Myocardial injury: Difference between revisions

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#redirect:[[STEMI]]
__NOTOC__
{{SI}}
 
{{CMG}}; {{AE}} {{Sara.Zand}}
 
{{SK}} 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==
*[[Troponin]]  was first discovered by [[setsuro ebashi]], a [[Japanese physiologist]], in 1963 as a component of [[muscle contraction]]. <ref name="pmid18365325">{{cite journal |vauthors=Perry SV |title=Background to the discovery of troponin and Setsuro Ebashi's contribution to our knowledge of the mechanism of relaxation in striated muscle |journal=Biochem Biophys Res Commun |volume=369 |issue=1 |pages=43–8 |date=April 2008 |pmid=18365325 |doi=10.1016/j.bbrc.2007.11.185 |url=}}</ref>
 
*In 2000, use of [[troponin]]  was established as the biomarker of choice in diagnosis of [[myocardial infarction]] by [[European Society of Cardiology]] ([[ESC]]) and [[American College of Cardiology]] ([[ACC]]).<ref name="AntmanBassand2000">{{cite journal|last1=Antman|first1=Elliott|last2=Bassand|first2=Jean-Pierre|last3=Klein|first3=Werner|last4=Ohman|first4=Magnus|last5=Lopez Sendon|first5=Jose Luis|last6=Rydén|first6=Lars|last7=Simoons|first7=Maarten|last8=Tendera|first8=Michal|title=Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction|journal=Journal of the American College of Cardiology|volume=36|issue=3|year=2000|pages=959–969|issn=07351097|doi=10.1016/S0735-1097(00)00804-4}}</ref>
 
==Classification==
*[[Myocardial injury]] may be classified into acute and chronic based upon the pattern of [[troponin]] concentration.<ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
* [[Acute]] [[myocardial injury]] is considered when there is a rise and/or fall of [[cardiac]] [[troponin]] concentrations exceeding the biological and/or analytical variation.<ref name="TwerenboldJaffe2012">{{cite journal|last1=Twerenbold|first1=R.|last2=Jaffe|first2=A.|last3=Reichlin|first3=T.|last4=Reiter|first4=M.|last5=Mueller|first5=C.|title=High-sensitive troponin T measurements: what do we gain and what are the challenges?|journal=European Heart Journal|volume=33|issue=5|year=2012|pages=579–586|issn=0195-668X|doi=10.1093/eurheartj/ehr492}}</ref>
* [[Chronic]] [[myocardial injury]] may occur when [[cardiac]] [[troponin]] is greater than 99th-percentile URL without a rise and/or fall over a period of serial [[measurements]] ( more than 8 hours) in the [[condition]]s such as [[structural heart disease]] ([[hypertensive heart disease]], [[ischemic cardiomyopathy]], [[dilated cardiomyopathy]]) or secondary to non-[[cardiac]] causes such as [[chronic renal failure]].
* Table below shown the classification of [[myocardial injury]] and also different types of [[myocardial infarction]]:
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Classification}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF| Definition }}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Acute [[myocardial injury]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Dynamic rise and/or fall of [[troponin]] [[concentration]]
associated with  [[cardiovascular]] or [[noncardiovascular]] causes
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Chronic [[myocardial injury]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Stable  elevated [[troponin]] concentration related to [[cardiovascular]] or [[noncardiovascular]] causes
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Myocardial infarction]] type 1
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  [[Myocardial infarction]] due to [[plaque rupture]], [[ulceration]], or [[dissection]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Myocardial infarction]] type 2
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  [[Myocardial infarction]] attributable to [[oxygen supply-demand]]
mismatch
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Myocardial infarction]] type 3
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  [[Sudden cardiac death]] associated with [[myocardial infarction]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Myocardial infarction]] type 4
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  [[Myocardial infarction]] associated with [[percutaneous intervention]] or [[stent thrombosis]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Myocardial infarction]] type 5
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Myocardial infarction]] related to [[cardiac]] [[surgery]]
|}
 
==Pathophysiology==
 
*The pathogenesis of [[myocardial injury]] depends on increased [[cardiac]] [[troponin]] released by [[myocardial]] strain, [[inflammation]], [[apoptosis]], and [[cell injury]], or  decreased clearance of [[cardiac]] [[troponin]].
 
