Clinical significance of elevated troponin I levels in patients with nontraumatic subarachnoid hemorrhage

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Object. Aneurysmal subarachnoid hemorrhage (SAH) is associated with electrocardiographic abnormalities, regional or focal wall-motion abnormalities on echocardiograms, and/or increased creatine kinase MB isoenzyme (CK-MB) or cardiac troponin I (cTnI). The goal of this prospective study was to compare the sensitivity and specificity of cTnI with those of CK-MB in the prediction of left ventricular dysfunction on echocardiograms in patients with nontraumatic SAH. In addition, those patients with abnormal findings on their echocardiograms and elevated cTnI levels were further evaluated for the presence of coronary artery disease (CAD) by a cardiologist and to determine whether any left ventricular dysfunction that had been detected was reversible.

Methods. The authors obtained electrocardiograms and echocardiograms, and measured serial levels of cardiac enzymes (CK-MB and cTnI) in 43 patients with nontraumatic SAH. Patients with known CAD were excluded. Those patients found to have elevated enzyme levels and abnormal findings on their echocardiograms underwent additional evaluation for CAD. The sensitivity and specificity of both cTnI and CK-MB for detecting left ventricular function were determined.

Twenty-eight percent of patients with SAH in the study had elevated cTnI levels within the first 24 hours after hemorrhage. Seven of the 12 patients had evidence of left ventricular dysfunction on echocardiograms. In all these patients a return to baseline function was found during follow-up examinations. The authors found that cTnI is much more sensitive than CK-MB (100% compared with 29%) in the detection of left ventricular dysfunction in patients with SAH.

Conclusions. An elevated level of cTnI is a good indicator of left ventricular dysfunction in patients with SAH. In this study cardiac dysfunction was reversible and should not necessarily preclude these patients from undergoing operative interventions or becoming heart donors. Clinical management may require more aggressive hemodynamic monitoring until cardiac function returns to normal.

Article Information

Address reprint requests to: Ellen Deibert, M.D., Department of Neurology, Washington University School of Medicine, Box 8518, 4444 Forest Park Boulevard, St. Louis, Missouri 63108. email: deiberte@neuro.wustl.edu.

© AANS, except where prohibited by US copyright law.

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    Graph depicting cTnI values for all patients in Group 1 for consecutive 12-hour time intervals following SAH. Note: the cTnI peaks in the first 24 to 36 hours post-SAH in most patients.

References

  • 1.

    Adams JE IIISchechtman KBLandt Yet al: Comparable detection of acute myocardial infarction by creatine kinase MB isoenzyme and cardiac troponin I. Clin Chem 40:129112951994Adams JE III Schechtman KB Landt Y et al: Comparable detection of acute myocardial infarction by creatine kinase MB isoenzyme and cardiac troponin I. Clin Chem 40:1291–1295 1994

  • 2.

    Andreoli Adi Pasquale GPinelli Get al: Subarachnoid hemorrhage: frequency and severity of cardiac arrhythmias. A survey of 70 cases studied in the acute phase. Stroke 18:5585641987Andreoli A di Pasquale G Pinelli G et al: Subarachnoid hemorrhage: frequency and severity of cardiac arrhythmias. A survey of 70 cases studied in the acute phase. Stroke 18:558–564 1987

  • 3.

    AntmanEMTanasijevic MJThompson Bet al: Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 335:134213491996Antman EM Tanasijevic MJ Thompson B et al: Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 335:1342–1349 1996

  • 4.

    Arlati SBrenna SPrencipe Let al: Myocardial necrosis in ICU patients with acute non-cardiac disease: a prospective study. Intensive Care Med 26:31372000Arlati S Brenna S Prencipe L et al: Myocardial necrosis in ICU patients with acute non-cardiac disease: a prospective study. Intensive Care Med 26:31–37 2000

  • 5.

    Bajusz EJasmin G: Influence of variations in electrolyte intake upon the development of cardiac necrosis produced by vasopressor amines. Lab Invest 13:7577651964Bajusz E Jasmin G: Influence of variations in electrolyte intake upon the development of cardiac necrosis produced by vasopressor amines. Lab Invest 13:757–765 1964

  • 6.

