Case 1Case 1
64 year old male64 year old male Known history of IHD – 2x NSTEMI, Known history of IHD – 2x NSTEMI,
UAUA Two hours of central chest pain, Two hours of central chest pain,
identical to previous MIidentical to previous MI ECG: Lateral ST depressionECG: Lateral ST depression Trop T 0.07Trop T 0.07
Case 2Case 2
72 year old male72 year old male Presents with three hours central Presents with three hours central
chest pain, onset during dancingchest pain, onset during dancing Nausea, mildly dyspnoeicNausea, mildly dyspnoeic Ex-smoker; hypertensiveEx-smoker; hypertensive Not diabetic, no FH of IHDNot diabetic, no FH of IHD
Case 2Case 2
ECG shows dynamic inferior ST ECG shows dynamic inferior ST depressiondepression
Pain eased after IV GTN and Pain eased after IV GTN and morphine with resolution of ECG morphine with resolution of ECG changeschanges
Troponin 0.56Troponin 0.56
Case 3Case 3
62 year old female62 year old female Onset of palpitations and dyspnoea Onset of palpitations and dyspnoea
on wakingon waking GP found irregular pulse, rate ~160GP found irregular pulse, rate ~160
Case 3Case 3
Hypertensive; no other significant Hypertensive; no other significant co-morbidityco-morbidity
ECG: Fast AF, rate ~170ECG: Fast AF, rate ~170 BP 100/60BP 100/60 Pale, clammy, drowsyPale, clammy, drowsy DC Cardioversion – SR restoredDC Cardioversion – SR restored Troponin 0.13Troponin 0.13
TroponinTroponin
Component of cardiac and striated muscleComponent of cardiac and striated muscle Calcium binding initiates conformational Calcium binding initiates conformational
change to permit myosin to bind to actin change to permit myosin to bind to actin filamentfilament
Myosin conformational cycling on actin Myosin conformational cycling on actin acts as ‘molecular motor’ for muscle acts as ‘molecular motor’ for muscle contractioncontraction
Cardiac Troponins are specific for cardiac Cardiac Troponins are specific for cardiac myocyte damagemyocyte damage
Troponin is NOT specific for myocardial Troponin is NOT specific for myocardial infarctioninfarction
PICI/SICI/NICIPICI/SICI/NICI
Primary Ischaemic Cardiac InjuryPrimary Ischaemic Cardiac Injury
Secondary Ischaemic Cardiac InjurySecondary Ischaemic Cardiac Injury
Non-Ischaemic Cardiac InjuryNon-Ischaemic Cardiac Injury
PICIPICI
Coronary artery occlusion/stenosis Coronary artery occlusion/stenosis by thrombotic diseaseby thrombotic disease
STEMI/NSTEMISTEMI/NSTEMI
NSTEMINSTEMI
Any two of:Any two of: Typical chest painTypical chest pain Typical ECG changesTypical ECG changes Rise in cardiac enzymesRise in cardiac enzymes
New definition!New definition!
2007 Universal Definition2007 Universal Definition
Troponin > 99Troponin > 99thth centile of reference centile of reference rangerange (Locally agreed at Trop T > 0.1)(Locally agreed at Trop T > 0.1)
PLUS:PLUS: Ischaemic symptomsIschaemic symptoms ECG changesECG changes Regional wall motion abnormalityRegional wall motion abnormality Loss of viable myocardium on imagingLoss of viable myocardium on imaging
SICISICI
Secondary cause of coronary artery Secondary cause of coronary artery obstructionobstruction Embolic disease; during PCI; during Embolic disease; during PCI; during
CABGCABG Coronary vasospasm or inflammationCoronary vasospasm or inflammation
Primary; vasculitides; SLEPrimary; vasculitides; SLE Increased myocardial oxygen demandIncreased myocardial oxygen demand
Tachyarrythmias; prolonged exercise; Tachyarrythmias; prolonged exercise; sympathomimetic drugs; heart failure; PEsympathomimetic drugs; heart failure; PE
NICINICI
Direct traumaDirect trauma Penetrating; blunt; surgicalPenetrating; blunt; surgical
MyocarditisMyocarditis Infectious; auto-immune; drug/alcohol; Infectious; auto-immune; drug/alcohol;
inflammatoryinflammatory MetabolicMetabolic
Renal failure; multiple organ failure; Renal failure; multiple organ failure; sepsissepsis
CasesCases
Case 1: Typical chest pain, Trop T Case 1: Typical chest pain, Trop T 0.070.07 PICI, not criteria for NSTEMIPICI, not criteria for NSTEMI
Case 2: Typical chest pain, Trop T Case 2: Typical chest pain, Trop T 0.560.56 NSTEMINSTEMI
Case 3: Fast AF, no pain, Trop T 0.13Case 3: Fast AF, no pain, Trop T 0.13 SICI ( + NICI )SICI ( + NICI )
SummarySummary
Troponins are a sensitive marker of Troponins are a sensitive marker of cardiac myocyte damagecardiac myocyte damage
Not all cardiac myocyte damage Not all cardiac myocyte damage represents acute myocardial represents acute myocardial infarctioninfarction
Primary, secondary, and non-Primary, secondary, and non-ischaemic causes existischaemic causes exist
ReferencesReferences Thygesen, Kristian, Alpert, Joseph S., White, Harvey D., on behalf Thygesen, Kristian, Alpert, Joseph S., White, Harvey D., on behalf
of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction, of Myocardial Infarction, Universal Definition of Myocardial InfarctionUniversal Definition of Myocardial InfarctionJ Am Coll Cardiol 2007 50: 2173-2195J Am Coll Cardiol 2007 50: 2173-2195
Collinson, P O, Stubbs, P JCollinson, P O, Stubbs, P J
Are troponins confusing?Are troponins confusing?Heart 2003 89: 1285-1287Heart 2003 89: 1285-1287
http://www.trauma.org http://www.trauma.org
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