What should you call that elevated troponin?
This is NOT taught well and impacts more than you think.
Understand it in 2 minutes:
This is NOT taught well and impacts more than you think.
Understand it in 2 minutes:
The problem?
π Most don't understand how to interpret troponins
π Most don't understand the actual definition of an infarction
π Proper diagnosis (& documentation) β‘οΈ impacts clinical decisions and quality metrics
Let's dig in ‡οΈ
π Most don't understand how to interpret troponins
π Most don't understand the actual definition of an infarction
π Proper diagnosis (& documentation) β‘οΈ impacts clinical decisions and quality metrics
Let's dig in ‡οΈ
First, pay close attention to the three I-words:
1οΈβ£ Injury
2οΈβ£ Ischemia
3οΈβ£ Infarction
They have three distinct meanings and easy to get them mixed up.
1οΈβ£ Injury
2οΈβ£ Ischemia
3οΈβ£ Infarction
They have three distinct meanings and easy to get them mixed up.
Two things must be present for an acute Myocardial INFARCTION
1οΈβ£ Acute myocardial INJURY
2οΈβ£ ISCHEMIC Signs OR symptoms
(notice the *OR* here)
Let's break those down.
First, myocardial injury...
1οΈβ£ Acute myocardial INJURY
2οΈβ£ ISCHEMIC Signs OR symptoms
(notice the *OR* here)
Let's break those down.
First, myocardial injury...
1 / What is INJURY?
A fluctuation of troponins by 20%. Whether this be:
π A rise of 20% (with at least one elevated or
π A fall of 20% if initial was elevated
What if elevated but does not change by 20%? Will answer this later.
Next, ischemia...
A fluctuation of troponins by 20%. Whether this be:
π A rise of 20% (with at least one elevated or
π A fall of 20% if initial was elevated
What if elevated but does not change by 20%? Will answer this later.
Next, ischemia...
2 / What are ISCHEMIC Signs & symptoms?
Symptoms
π Angina
π Anginal Equivalents (SOB, diaphoresis, nausea, lightheadedness)
π Syncope
π Flash pulmonary edema
π Palpations
π Cardiac arrest
and signs?...
Symptoms
π Angina
π Anginal Equivalents (SOB, diaphoresis, nausea, lightheadedness)
π Syncope
π Flash pulmonary edema
π Palpations
π Cardiac arrest
and signs?...
Signs
π ST elevation or depression
π New flipped T wave
π New LBBB
π New pathological Q waves
π NM stress with new loss of viable myocardium (NOT scar)
π New ventricular wall motion abnormality
π Identification of coronary thrombus on LHC or autopsy
π ST elevation or depression
π New flipped T wave
π New LBBB
π New pathological Q waves
π NM stress with new loss of viable myocardium (NOT scar)
π New ventricular wall motion abnormality
π Identification of coronary thrombus on LHC or autopsy
3 / What are the types of INFARCTions?
Type 1 (STEMI vs NSTEMI)
π Acute coronary artery occlusion due to plaque disruption
π Treatment β‘οΈ dissolve clot / open blockage
(Reminder: Must have Injury + Ischemic signs or symptoms)
Type 1 (STEMI vs NSTEMI)
π Acute coronary artery occlusion due to plaque disruption
π Treatment β‘οΈ dissolve clot / open blockage
(Reminder: Must have Injury + Ischemic signs or symptoms)
Type 2 (NSTEMI)
π Imbalance between myocardial oxygen supply and/or demand results in INFARCTion
π Treatment β‘οΈ relieve demand / non-CAD factors
(Reminder: Must have Injury + Ischemic signs or symptoms)
π Imbalance between myocardial oxygen supply and/or demand results in INFARCTion
π Treatment β‘οΈ relieve demand / non-CAD factors
(Reminder: Must have Injury + Ischemic signs or symptoms)
Other types of infarctions:
Type 3 = Sudden death without biomarkers
Type 4a = PCI related AMI
Type 4b = Due to stent thrombosis
Type 4c = Stent re-stenosis
TYpe 5 = CABG related.
Won't go into detail about these.
Type 3 = Sudden death without biomarkers
Type 4a = PCI related AMI
Type 4b = Due to stent thrombosis
Type 4c = Stent re-stenosis
TYpe 5 = CABG related.
Won't go into detail about these.
4 / What about elevated troponins alone?
That is myocardial INJURY w/o ischemia (thus not infarction)
π 20% rise / fall? = Acute Injury
Ex: Acute CHF, myocarditis, etc.
π No 20% rise / fall? = Chronic injury
Ex: CKD, structural heart disease, etc.
Your "troponin leaks"
That is myocardial INJURY w/o ischemia (thus not infarction)
π 20% rise / fall? = Acute Injury
Ex: Acute CHF, myocarditis, etc.
π No 20% rise / fall? = Chronic injury
Ex: CKD, structural heart disease, etc.
Your "troponin leaks"
5 / What is Demand Ischemia?!
This DOES NOT exist in the 4th universal definition of MI.
but it does in coding.
Guidance is unclear & conflicting.
Use this if:
π Have a setting of supply / demand mismatch
π But have ischemia WITHOUT injury (but not both bc then = T2 NSTEMI)
This DOES NOT exist in the 4th universal definition of MI.
but it does in coding.
Guidance is unclear & conflicting.
Use this if:
π Have a setting of supply / demand mismatch
π But have ischemia WITHOUT injury (but not both bc then = T2 NSTEMI)
In summary:
1οΈβ£ Myocardial Injury = 20% change of elevated troponins
2οΈβ£ Infarct = Injury + Ischeimic signs *OR* symptoms
3οΈβ£ Troponemia, troponin leak, troponitis, & Elevated troponin are not diagnoses.
4οΈβ£ Demand ischemia = ischemia without injury
1οΈβ£ Myocardial Injury = 20% change of elevated troponins
2οΈβ£ Infarct = Injury + Ischeimic signs *OR* symptoms
3οΈβ£ Troponemia, troponin leak, troponitis, & Elevated troponin are not diagnoses.
4οΈβ£ Demand ischemia = ischemia without injury
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