0
Editor's Correspondence |

Are Guideline-Based Therapies for Myocardial Infarction Generalizable to Troponin-Only Positive Patients?

Heather Horton, MD, PhD
Arch Intern Med. 2008;168(4):436-437. doi:10.1001/archinternmed.2007.118.
Text Size: A A A
Published online

Extract

Shah et al1 have analyzed troponin-only positive “myocardial infarctions” (MIs) with regard to guideline-based management and report that guideline-based therapies are underused. I am not certain their analysis is correct. When the criteria for MI were revised to include troponin-only positive MIs, I was concerned that we were not looking at a homogeneous population when compared with patients who presented with electrocardiographic changes and elevated creatine phosphokinase of muscle band (CPK-MB) level. When I expressed my concern to a member of the committee who revised the definition, I was told not to worry about it, that it would be better for the hospital because we would get more reimbursement for all these new MIs. Recently, in my own cardiology practice I have seen elevated troponin levels in cases of diabetic ketoacidosis (cardiac catheterization showed normal coronary arteries), urosepsis, acidosis, pneumonia, sepsis, severe chronic obstructive pulmonary disease, pulmonary embolus, disseminated intravascular coagulation, and many other conditions. It is not clear to me that this represents the same pathology that is seen with a traditional MI with chest pain, electrocardiographic changes, and an elevated CPK-MB level (coronary atherosclerosis, unstable plaque, and plaque rupture). If the pathology is different, I do not think that we can assume that therapies that were tested for that type of MI are necessarily beneficial for elevated troponin level in settings of severe myocardial stress without likely plaque instability. For instance, despite inclusion in the article, positive troponin status by itself is not an indication for either lytic therapy or primary percutaneous coronary intervention. Having participated in a moderate number of multicenter clinical trials in cardiology, I can think of none in which a patient with elevated troponin but normal CPK and CPK-MB levels, with severe comorbidities such as sepsis, diabetic ketoacidosis, disseminated intravascular coagulation, chronic obstructive pulmonary disease requiring intubation, or pulmonary embolism, would be considered an appropriate candidate for inclusion.

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

First Page Preview

View Large
/>
First page PDF preview

Figures

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
Jobs
JAMAevidence.com

Users' Guides to the Medical Literature
Clinical Resolution

Users' Guides to the Medical Literature
Clinical Scenario

brightcove.createExperiences();