Clinical Case Database / Category: Case Based Discussion
Not all chest pain is cardiac, even when the troponin is high
Dr Alexandra CM Thompson, Dr Ashfaq Mohammed, Prof. Jerry Murphy
Foundation Years Journal, volume 8, issue 2, p.42 (123Doc Education, London, February 2014)
A 64 year old man presents with central chest heaviness, dyspnoea with a positive troponin and is diagnosed with a myocardial infarction. This scenario is encountered frequently on the acute medical take but differentiating acute coronary syndromes from other causes of chest pain is not always straight forward. This article provides an overview of the case and investigations and reviews the reasons for troponin elevation and the pitfalls of assuming that this always represents myocardial infarction.
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Dr Alexandra CM Thompson
Senior Trust Cardiology Research Fellow, Darlington Memorial Hospital
Dr Ashfaq Mohammed
ST3 Cardiology Trainee, Darlington Memorial Hospital
Prof. Jerry Murphy
Hon. Prof. of Cardiovascular Medicine
Consultant Cardiologist, Darlington Memorial Hospital
1. National Institute for Health and Clinical Excellence (NICE) clinical guideline 95. Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin, 2010. http://guidance.nice.org.uk/CG95/NICEGuidance/pdf/English
2. Thygesen K, Alpert JS, White HD, as part of the Joint ESC/ACCF/AHA/WHF Task Force for the
Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Eur Heart J 2012, 33:2551â€“67.
3. Wong P, Murray S, Ramsewak A, et al. Raised cardiac troponin T levels in patients without acute coronary syndrome. Postgrad Med J 2007, 83:200-05.
4. Alcalai R, Planer D, Culhaoglu A, et al. Acute coronary syndrome vs nonspecific troponin elevation: clinical predictors and survival analysis. Arch Intern Med 2007, 167(3):276-81.
5. Blich M, Sebbag A, Attias J, et al. Cardiac troponin I elevation in hospitalized patients without acute coronary syndromes. Am J Cardiol 2008, 101:1384-88.
6. Ilva TJ, Eskola MJ, Nikus KC, et al. The etiology and prognostic significance of cardiac troponin I elevation in unselected emergency department patients. J Emerg Med 2010, 38:1-5.
7. Torbicki A, Perrier A, Konstantinides S, as part of The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2008, 29: 2276â€“2315.
8. Agewall S, Giannitsis E, Jernberg T, et al. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J 2011, 32:404-11.
9. Jacobs LH, van de Kerkhof J, Mingels AM, et al. Haemodialysis patients longitudinally assessed by highly sensitive cardiac troponin T and commercial cardiac troponin T and cardiac troponin I assays. Ann Clin Biochem 2009, 46:283-90.
10. PiÃ©rard LA, Lancellotti P, et al. Echocardiography in the emergency room. Heart 2009,95:164-170.
11. McConnell MV, Solomon SD, Rayan ME, et al. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996,78:469â€“473.
12. Kurzyna M, Torbicki A, Pruszczyk P, et al. Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism. Am J Cardiol 2002, 90:507â€“511.
13. Gallagher S, Jones DA, Anand V, et al. Diagnosis and management of patients with acute cardiac symptoms, troponin elevation and culprit-free angiograms. Heart 2012, 98:974-981.
14. Assomull RG, Lyne JC, Keenen N, et al. The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed arteries. Eur Heart J 2007,28:1242-49.
15. Chopard R, Jehl J, Dutheil J, et al. Evolution of acute coronary syndrome with normal coronary arteries and normal cardiac magnetic resonance imaging. Arch Cardiovasc Dis 2011,104:509-517.
16. Gerbaud E, Harcaut E, Coste P, et al. Cardiac magnetic resonance imaging for the diagnosis of patients presenting with chest pain, raised troponin, and unobstructed coronary arteries. Int J
Cardiovasc Imaging 2012,28:783-94
17. Leurent G, Langella B, Fougerou C, et al. Diagnostic contributions of cardiac magnetic resonance imaging in patients presenting with elevated troponin, acute chest pain syndrome and unobstructed coronary arteries. Arch Cardiovasc Dis 2011,104:161-70.
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