* It is thought that increased [[troponin]] level in  [[patients]] with advanced [[ kidney disease]] is caused by either decreased clearance of [[cardiac troponin]], underlying [[coronary artery disease]] and the presence of a [[left ventricular hypertrophy]].<ref name="JanuzziGaggin2012">{{cite journal|last1=Januzzi|first1=James|last2=Gaggin|first2=Hanna|last3=Wolf|first3=Myles|last4=Christenson|first4=Robert H|last5=Hise|first5=Michael|last6=Duh|first6=Show-Hong|last7=Kelley|first7=Walter|last8=Seliger|first8=Stephen L|last9=deFilippi|first9=Christopher|title=Interpreting Cardiac Troponin Results from High-Sensitivity Assays in Chronic Kidney Disease without Acute Coronary Syndrome|journal=Clinical Chemistry|volume=58|issue=9|year=2012|pages=1342–1351|issn=0009-9147|doi=10.1373/clinchem.2012.185322}}</ref>
* The [[presence]] of [[chronic]] [[myocardial injury]] and [[cardiac]] [[troponin]] in [[valvular heart disease]] such as [[aortic stenosis]]  may be associated with [[cardiac mass]], replacement [[fibrosis]], and [[prognosis]].<ref name="ChinShah2014">{{cite journal|last1=Chin|first1=C. W. L.|last2=Shah|first2=A. S. V.|last3=McAllister|first3=D. A.|last4=Joanna Cowell|first4=S.|last5=Alam|first5=S.|last6=Langrish|first6=J. P.|last7=Strachan|first7=F. E.|last8=Hunter|first8=A. L.|last9=Maria Choy|first9=A.|last10=Lang|first10=C. C.|last11=Walker|first11=S.|last12=Boon|first12=N. A.|last13=Newby|first13=D. E.|last14=Mills|first14=N. L.|last15=Dweck|first15=M. R.|title=High-sensitivity troponin I concentrations are a marker of an advanced hypertrophic response and adverse outcomes in patients with aortic stenosis|journal=European Heart Journal|volume=35|issue=34|year=2014|pages=2312–2321|issn=0195-668X|doi=10.1093/eurheartj/ehu189}}</ref>
 
==Causes==
*Common causes associated with [[myocardial injury]] include:
 
*'' [[Cardiovascular]] causes of chronic [[myocardial injury]]'':<ref name="SandovalSmith2017">{{cite journal|last1=Sandoval|first1=Yader|last2=Smith|first2=Stephen W.|last3=Sexter|first3=Anne|last4=Thordsen|first4=Sarah E.|last5=Bruen|first5=Charles A.|last6=Carlson|first6=Michelle D.|last7=Dodd|first7=Kenneth W.|last8=Driver|first8=Brian E.|last9=Hu|first9=Yan|last10=Jacoby|first10=Katherine|last11=Johnson|first11=Benjamin K.|last12=Love|first12=Sara A.|last13=Moore|first13=Johanna C.|last14=Schulz|first14=Karen|last15=Scott|first15=Nathaniel L.|last16=Apple|first16=Fred S.|title=Type 1 and 2 Myocardial Infarction and Myocardial Injury: Clinical Transition to High-Sensitivity Cardiac Troponin I|journal=The American Journal of Medicine|volume=130|issue=12|year=2017|pages=1431–1439.e4|issn=00029343|doi=10.1016/j.amjmed.2017.05.049}}</ref>
* [[Chronic heart failure]]<ref name="AimoJanuzzi2018">{{cite journal|last1=Aimo|first1=Alberto|last2=Januzzi|first2=James L.|last3=Vergaro|first3=Giuseppe|last4=Ripoli|first4=Andrea|last5=Latini|first5=Roberto|last6=Masson|first6=Serge|last7=Magnoli|first7=Michela|last8=Anand|first8=Inder S.|last9=Cohn|first9=Jay N.|last10=Tavazzi|first10=Luigi|last11=Tognoni|first11=Gianni|last12=Gravning|first12=Jørgen|last13=Ueland|first13=Thor|last14=Nymo|first14=Ståle H.|last15=Brunner-La Rocca|first15=Hans-Peter|last16=Genis|first16=Antoni Bayes|last17=Lupón|first17=Josep|last18=de Boer|first18=Rudolf A.|last19=Yoshihisa|first19=Akiomi|last20=Takeishi|first20=Yasuchika|last21=Egstrup|first21=Michael|last22=Gustafsson|first22=Ida|last23=Gaggin|first23=Hanna K.|last24=Eggers|first24=Kai M.|last25=Huber|first25=Kurt|last26=Tentzeris|first26=Ioannis|last27=Tang|first27=Wai H.W.|last28=Grodin|first28=Justin|last29=Passino|first29=Claudio|last30=Emdin|first30=Michele|title=Prognostic Value of High-Sensitivity Troponin T in Chronic Heart Failure|journal=Circulation|volume=137|issue=3|year=2018|pages=286–297|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031560}}</ref>
 
