appropriate use and interpretation of cardiac...

Appropriate Use and Interpretation of Cardiac Biomarkers

Dr. Vikas TandonAssociate Professor, Cardiology

McMaster UniversityNovember 1, 2017

Canadian Society of Internal MedicineAnnual Meeting 2017

Toronto, ON

CSIM Annual Meeting 2017Conflict Disclosures

I have the following conflicts to declare:

Company/Organization Details

Advisory Board or equivalent X X

Speakers bureau member X X

Payment from a commercial organization. (including gifts or other consideration or ‘in kind’ compensation)

X X

Grant(s) or an honorarium X X

Patent for a product referred to or marketed by a commercial organization. X X

Investments in a pharmaceutical organization, medical devices company or communications firm.

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Participating or participated in a clinical trial McMaster University Participated in periop research studies

including VISION, POISE-2, MANAGE

CSIM Annual Meeting 2017

The following presentation represents the views of the speakerat the time of the presentation. This information is meant foreducational purposes, and should not replace other sources

of information or your medical judgment.

Learning Objectives:• Develop an approach to managing patients elevated troponins who present with non-coronary presentations • Develop short- and long-term management plans for patients with post-operative troponin elevations • Understand the indications for ordering a BNP in acute medical patients and interpret results

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• Biomarkers are commonly used in medical patients as a means to diagnosis and prognosis

• Biomarkers very sensitive but not necessarily specific for any one particular disease process

• Interpretation can sometimes be challenging thus requiring an organized approach

Scope of problem

• 66 F presents with 8/10 RSCP, diaphoresis, palpitations• Baseline ECG shows rapid atrial fibrillation on admission

• Cardiac RF – DM, HTN, dyslipidemia, remote smoker• Meds: ASA 81 mg, Rosuvastatin 10 mg, Perindopril 8 mg,

Metoprolol 50 mg BID

• O/E – HR 120-140 bpm, BP 130/78; otherwise normal• hs-trop I 620 (peak)

Case 1

12 Lead

1. Normal coronaries

2. Mild atherosclerotic plaque with no significant stenosis

3. Single vessel disease

4. Multivessel disease

This patient has:

• 50 F presents with 2 day history of headaches, chest and back pain lasting hours at a time

• Cardiac RF – HTN, current smoker (30 pack year history)

• O/E – Hypertensive urgency with BP 200/118 on admission, HR 67; symptoms resolved when normotensive in hospital

• hs-trop I 68 (peak)

Case 2

12 Lead





This patient has:

• 58 F presents with bright red blood per rectum, known history of Ulcerative Colitis

• Cardiac RF – HTN, 40 pack year smoking history (recently quit)

• No cardiac symptoms. O/E – HR 110-120, BP 130/78

• hs-trop I 108 (peak), Hb 118 (stable)

Case 3

12 Lead





This patient has:

The cases thus far:Case 1 Case 2 Case 3

66 F w 8/10 RSCPrapid A Fib 120-140

50 F headaches, CP and back pain lasting hoursHTN urgency: BP 200/118

58 F bright red blood per rectum; known UC

DM, HTN, Chol, remote smoker (5 pack yr history)

HTN, current smoker (30 pack year history)

HTN, recent smoker (40 pack year history)

Peak trops = 620 Peak trops = 68 Peak trops = 108

The cases thus far:Case 1 Case 2 Case 3

66 F w 8/10 RSCPrapid A Fib 120-140

50 F headaches, CP and back pain lasting hoursHTN urgency: BP 200/118

58 F bright red blood per rectum; known UC

DM, HTN, Chol, remote smoker (5 pack yr history)

HTN, current smoker (30 pack year history)

HTN, recent smoker (40 pack year history)

Peak trops = 620 Peak trops = 68 Peak trops = 108

Cath: Mild plaque No significant stenosis

Cath: 90% stenosis ostialRCA; mild dz LAD/LCX

Cardiac CT: Normal coronaries

• The size of the troponin elevation does not correlate with extent of coronary disease

But

• The rise of the troponin does indicate poorer outcome in patients compared to normal troponin counterparts

Concept

Ostermann et al. Critical Care 2014

Lim et al, Arch Intern Med 2006

Other Medical Conditions

Condition Hazard Ratio

Critical Illness OR 2.5 for all cause mortality

Chronic Kidney Disease Trop T adjusted HR = 3Trop I adjusted HR = 2.7

Pulmonary Embolism OR 4.8 for all cause mortality

The Importance of Myocardial Injury

Devereaux, JAMA, 2012

Approach• Look for and correct physiological abnormalities

– hypoxia, hypotension, tachycardia (if BP adequate), Hb if <70, sepsis, PE

• If no signs of bleeding initiate ASA 81 mg daily

• Initiate or intensify Statin therapy

• Inpatient vs. outpatient risk stratification and follow up

CASE 4: Postoperative troponin monitoring

• 64 y/o male • Postop day 3 orthopedic surgery• No symptoms, trop 0.15 (0.04 ULN)• EKG: Anterior biphasic T waves • Cath/OCT - 3 days after trop increase



