Myocardial injury

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Synonyms and keywords: Acute myocardial injury, Chronic myocardial injury, Myocardial ischemia, troponin concentration, systemic illness

Overview

myocardial injury is defined as elevated troponin concentrations without sign and symptom indicating overt myocardial ischemia and is the most common cause of increased troponin level. Traditionally, elevated troponin level was eqaul to myocardial infarction. Diagnosis of myocardial injury is a challange for clinicians. By improving the laboratory method for detecting high sensitive troponin and clinical approach to diagnosis of myocardial ischemia, patients with myocardial injury due to underlying diseases were excluded and treated. Evaluation and treatment of percipitant factors of myocardial injury including sepsis, anemia, chronic kidney disease, cardiomyopathy are practically indicated. However, patients with evidence of myocardial injury and myocardial ischemia both have poor short and long term outcome.

Historical Perspective

Classification

Classification Definition
Acute myocardial injury Dynamic rise and/or fall of troponin concentration

associated with cardiovascular or noncardiovascular causes

Chronic myocardial injury Stable elevated troponin concentration related to cardiovascular or noncardiovascular causes
Myocardial infarction type 1 Myocardial infarction due to plaque rupture, ulceration, or dissection
Myocardial infarction type 2 Myocardial infarction attributable to oxygen supply-demand

mismatch

Myocardial infarction type 3 Sudden cardiac death associated with myocardial infarction
Myocardial infarction type 4 Myocardial infarction associated with percutaneous intervention or stent thrombosis
Myocardial infarction type 5 Myocardial infarction related to cardiac surgery

Pathophysiology

Causes





Differentiating myocardial injury from other Diseases

Epidemiology and Demographics


Risk Factors

Common risk factors in the development of myocardial injury include:

Screening

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice



 
 
 
 
Myocardial injury
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute myocardial injury
 
 
 
Chronic myocardial injury
  • Stable but elevated troponin
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    History and physical examination
     
     
     
    History and physician examination
  • Laboratory findings
  • Creatinine, glomerular filtration rate
  • Natriuretic peptide
  • Complete blood cell count
  • C-reactive protein, erythrocyte sedimentation rate, D-dimer testing
  • Electrocardiogram
  • Transthoracic echocardiography
  • Cardiac magnetic resonance imaging
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Evidence of myocardial ischemia
     
    NO evidence of ischemia
  • Causes of Nonischemic myocardial injury:
  • Cardiovascular causes:
  • Hypertension
  • Cardiac arrhythmias
  • Acute valvular heart disease
  • Takotsubo cardiomyopathy
  • Cardiac contusions
  • Acute heart failure
  • Pulmonary embolism
  • Myocarditis
  • Aortic dissection
  • Cardiac surgery or procedures
  • Noncardiovascular causes:
  • Acute renal failure
  • Sepsis
  • Anemia
  • Hypotension
  • Hypoxia
  • Noncardiac surgery
  • Critical illness
  • Rhabdomyolysis
  • Drug-induced
  • Stroke, brain hemorrhage
  • Extreme exertion
  •  
    Cardiovascular causes of chronic myocardial injury
  • Chronic heart failure
  • Infiltrative cardiomyopathy
  • Hypertrophic cardiomyopathy
  • Stable coronary artery disease
  • Hypertension
  • Valvular heart disease
  • Persistent arrhythmias
  • Noncardiovascular causes of chronic myocardial injury
  • Chronic renal disease
  • Pulmonary hypertension
  • Diabetes mellitus
  • Drug-induced
  • Toxin exposure
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Management based on the type of myocardial infarction
     
     
    Management based on the causes of myocardial injury and clinical course
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

    History and Symptoms

    Common symptoms associated with underlying causes of myocardial injury include:

    Physical Examination

    Laboratory Findings

    Laboratory investigation consistent with the diagnosis of myocardial injury include: [3]


    Electrocardiogram

    There are no specific ECG findings associated with myocardial injury. Findings on an ECG suggestive of myocardial injury may include:[3]

    X-ray

    There are no x-ray findings associated with myocardial injury.

    Echocardiography or Ultrasound

    Echocardiography may be helpful in the diagnosis of underlying causes of myocardial injury.

    CT scan

    There are no CT scan findings associated with myocardial injury. However, a CT scan may be helpful in suspicion of pulmonary thromboembolism or aortic dissection.

    MRI

    Cardiac MRI may be helpful when there is clinically suspicion of myocarditis or infiltrative cardiomyopathy as the underlying causes of myocardial injury.

    Other Imaging Findings

    There are no other imaging findings associated with myocardial injury.

    Other Diagnostic Studies

    There are no other diagnostic studies associated with myocardial injury.

    Treatment

    Medical Therapy


    Surgery

    Surgical intervention is not recommended for the management of myocardial injury.

    Primary Prevention

    There are no established measures for the primary prevention of myocardial injury.

    Secondary Prevention

    There are no established measures for the secondary prevention of myocardial injury.

    References

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