* [[Infiltrative cardiomyopathies]] ([[amyloidosis]], [[hemochromatosis]], [[sarcoidosis]])<ref>{{cite journal|doi=10.3969/j.issn.1671-5411.2014.02.011}}</ref>
 
* [[Hypertrophic cardiomyopathy]]<ref name="KuboKitaoka2013">{{cite journal|last1=Kubo|first1=Toru|last2=Kitaoka|first2=Hiroaki|last3=Yamanaka|first3=Shigeo|last4=Hirota|first4=Takayoshi|last5=Baba|first5=Yuichi|last6=Hayashi|first6=Kayo|last7=Iiyama|first7=Tatsuo|last8=Kumagai|first8=Naoko|last9=Tanioka|first9=Katsutoshi|last10=Yamasaki|first10=Naohito|last11=Matsumura|first11=Yoshihisa|last12=Furuno|first12=Takashi|last13=Sugiura|first13=Tetsuro|last14=Doi|first14=Yoshinori L.|title=Significance of High-Sensitivity Cardiac Troponin T in Hypertrophic Cardiomyopathy|journal=Journal of the American College of Cardiology|volume=62|issue=14|year=2013|pages=1252–1259|issn=07351097|doi=10.1016/j.jacc.2013.03.055}}</ref>
 
* Stable [[coronary artery disease]]<ref name="JanuzziSuchindran2019">{{cite journal|last1=Januzzi|first1=James L.|last2=Suchindran|first2=Sunil|last3=Coles|first3=Adrian|last4=Ferencik|first4=Maros|last5=Patel|first5=Manesh R.|last6=Hoffmann|first6=Udo|last7=Ginsburg|first7=Geoffrey S.|last8=Douglas|first8=Pamela S.|title=High-Sensitivity Troponin I and Coronary Computed Tomography in Symptomatic Outpatients With Suspected CAD|journal=JACC: Cardiovascular Imaging|volume=12|issue=6|year=2019|pages=1047–1055|issn=1936878X|doi=10.1016/j.jcmg.2018.01.021}}</ref>
 
* [[ Hypertension]]<ref name="AeschbacherSchoen2015">{{cite journal|last1=Aeschbacher|first1=Stefanie|last2=Schoen|first2=Tobias|last3=Bossard|first3=Matthias|last4=van der Lely|first4=Stephanie|last5=Glättli|first5=Kathrin|last6=Todd|first6=John|last7=Estis|first7=Joel|last8=Risch|first8=Martin|last9=Mueller|first9=Christian|last10=Risch|first10=Lorenz|last11=Conen|first11=David|title=Relationship Between High-Sensitivity Cardiac Troponin I and Blood Pressure Among Young and Healthy Adults|journal=American Journal of Hypertension|volume=28|issue=6|year=2015|pages=789–796|issn=0895-7061|doi=10.1093/ajh/hpu226}}</ref>
 
* [[Valvular heart disease]]<ref name="RøsjøAndreassen2011">{{cite journal|last1=Røsjø|first1=Helge|last2=Andreassen|first2=Johanna|last3=Edvardsen|first3=Thor|last4=Omland|first4=Torbjørn|title=Prognostic Usefulness of Circulating High-Sensitivity Troponin T in Aortic Stenosis and Relation to Echocardiographic Indexes of Cardiac Function and Anatomy|journal=The American Journal of Cardiology|volume=108|issue=1|year=2011|pages=88–91|issn=00029149|doi=10.1016/j.amjcard.2011.02.346}}</ref>
 
* Persistent [[arrhythmias]] ([[atrial fibrillation]])<ref name="van den BosConstantinescu2011">{{cite journal|last1=van den Bos|first1=E. J.|last2=Constantinescu|first2=A. A.|last3=van Domburg|first3=R. T.|last4=Akin|first4=S.|last5=Jordaens|first5=L. J.|last6=Kofflard|first6=M. J. M.|title=Minor elevations in troponin I are associated with mortality and adverse cardiac events in patients with atrial fibrillation|journal=European Heart Journal|volume=32|issue=5|year=2011|pages=611–617|issn=0195-668X|doi=10.1093/eurheartj/ehq491}}</ref>
 
 
 