3. Single vessel disease with plaque rupture/thrombus

4. Single vessel disease but no thrombus/stable plaque

This patient has:

CASE 5: Perioperative Myocardial Infarction

• 83 y/o male • Postop day 5 orthopedic surgery• Sudden chest pain trop 9.85 (0.04 ULN), • EKG: No acute changes • Cath/OCT - 2 days after trop increase



3. Single vessel disease with plaque rupture/thrombus

4. Single vessel disease but no thrombus/stable plaque

This patient has:

Summary of Cases 4 and 5Case 4 Case 5

64 year old male 83 year old male

POD 3 orthopedic surgery POD 5 orthopedic surgery

No symptoms, trop 0.15 (ULN 0.04) Sudden chest pain, trops 9.85 (ULN 0.04)

Biphasic T waves anterior leads No acute ECG changes

Case 4 Cath Findings

Case 4 OCT findings

PCI with BMS, Dual antiplatelet therapy with ASA and Plavix for 1 year

Uncomplicated course at 1 year

CASE 5: Perioperative Myocardial Infarction

• 83 y/o male • Postop day 5 orthopedic surgery• Sudden chest pain trop 9.85 (0.04 ULN), • EKG: No acute changes • Cath/OCT - 2 days after trop increase

Case 5 Cath Findings

Moderate LAD stenosis Distal LCX stenosis >80% in small vessel

Normal LV function

Case 5 OCT findings

PCI with BMS 3.5 mm

Dual antiplatelet therapy x 12 months

Uncomplicated course at 30 days






Plaque rupture and thrombus - LAD Significant stenosis RCA but no plaque rupture

• The size of the troponin elevation does not correlate pathophysiology– i.e. cannot distinguish between plaque rupture vs.

supply demand

• Presence or absence of symptoms not helpful in determining pathophysiology– Further, no significant difference in mortality

outcomes

Concept

MINS that probably will go undetected without trop monitoring

• MINS without chest discomfort, other possible symptoms (i.e., arm, neck, or jaw discomfort, shortness of breath), or pulmonary edema

• 84.2%

MINS – High Sensitivity Assay

• Among 3904 patients who had MINS

• 93.1% did not experience an ischemic symptom

• 21.7% fulfilled universal definition of MI – elevated hsTnT with ≥1 ischemic feature

• Thus, troponin screening is the most effective way to screen for cardiac complications

Approach to MINS• Look for and correct physiological

abnormalities – hypoxia, hypotension, tachycardia (if BP adequate),

Hb if <70

• If no signs of bleeding initiate ASA 81 mg daily

• Initiate or intensify Statin therapy

BNP/nt-pro BNP

• Usage in diagnosis of CHF vs. Resp cause

• Usage in prognosis of CHF and acute decomp

• Usage in periop risk stratification

Case 6

• 67 M seen in preop for bariatric surgery• Cardiac RF: DM, HTN, remote smoker• Other PMHX: prev colon ca, OSA, GERD,

migraines• Meds: Rosuvastatin, Ramipril, Metformin,

Empagliflozin• “Asymptomatic” but nt-pro BNP = 219

Nuclear Perfusion StudyNo Persantine ECG changes

Nuclear Perfusion Study

Nuclear Perfusion – PET/CT

Concept

• For the vast majority of patients pre-op BNP/nt-pro BNP will filter out low risk patients

• Need for a patient centred approach when the nt-pro BNP is abnormal– Symptoms– Urgency of surgery– Awareness of risk involved– Patient preferences

Summary

• Patients with troponin elevation are prognostically at higher risk of death at 180-365 days compared to their normal trop counterparts– Critical care, PE, CKD, Periop literature

• Approach includes treating the underlying medical condition– Initiating basic cardiovascular therapies such as ASA, statins– In/Outpatient risk stratification plan and followup

• While for the vast majority, BNP/NT-proBNP will clear people into lower risk categories– Need a patient centred approach for when abnormal– Patient symptoms, urgency of surgery, risk involved, pt preferences

CSIM Annual Meeting 2017

Special thanks to Dr. PJ Devereaux• Scientific Leader, Perioperative Research

Group, PHRI, McMaster University• VISION, POISE 1, POISE 2• MANAGE, HIP ATTACK, VISION 2, POISE 3

• Co-Chair, CCS Perioperative Guidelines

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