Dr Lee Chien-Chang
Deputy Director of Intelligent Healthcare and Professor of Emergency Medicine, National Taiwan University Hospital, Taiwan
 

Dr Lee’s Clinical Cases: hs-TnT Chronic Elevation non-AMI cases

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
  ECG showing Atrial fibrillation with rapid ventricular response; nonspecific ST and T wave abnormality.
 
Troponin kinetic profile   Troponin kinetic profile showing increase in cTnT-hs level from 19.43 ng/L at T0 to 21.19 ng/L at T6 to 22.95 ng/L at T27.
 
Chest X-ray
 
Chest x-ray. Text on tip right reads: "L89"
 
9
Prof Lee's Clinical Case - 6

What is the diagnosis of this case?

 
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
  ECG at admission showing concave ST elevation at lead II, III, aVF.
 
Subsequent
ECG

Evolutionary changes with normalisation of ST elevation and diffuse T-wave inversion
  Subsequent ECG showing evolutionary changes with normalization of ST elevation and diffuse T-wave inversion.
 
Troponin kinetic profile   Troponin kinetic profile with fluctuating cTnT-hs levels between 349.9 ng/L and 831.7 ng/L between T0 to T84 after admission. Lowest level of cTnT-hs occurs during T0, and highest level occurs during T36.
 
Chest X-ray
 
Chest X-ray
 
Echocardiography
Normal LV size and function; no pericardial effusion
 
Echocardiography showing normal LV size and function and no pericardial effusion.
 
1
Prof Lee's Clinical Case - 8

What is the diagnosis of this case?

 

 
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
  ECG showing ST depressed in lateral leads.
 
Troponin kinetic profile   Troponin Kinetic Profile showing rise in cTnT-hs level from 8.93 ng/L at T0 after admission to 117 ng/L at T18. After T18, there is a decrease in cTnT-hs levels to 42.07 ng/L at T45.
 
Chest X-ray
 
Sitting chest X-ray
 
1
Prof Lee's Clinical Case - 9

What is the diagnosis of this case?

 
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.
 
 

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