* ''Noncardiovascular causes of chronic [[myocardial injury]]'':
* [[Chronic renal disease]]<ref name="AppleMurakami2002">{{cite journal|last1=Apple|first1=Fred S.|last2=Murakami|first2=MaryAnn M.|last3=Pearce|first3=Lesly A.|last4=Herzog|first4=Charles A.|title=Predictive Value of Cardiac Troponin I and T for Subsequent Death in End-Stage Renal Disease|journal=Circulation|volume=106|issue=23|year=2002|pages=2941–2945|issn=0009-7322|doi=10.1161/01.CIR.0000041254.30637.34}}</ref>
 
* [[Pulmonary hypertension]]<ref name="HeresiTang2012">{{cite journal|last1=Heresi|first1=G.A.|last2=Tang|first2=W.H.W.|last3=Aytekin|first3=M.|last4=Hammel|first4=J.|last5=Hazen|first5=S.L.|last6=Dweik|first6=R.A.|title=Sensitive cardiac troponin I predicts poor outcomes in pulmonary arterial hypertension|journal=European Respiratory Journal|volume=39|issue=4|year=2012|pages=939–944|issn=0903-1936|doi=10.1183/09031936.00067011}}</ref>
 
* [[Toxins]] <ref name="RileyHsue2017">{{cite journal|last1=Riley|first1=Elise D.|last2=Hsue|first2=Priscilla Y.|last3=Vittinghoff|first3=Eric|last4=Wu|first4=Alan H.B.|last5=Coffin|first5=Phillip O.|last6=Moore|first6=Peter K.|last7=Lynch|first7=Kara L.|title=Higher prevalence of detectable troponin I among cocaine-users without known cardiovascular disease|journal=Drug and Alcohol Dependence|volume=172|year=2017|pages=88–93|issn=03768716|doi=10.1016/j.drugalcdep.2016.11.039}}</ref>
 
* [[Diabetes mellitus]]<ref name="SegreHueb2015">{{cite journal|last1=Segre|first1=Carlos Alexandre Wainrober|last2=Hueb|first2=Whady|last3=Garcia|first3=Rosa Maria Rahmi|last4=Rezende|first4=Paulo Cury|last5=Favarato|first5=Desiderio|last6=Strunz|first6=Celia Maria Cassaro|last7=Sprandel|first7=Marília da Costa Oliveira|last8=Roggério|first8=Alessandra|last9=Carvalho|first9=Ana Luiza de Oliveira|last10=Maranhão|first10=Raul Cavalcante|last11=Ramires|first11=José Antonio Franchini|last12=Filho|first12=Roberto Kalil|title=Troponin in diabetic patients with and without chronic coronary artery disease|journal=BMC Cardiovascular Disorders|volume=15|issue=1|year=2015|issn=1471-2261|doi=10.1186/s12872-015-0051-z}}</ref>
 
 
*''[[Cardiovascular]] causes of acute [[myocardial injury]]'':
* [[Myocardial infarction]] <ref name="SandovalSmith2017">{{cite journal|last1=Sandoval|first1=Yader|last2=Smith|first2=Stephen W.|last3=Sexter|first3=Anne|last4=Thordsen|first4=Sarah E.|last5=Bruen|first5=Charles A.|last6=Carlson|first6=Michelle D.|last7=Dodd|first7=Kenneth W.|last8=Driver|first8=Brian E.|last9=Hu|first9=Yan|last10=Jacoby|first10=Katherine|last11=Johnson|first11=Benjamin K.|last12=Love|first12=Sara A.|last13=Moore|first13=Johanna C.|last14=Schulz|first14=Karen|last15=Scott|first15=Nathaniel L.|last16=Apple|first16=Fred S.|title=Type 1 and 2 Myocardial Infarction and Myocardial Injury: Clinical Transition to High-Sensitivity Cardiac Troponin I|journal=The American Journal of Medicine|volume=130|issue=12|year=2017|pages=1431–1439.e4|issn=00029343|doi=10.1016/j.amjmed.2017.05.049}}</ref>
 
* [[Pulmonary embolism]]
* [[Myocarditis]]
*[[ Myopericarditis]]
*[[ Aortic dissection]]
* [[Cardiac]] [[surgery]] or [[procedures]] ([[ cardioversion]] or [[ablation]])
*[[Hypertension]]
* [[Arrhythmias]]
*[[Acute heart failure]]
* Acute [[valvular heart disease]] ([[ aortic regurgitation]] or [[mitral regurgitation]])
* [[Takotsubo cardiomyopathy]]
* [[Cardiac contusions]] ( [[chest compressions]])
 
 
 