    Benoit MOParis MSilleran Jet al: Cardiac troponin I: its contribution to the diagnosis of perioperative myocardical infarction and various complications of cardiac surgery. Crit Care Med 29:188018862001Benoit MO Paris M Silleran J et al: Cardiac troponin I: its contribution to the diagnosis of perioperative myocardical infarction and various complications of cardiac surgery. Crit Care Med 29:1880–1886 2001

  • 7.

    Bodor GSPorter SLandt Yet al: Development of monoclonal antibodies for an assay of cardiac troponin-I and preliminary results in suspected cases of myocardial infarction. Clin Chem 38:220322141992Bodor GS Porter S Landt Y et al: Development of monoclonal antibodies for an assay of cardiac troponin-I and preliminary results in suspected cases of myocardial infarction. Clin Chem 38:2203–2214 1992

  • 8.

    Briassoulis GNarlioglou MZavras Net al: Myocardial injury in meningococcus-induced purpura fulminans in children. Intensive Care Med 27:107310822001Briassoulis G Narlioglou M Zavras N et al: Myocardial injury in meningococcus-induced purpura fulminans in children. Intensive Care Med 27:1073–1082 2001

  • 9.

    Brouwers PJAMWijdicks EFMHasan Det al: Serial electrocardiographic recording in aneurysmal subarachnoid hemorrhage. Stroke 20:116211671989Brouwers PJAM Wijdicks EFM Hasan D et al: Serial electrocardiographic recording in aneurysmal subarachnoid hemorrhage. Stroke 20:1162–1167 1989

  • 10.

    CebelinMSHirsch CS: Human stress cardiomyopathy. Myocardial lesions in victims of homicidal assaults without internal injuries. Hum Pathol 82:1231321980Cebelin MS Hirsch CS: Human stress cardiomyopathy. Myocardial lesions in victims of homicidal assaults without internal injuries. Hum Pathol 82:123–132 1980

  • 11.

    Chappel CIRona GBalazs Tet al: Comparison of cardiotoxic actions of certain sympathomimetic amines. Can J Biochem Physiol 37:35421959Chappel CI Rona G Balazs T et al: Comparison of cardiotoxic actions of certain sympathomimetic amines. Can J Biochem Physiol 37:35–42 1959

  • 12.

    Cropp GJManning GW: Electrocardiographic changes simulating myocardial ischemia and infarction associated with spontaneous intracranial hemorrhage. Circulation 22:25381960Cropp GJ Manning GW: Electrocardiographic changes simulating myocardial ischemia and infarction associated with spontaneous intracranial hemorrhage. Circulation 22:25–38 1960

  • 13.

    Cruickshank JMNeil-Dwyer GStott AW: Possible role of catecholamines, corticosteroids, and potassium in production of electrocardiographic abnormalities associated with subarachnoid hemorrhage. Br Heart J 36:6977061974Cruickshank JM Neil-Dwyer G Stott AW: Possible role of catecholamines corticosteroids and potassium in production of electrocardiographic abnormalities associated with subarachnoid hemorrhage. Br Heart J 36:697–706 1974

  • 14.

    Deibert EAiyagari VDiringer MN: Reversible left ventricular dysfunction associated with raised troponin I after subarachnoid haemorrhage does not preclude heart transplantation. Heart 84:2052072000Deibert E Aiyagari V Diringer MN: Reversible left ventricular dysfunction associated with raised troponin I after subarachnoid haemorrhage does not preclude heart transplantation. Heart 84:205–207 2000

  • 15.

    Di Pasquale GPinelli GAndreoli Aet al: Holter detection of cardiac arrhythmias in intracranial subarachnoid hemorrhage. Am J Cardiol 59:5966001987Di Pasquale G Pinelli G Andreoli A et al: Holter detection of cardiac arrhythmias in intracranial subarachnoid hemorrhage. Am J Cardiol 59:596–600 1987

  • 16.

    Dixit SCastle MVelu RPet al: Cardiac involvement in patients with acute neurologic disease: confirmation with cardiac troponin I. Arch Intern Med 160:315331582000Dixit S Castle M Velu RP et al: Cardiac involvement in patients with acute neurologic disease: confirmation with cardiac troponin I. Arch Intern Med 160:3153–3158 2000

  • 17.

    Doshi RNeil-Dwyer G: A clinicopathological study of patients following a subarachnoid hemorrhage. J Neurosurg 52:2953011980Doshi R Neil-Dwyer G: A clinicopathological study of patients following a subarachnoid hemorrhage. J Neurosurg 52:295–301 1980

  • 18.

