Appropriate Use and Interpretation of Cardiac Biomarkers Dr. Vikas - PowerPoint PPT Presentation

Canadian Society of Internal Medicine Annual Meeting 2017 Toronto, ON Appropriate Use and Interpretation of Cardiac Biomarkers Dr. Vikas Tandon Associate Professor, Cardiology McMaster University November 1, 2017

CSIM Annual Meeting 2017 Conflict 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. X X (including gifts or other consideration or ‘in kind’ compensation) Grant(s) or an honorarium X X Patent for a product referred to or X X marketed by a commercial organization. Investments in a pharmaceutical X X organization, medical devices company or communications firm. Participating or participated in a clinical Participated in periop research studies McMaster University trial including VISION, POISE-2, MANAGE

CSIM Annual Meeting 2017 The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational 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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Scope of problem • 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

Case 1 • 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)

12 Lead

This patient has: 1. Normal coronaries 2. Mild atherosclerotic plaque with no significant stenosis 3. Single vessel disease 4. Multivessel disease

Case 2 • 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)

12 Lead

This patient has: 1. Normal coronaries 2. Mild atherosclerotic plaque with no significant stenosis 3. Single vessel disease 4. Multivessel disease

Case 3 • 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)

12 Lead

This patient has: 1. Normal coronaries 2. Mild atherosclerotic plaque with no significant stenosis 3. Single vessel disease 4. Multivessel disease

The cases thus far: Case 1 Case 2 Case 3 66 F w 8/10 RSCP 50 F headaches, CP and 58 F bright red blood per rapid A Fib 120-140 back pain lasting hours rectum; known UC HTN urgency: BP 200/118 DM, HTN, Chol, remote HTN, current smoker HTN, recent smoker smoker (5 pack yr history) (30 pack year history) (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 RSCP 50 F headaches, CP and 58 F bright red blood per rapid A Fib 120-140 back pain lasting hours rectum; known UC HTN urgency: BP 200/118 DM, HTN, Chol, remote HTN, current smoker HTN, recent smoker smoker (5 pack yr history) (30 pack year history) (40 pack year history) Peak trops = 620 Peak trops = 68 Peak trops = 108 Cath: Mild plaque Cath: 90% stenosis ostial Cardiac CT: Normal No significant stenosis RCA; mild dz LAD/LCX coronaries

Concept • 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

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 = 3 Trop 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

This patient has: 1. Normal coronaries 2. Mild atherosclerotic plaque with no significant stenosis 3. Single vessel disease with plaque rupture/thrombus 4. Single vessel disease but no thrombus/stable plaque

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

This patient has: 1. Normal coronaries 2. Mild atherosclerotic plaque with no significant stenosis 3. Single vessel disease with plaque rupture/thrombus 4. Single vessel disease but no thrombus/stable plaque

Summary of Cases 4 and 5 Case 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

Summary of Cases 4 and 5 Case 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

Summary of Cases 4 and 5 Case 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 Plaque rupture and thrombus - LAD Significant stenosis RCA but no plaque rupture

Concept • 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

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 Study No Persantine ECG changes

Nuclear Perfusion Study

Nuclear Perfusion – PET/CT

Cath