*''Noncardiovascular causes of acute [[myocardial injury]]'':
* [[Acute renal failure]]
* [[Sepsis]]
* [[Anemia]] <ref name="BellottoFagiuoli2005">{{cite journal|last1=Bellotto|first1=Fabio|last2=Fagiuoli|first2=Stefano|last3=Pavei|first3=Andrea|last4=Gregory|first4=Shawn A.|last5=Cati|first5=Arianna|last6=Silverj|first6=Elisabetta|last7=Plebani|first7=Mario|last8=Zaninotto|first8=Martina|last9=Mancuso|first9=Tommaso|last10=Iliceto|first10=Sabino|title=Anemia and ischemia: Myocardial injury in patients with gastrointestinal bleeding|journal=The American Journal of Medicine|volume=118|issue=5|year=2005|pages=548–551|issn=00029343|doi=10.1016/j.amjmed.2005.01.026}}</ref>
 
* [[Hypotension]]
* [[Hypoxia]]
* [[Noncardiac ]] [[surgery]] <ref name="PuelacherLurati Buse2018">{{cite journal|last1=Puelacher|first1=Christian|last2=Lurati Buse|first2=Giovanna|last3=Seeberger|first3=Daniela|last4=Sazgary|first4=Lorraine|last5=Marbot|first5=Stella|last6=Lampart|first6=Andreas|last7=Espinola|first7=Jaqueline|last8=Kindler|first8=Christoph|last9=Hammerer|first9=Angelika|last10=Seeberger|first10=Esther|last11=Strebel|first11=Ivo|last12=Wildi|first12=Karin|last13=Twerenbold|first13=Raphael|last14=du Fay de Lavallaz|first14=Jeanne|last15=Steiner|first15=Luzius|last16=Gurke|first16=Lorenz|last17=Breidthardt|first17=Tobias|last18=Rentsch|first18=Katharina|last19=Buser|first19=Andreas|last20=Gualandro|first20=Danielle M.|last21=Osswald|first21=Stefan|last22=Mueller|first22=Christian|last23=Seeberger|first23=Manfred|last24=Christ-Crain|first24=Mirjam|last25=Cuculi|first25=Florim|last26=Badertscher|first26=Patrick|last27=Nestelberger|first27=Thomas|last28=Wussler|first28=Desiree|last29=Flores|first29=Dayana|last30=Boeddinghaus|first30=Jasper|last31=Sabti|first31=Zaid|last32=Giménez|first32=Maria Rubini|last33=Kozhuharov|first33=Nikola|last34=Shrestha|first34=Samyut|last35=Kloos|first35=Wanda|last36=Lohrmann|first36=Jens|last37=Reichlin|first37=Tobias|last38=Freese|first38=Michael|last39=Meissner|first39=Kathrin|last40=Kaiser|first40=Christoph|last41=Buser|first41=Andreas|title=Perioperative Myocardial Injury After Noncardiac Surgery|journal=Circulation|volume=137|issue=12|year=2018|pages=1221–1232|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.030114}}</ref>
 
* Critical [[illness]]<ref name="Lim2006">{{cite journal|last1=Lim|first1=Wendy|title=Elevated Cardiac Troponin Measurements in Critically Ill Patients|journal=Archives of Internal Medicine|volume=166|issue=22|year=2006|pages=2446|issn=0003-9926|doi=10.1001/archinte.166.22.2446}}</ref>
 
* [[Rhabdomyolysis]]<ref name="PunukolluGowda2004">{{cite journal|last1=Punukollu|first1=Gopikrishna|last2=Gowda|first2=Ramesh M|last3=Khan|first3=Ijaz A|last4=Mehta|first4=Nirav J|last5=Navarro|first5=Victor|last6=Vasavada|first6=Balendu C|last7=Sacchi|first7=Terrence J|title=Elevated serum cardiac troponin I in rhabdomyolysis|journal=International Journal of Cardiology|volume=96|issue=1|year=2004|pages=35–40|issn=01675273|doi=10.1016/j.ijcard.2003.04.053}}</ref>
 
* [[Drug]]-induced causes ([[chemotherapy]])
* [[Stroke]]
* [[Extreme]] [[exertion]]
 
==Differentiating [[myocardial injury]] from other Diseases==
 
*[[Myocardial injury]] must be differentiated from [[myocardial ischemia]] based on the [[troponin]] concentration changes, [[ECG]] changes and [[clinical approach]].
 