    Doshi RNeil-Dwyer G: Hypothalamic and myocardial lesions after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 40:8218261977Doshi R Neil-Dwyer G: Hypothalamic and myocardial lesions after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 40:821–826 1977

  • 19.

    Fisher CMKistler JPDavis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:191980Fisher CM Kistler JP Davis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:1–9 1980

  • 20.

    Hirsch RLandt YPorter Set al: Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury. J Pediatr 130:8728771997Hirsch R Landt Y Porter S et al: Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury. J Pediatr 130:872–877 1997

  • 21.

    Horowitz MBWillet DKeffer J: The use of cardiac troponin-I (cTnI) to determine the incidence of myocardial ischemia and injury in patients with aneurysmal and presumed aneurysmal subarachnoid hemorrhage. Acta Neurochir 140:87931998Horowitz MB Willet D Keffer J: The use of cardiac troponin-I (cTnI) to determine the incidence of myocardial ischemia and injury in patients with aneurysmal and presumed aneurysmal subarachnoid hemorrhage. Acta Neurochir 140:87–93 1998

  • 22.

    Hunt WEHess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14201968Hunt WE Hess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20 1968

  • 23.

    Jacob WAVan Bogaert ADe Groot-Lasseel MHA: Myocardial ultrastructural and haemodynamic reactions during experimental subarachnoid hemorrhage. J Mol Cell Cardiol 4:2872981972Jacob WA Van Bogaert A De Groot-Lasseel MHA: Myocardial ultrastructural and haemodynamic reactions during experimental subarachnoid hemorrhage. J Mol Cell Cardiol 4:287–298 1972

  • 24.

    Jaffe ASLandt YParvin CAet al: Comparative sensitivity of cardiac troponin I and lactate dehydrogenase isoenzymes for diagnosing acute myocardial infarction. Clin Chem 42:177017761996Jaffe AS Landt Y Parvin CA et al: Comparative sensitivity of cardiac troponin I and lactate dehydrogenase isoenzymes for diagnosing acute myocardial infarction. Clin Chem 42:1770–1776 1996

  • 25.

    Karch SBBillingham ME: Myocardial contraction bands revisited. Hum Pathol 17:9131986Karch SB Billingham ME: Myocardial contraction bands revisited. Hum Pathol 17:9–13 1986

  • 26.

    Keffer JH: The cardiac profile and proposed practice guideline for acute ischemic heart disease. Am J Clin Pathol 107:3984081997Keffer JH: The cardiac profile and proposed practice guideline for acute ischemic heart disease. Am J Clin Pathol 107:398–408 1997

  • 27.

    Kono TMorita HKuroiwa Tet al: Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium. J Am Coll Cardiol 24:6366401994Kono T Morita H Kuroiwa T et al: Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium. J Am Coll Cardiol 24:636–640 1994

  • 28.

    Labarrere CANelson DRCox CJet al: Cardiac-specific troponin I levels and risk of coronary artery disease and graft failure following heart transplantation. JAMA 284:4574642000Labarrere CA Nelson DR Cox CJ et al: Cardiac-specific troponin I levels and risk of coronary artery disease and graft failure following heart transplantation. JAMA 284:457–464 2000

  • 29.

    MayerSAFink MEHomma Set al: Cardiac injury associated with neurogenic pulmonary edema following subarachnoid hemorrhage. Neurology 44:8158201994Mayer SA Fink ME Homma S et al: Cardiac injury associated with neurogenic pulmonary edema following subarachnoid hemorrhage. Neurology 44:815–820 1994

  • 30.

    Mayer SALiMandri GSherman Det al: Electrocardiographic markers of abnormal left ventricular wall motion in acute subarachnoid hemorrhage. J Neurosurg 83:8898961995Mayer SA LiMandri G Sherman D et al: Electrocardiographic markers of abnormal left ventricular wall motion in acute subarachnoid hemorrhage. J Neurosurg 83:889–896 1995

  • 31.

    Melville KIBlum BShister HEet al: Cardiac ischemic changes and arrhythmias induced by hypothalamic stimulation. Am J Cardiol 12:7817911963Melville KI Blum B Shister HE et al: Cardiac ischemic changes and arrhythmias induced by hypothalamic stimulation. Am J Cardiol 12:781–791 1963

  • 32.

