Deputy Director of Intelligent Healthcare and Professor of Emergency Medicine, National Taiwan University Hospital, Taiwan
Home > Education & CME > Dr Lee’s Clinical Cases: hs-TnT Chronic Elevation non-AMI cases
Dr Lee’s Clinical Cases: hs-TnT Chronic Elevation non-AMI cases
21 April 2021
Review the clinical case details and select the most probable diagnosis below. More information on the diagnosis and Dr Lee’s opinion can be seen by clicking on the “Click to review the answer” button.
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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
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
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
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.
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