==Epidemiology and Demographics==
*The [[prevalence]] of [[myocardial injury]] is approximately 12,400 per 100,000 individuals presented in [[emergency department]].<ref name="LeeNoaman2019">{{cite journal|last1=Lee|first1=Kuan Ken|last2=Noaman|first2=Ala|last3=Vaswani|first3=Amar|last4=Gibbins|first4=Matthew|last5=Griffiths|first5=Megan|last6=Chapman|first6=Andrew R.|last7=Strachan|first7=Fiona|last8=Anand|first8=Atul|last9=McAllister|first9=David A.|last10=Newby|first10=David E.|last11=Gray|first11=Alasdair J.|last12=Mills|first12=Nicholas L.|last13=Shah|first13=Anoop S.V.|title=Prevalence, Determinants, and Clinical Associations of High-Sensitivity Cardiac Troponin in Patients Attending Emergency Departments|journal=The American Journal of Medicine|volume=132|issue=1|year=2019|pages=110.e8–110.e21|issn=00029343|doi=10.1016/j.amjmed.2018.10.002}}</ref>
 
 
*Between 2010 to 2011, the incidence of [[myocardial injury]] was approximately 29,000 per 100,000 individuals with a [[mortality rate]] of 39%.<ref name="SarkisianSaaby2016">{{cite journal|last1=Sarkisian|first1=Laura|last2=Saaby|first2=Lotte|last3=Poulsen|first3=Tina S.|last4=Gerke|first4=Oke|last5=Jangaard|first5=Nikolaj|last6=Hosbond|first6=Susanne|last7=Diederichsen|first7=Axel C.P.|last8=Thygesen|first8=Kristian|last9=Mickley|first9=Hans|title=Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins|journal=The American Journal of Medicine|volume=129|issue=4|year=2016|pages=446.e5–446.e21|issn=00029343|doi=10.1016/j.amjmed.2015.11.006}}</ref>
*The incidence of [[myocardial injury]] increases with age.
*There is no racial predilection to [[myocardial injury]].
*[[women]] are more commonly affected by [[myocardial injury]] than [[men]].
 
==Risk Factors==
 
Common risk factors in the development of [[myocardial injury]] include:
* older [[age]]
* [[Hypertension]]
* [[ Diabetes mellitus]]
* [[ Cardiovascular disease]]
 
==Screening==
*According to the [[Canadian Cardiovascular Society]],[[cardiac]] [[troponin]] [[screening]]  for [[myocardial injury]] in [[noncardiac surgery]] (stayed at least 1 night in [[hospital]] ) is indicated for [[patients]] with history of:<ref name="PuelacherBollen Pinto2021">{{cite journal|last1=Puelacher|first1=Christian|last2=Bollen Pinto|first2=Bernardo|last3=Mills|first3=Nicholas L.|last4=Duceppe|first4=Emmanuelle|last5=Popova|first5=Ekaterine|last6=Duma|first6=Andreas|last7=Nagele|first7=Peter|last8=Omland|first8=Torbjørn|last9=Hammerer-Lercher|first9=Angelika|last10=Lurati Buse|first10=Giovanna|title=Expert consensus on peri-operative myocardial injury screening in noncardiac surgery|journal=European Journal of Anaesthesiology|volume=38|issue=6|year=2021|pages=600–608|issn=0265-0215|doi=10.1097/EJA.0000000000001486}}</ref>
 
*Age >45 years old with known [[cardiovascular disease]] such as [[coronary artery disease]], [[cerebral vascular disease]], [[peripheral arterial disease]], [[congestive heart failure]],
* Age between 18-64 years old with [[significant]] [[ cardiovascular disease]] scheduled for urgent or semi-urgent [[surgery]] ([[hip fracture]])
* Age at least 65 years old
* A [[Revised Cardiac Risk Score Index]] ([[RCRI]]>1)
 