    Neil-Dwyer GCruickshank JMDoshi R: The stress response in subarachnoid haemorrhage and head injury. Acta Neurochir Suppl 47:1021101990Neil-Dwyer G Cruickshank JM Doshi R: The stress response in subarachnoid haemorrhage and head injury. Acta Neurochir Suppl 47:102–110 1990

  • 33.

    Parekh NVenkatesh BCross Det al: Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage. J Am Coll Cardiol 36:132813352000Parekh N Venkatesh B Cross D et al: Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage. J Am Coll Cardiol 36:1328–1335 2000

  • 34.

    Parker MM: Myocardial dysfunction in sepsis: injury or depression? Crit Care Med 27:203520361999Parker MM: Myocardial dysfunction in sepsis: injury or depression? Crit Care Med 27:2035–2036 1999

  • 35.

    Pearce RM: Experimental myocarditis: a study of the histological changes following intravenous injections of adrenalin. J Exp Med 8:4004091906Pearce RM: Experimental myocarditis: a study of the histological changes following intravenous injections of adrenalin. J Exp Med 8:400–409 1906

  • 36.

    Portney LGWatkins MP: Foundations of Clinical Research. Applications to Practice. Norwalk, CT: Appleton & Lange1993Portney LG Watkins MP: Foundations of Clinical Research. Applications to Practice. Norwalk CT: Appleton & Lange 1993

  • 37.

    Potapov EVIvanitskaia EALoebe Met al: Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure. Transplantation 71:139414002001Potapov EV Ivanitskaia EA Loebe M et al: Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure. Transplantation 71:1394–1400 2001

  • 38.

    Rosenblum IWohl AStein AA: Studies of cardiac necrosis. I. Production of cardiac lesions with sympathomimetic amines. Toxicol Appl Pharmacol 7:181965Rosenblum I Wohl A Stein AA: Studies of cardiac necrosis. I. Production of cardiac lesions with sympathomimetic amines. Toxicol Appl Pharmacol 7:1–8 1965

  • 39.

    Selye HBajusz E: Conditioning by corticoids for the production of cardiac lesions with noradrenaline. Acta Endocrinol 30:1831871959Selye H Bajusz E: Conditioning by corticoids for the production of cardiac lesions with noradrenaline. Acta Endocrinol 30:183–187 1959

  • 40.

    Shivvers SAWians FH JrKeffer JHet al: Maternal cardiac troponin I levels during normal labor and delivery. Am J Obstet Gynecol 180:1221999Shivvers SA Wians FH Jr Keffer JH et al: Maternal cardiac troponin I levels during normal labor and delivery. Am J Obstet Gynecol 180:122 1999

  • 41.

    Srivastava SCRobson AO: Electrocardiographic abnomalities associated with subarachnoid haemorrhage. Lancet 2:4314331964Srivastava SC Robson AO: Electrocardiographic abnomalities associated with subarachnoid haemorrhage. Lancet 2:431–433 1964

  • 42.

    Thiru YPathan NBignall Set al: A myocardial cytotoxic process is involved in the cardiac dysfunction of meningococcal septic shock. Crit Care Med 28:297929832000Thiru Y Pathan N Bignall S et al: A myocardial cytotoxic process is involved in the cardiac dysfunction of meningococcal septic shock. Crit Care Med 28:2979–2983 2000

  • 43.

    Tsuchihashi KUeshima KUchida Tet al: Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigators in Japan. J Am Coll Cardiol 38:11182001Tsuchihashi K Ueshima K Uchida T et al: Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigators in Japan. J Am Coll Cardiol 38:11–18 2001

  • 44.

    Van Vliet PDBurchell HBTitus JL: Focal myocarditis associated with pheochromocytoma. N Engl J Med 274:110211081966Van Vliet PD Burchell HB Titus JL: Focal myocarditis associated with pheochromocytoma. N Engl J Med 274:1102–1108 1966

  • 45.

    Vijay PScavo VAMorelock RJet al: Donor cardiac troponin T: a marker to predict heart transplant rejection. Ann Thorac Surg 66:193419391998Vijay P Scavo VA Morelock RJ et al: Donor cardiac troponin T: a marker to predict heart transplant rejection. Ann Thorac Surg 66:1934–1939 1998

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