST elevation and diffuse T-wave inversion. • Troponins does not follow the kinetics of peak and fall commonly seen in patients with MI. • Symptoms quickly subside after NSAID (nonsteroidal anti-inflammatory drugs) treatment.

Author’s opinion

• Pericarditis and myocarditis are characterized by ECG changes and elevated cardiac enzymes, respectively, and patients with perimyocarditis often complain of chest discomfort. • These findings are nonspecific and often lead to diagnostic difficulties, as ST-elevation myocardial infarction commonly presents in a similar fashion. • Perimyocarditis usually manifest with concave ST elevations, which did not conform to a particular coronary artery territory. • In this case, the ECG change was limited to inferior lead. However, due to the benign course with no known risk factors, acute perimyocarditis is most likely the diagnosis.

Case   82-year woman

Key signs and symptoms   Fever and fank pain.

Medical history/ Clinical examination   Medical history: Stroke, hypertension and parkinsonism. Clinical examination: BP 172/89mmHg, HR 88BPM, RR 20BPM, temperature 38.6C, oxygen saturation 93%, Glasgow coma scale 15.

Laboratory test results   Test   Value   Reference range WBC (x103/μL)   16.34   3.54 – 9.06 Segmented neutrophil (%)   89.2   50 – 70 Hemoglobin (g/dL)   14.2   10.8 – 14.9 CRP (mg/dL)   3.20   <1 Creatinine clearance (ml/min)   101.7   90 – 139 NT-proBNP (pg/mL)   240   Rule out of acute heart failure (AHF): <300 pg/mL Rule in AHF: < 50 years: >450 pg/mL 50 – 75 years: >900 pg/mL >75 years: >1800 pg/mL

ECG ST depressed in lateral leads

Troponin kinetic profile

Chest X-ray

1 Prof Lee's Clinical Case - 9 What is the diagnosis of this case? Urinary Tract Infection Pulmonary embolism Takotsubo syndrome Tachyarrhythmias

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Diagnosis

Urinary tract infection

• The mild rise and fall of cardiac troponin with lateral lead ST-depression does not favor a occlusive coronary pathology.

Author’s opinion

• This is a case with troponin elevation with relevant changes but without clear clinical context of ischemia. Troponin elevation is compatible with severe infection or sepsis.