==Natural History, Complications, and Prognosis==
*60% of cases of abnormal [[troponin]] concentrations , and 1 in 8 [[patients]] presenting to the [[hospital]] will have evidence of [[myocardial injury]].
* Evidence of [[myocardial injury]] in [[chronic heart failure]] [[disease]] was associated with increased [[all-cause mortality]], [[cardiovascular death]], [[cardiovascular hospitalization]].<ref name="AimoJanuzzi2018">{{cite journal|last1=Aimo|first1=Alberto|last2=Januzzi|first2=James L.|last3=Vergaro|first3=Giuseppe|last4=Ripoli|first4=Andrea|last5=Latini|first5=Roberto|last6=Masson|first6=Serge|last7=Magnoli|first7=Michela|last8=Anand|first8=Inder S.|last9=Cohn|first9=Jay N.|last10=Tavazzi|first10=Luigi|last11=Tognoni|first11=Gianni|last12=Gravning|first12=Jørgen|last13=Ueland|first13=Thor|last14=Nymo|first14=Ståle H.|last15=Brunner-La Rocca|first15=Hans-Peter|last16=Genis|first16=Antoni Bayes|last17=Lupón|first17=Josep|last18=de Boer|first18=Rudolf A.|last19=Yoshihisa|first19=Akiomi|last20=Takeishi|first20=Yasuchika|last21=Egstrup|first21=Michael|last22=Gustafsson|first22=Ida|last23=Gaggin|first23=Hanna K.|last24=Eggers|first24=Kai M.|last25=Huber|first25=Kurt|last26=Tentzeris|first26=Ioannis|last27=Tang|first27=Wai H.W.|last28=Grodin|first28=Justin|last29=Passino|first29=Claudio|last30=Emdin|first30=Michele|title=Prognostic Value of High-Sensitivity Troponin T in Chronic Heart Failure|journal=Circulation|volume=137|issue=3|year=2018|pages=286–297|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031560}}</ref>
*Increases in [[cTnI]] [[concentration]]s in [[patient]]s undergoing high-dose [[chemotherapy]] for [[aggressive]] [[malignant]] [[conditions]] have been correlated with future decreases in [[left ventricular]] [[ejection fraction]].
* In [[patients]] with [[chronic kidney disease]] and [[end stage renal disease]], [[amyloidosis]], [[pulmonary embolism]], increased level of [[troponin]] was associated with increased  all-cause [[mortality]].<ref name="AppleLer2016">{{cite journal|last1=Apple|first1=Fred S|last2=Ler|first2=Ranka|last3=Young|first3=Amy|last4=Brunelli|first4=Steven M|last5=Gilbertson|first5=David|last6=Wu|first6=Alan H B|last7=Hu|first7=Yan|last8=Cao|first8=Jing|last9=Love|first9=Sara A|last10=Herzog|first10=Charles A|last11=Sandoval|first11=Yader|title=Prognostic Value of Serial Changes in High-Sensitivity Cardiac Troponin I and T over 3 Months Using Reference Change Values in Hemodialysis Patients|journal=Clinical Chemistry|volume=62|issue=4|year=2016|pages=631–638|issn=0009-9147|doi=10.1373/clinchem.2015.251835}}</ref><ref name="La Vecchia2004">{{cite journal|last1=La Vecchia|first1=L|title=Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism|journal=Heart|volume=90|issue=6|year=2004|pages=633–637|issn=0007-0769|doi=10.1136/hrt.2003.019745}}</ref>
*Among [[patients]] admitted in [[emergency department]], evidence of acute [[myocardial injury ]] was associated with higher rate of all cause [[mortality]] and [[heart failure]] compared with chronic [[myocardial injury]].<ref name="KadesjoRoos2019">{{cite journal|last1=Kadesjo|first1=Erik|last2=Roos|first2=Andreas|last3=Siddiqui|first3=Anwar J.|last4=Desta|first4=Liyew|last5=Lundback|first5=Magnus|last6=Holzmann|first6=Martin|title=ACUTE VERSUS CHRONIC MYOCARDIAL INJURY AND OUTCOMES|journal=Journal of the American College of Cardiology|volume=73|issue=9|year=2019|pages=105|issn=07351097|doi=10.1016/S0735-1097(19)30713-2}}</ref>
 
*[[Prognosis]] is generally poor especially in non-[[cardiac]] causes of [[myocardial injury]] which have higher [[in-hospital]] [[mortality rate]] ( compared with [[cardiac]] causes of chronic [[myocardial injury]]).<ref name="IlvaEskola2010">{{cite journal|last1=Ilva|first1=Tuomo J.|last2=Eskola|first2=Markku J.|last3=Nikus|first3=Kjell C.|last4=Voipio-Pulkki|first4=Liisa-Maria|last5=Lund|first5=Juha|last6=Pulkki|first6=Kari|last7=Mustonen|first7=Harri|last8=Niemelä|first8=Kari O.|last9=Karhunen|first9=Pekka J.|last10=Porela|first10=Pekka|title=The Etiology and Prognostic Significance of Cardiac Troponin I Elevation in Unselected Emergency Department Patients|journal=The Journal of Emergency Medicine|volume=38|issue=1|year=2010|pages=1–5|issn=07364679|doi=10.1016/j.jemermed.2007.09.060}}</ref>
* The 5-year [[mortality rate]] of [[patients]] with [[myocardial injury]] is approximately 70%.<ref name="ChapmanShah2018">{{cite journal|last1=Chapman|first1=Andrew R.|last2=Shah|first2=Anoop S.V.|last3=Lee|first3=Kuan Ken|last4=Anand|first4=Atul|last5=Francis|first5=Oliver|last6=Adamson|first6=Philip|last7=McAllister|first7=David A.|last8=Strachan|first8=Fiona E.|last9=Newby|first9=David E.|last10=Mills|first10=Nicholas L.|title=Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury|journal=Circulation|volume=137|issue=12|year=2018|pages=1236–1245|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031806}}</ref>
 
==Diagnosis==
===Diagnostic Study of Choice===
* There are no established criteria for the diagnosis of [[myocardial injury]]. However, in [[patients]] with increased level of [[cardiac]] [[troponin]], after evaluation about [[myocardial ischemia]], diagnosis and treating the underlying disorders is considered.<ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
 
 
 
 
{{Family tree/start}}
{{Family tree| | | | | A01 | | | |A01=
[[Myocardial injury]]
*Elevated [[cardiac]] [[troponin ]] value >99th [[percentile]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | A02 | | | | A03 |A02=
Acute [[myocardial injury]]
*Rising and/or falling [[troponin]]|A03=
Chronic [[myocardial injury]]
*Stable but elevated [[troponin]] }}
{{Family tree| | |!| | | | | |!| | | | |}}
{{Family tree| |  A4 | | | |  A5 | | | | | | |A4=
[[History]] and [[physical examination]]
*Evaluation for [[myocardial ischemia]]:
*[[Symptoms]]
* New [[electrocardiographic]] changes
*New [[wall-motion abnormalities]] on [[imaging]]
*[[Coronary occlusion]] at [[angiography]]|A5=
[[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]]}}
{{Family tree| |,|^|-|-|.| | | |!| | | | |}}
{{Family tree| |A6 | | A7  | |A8 | | | | | | | | |A6= '''Evidence of [[myocardial]] [[ischemia]]'''
*Type 1 [[Myocardial infarction]] associated with [[Plaque]] [[rupture]], [[ulceration]], or [[dissection]] leading to [[coronary thrombus]]
*Type 2 [[Myocardial infarction]] related to [[supply-demand mismatch]]
*Type 3 [[Sudden cardiac death]] secondary to [[myocardial infarction]]
*Type 4 [[Myocardial infarction]] attributable with [[percutaneous coronary intervention]] or [[stent thrombosis]]
*Type 5 [[Myocardial infarction]] associated with [[cardiac surgery]]|A7='''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]]| A8='''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}}
{{Family tree| |!| | | |`|V|-|-|'| | | | |}}
{{Family tree| |A9 | | |  A10| | | | | | | |A9=Management based on the type of [[myocardial infarction]]| A10=Management based on the causes of [[myocardial injury]] and [[clinical]] course }}
{{Family tree| | | | | | | | | | | | | | |}}
{{Family tree/end}}
 
===[[History]] and [[Symptoms]]===
 
 
*The initial workup includes an evaluation about [[myocardial ischemia]].<ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
* If [[myocardial infarction]] is ruled out, further assessment involves a detailed [[history]], [[physical examination]], [[laboratory testing]], a 12-lead [[electrocardiogram]], and an [[echocardiogram]].
*Medical history should be taken about:
*Recent [[procedures]] ([[cardiac]] and non-[[cardiac]])
* Use of [[cardiotoxic]] [[medications]] ( [[chemotherapy]] and [[substance abuse]])
* [[Activity ]]( [[intense]] [[exercise]] regimens)
* Life [[stressors]] ([[takotsubo cardiomyopathy]])
* Recent [[travel]]
* Comorbidities (specifically [[cardiovascular]], [[pulmonary]], [[renal]] )
* The most practical approach is identifying and treating the underlying causes of [[myocardial injury]].
Common [[symptoms]] associated with underlying causes of [[myocardial injury]] include:
* [[Pleuritic chest pain]] may suggest [[pulmonary embolism]], [[pneumonia]], or [[myocarditis]].
* [[Chest discomfort]] radiating to the [[back]] may suggest [[aortic dissection]].
* [[Dyspnea]], [[orthopnea]], [[paroxysmal nocturnal dyspnea]], and [[peripheral edema]] may suggest  [[heart failure]] [[disease]]
* [[Syncope]], [[angina]], [[dyspnea]] may suggest  [[valvular heart disease]]
* [[Palpitations]], [[syncope]] may be seen in [[patients]] with [[cardiac ]] [[arrhythmias]]
* [[Fevers]], [[chills]] may suggest [[infection]]
 
===Physical Examination===
 
 
*There are no specific [[physical examination]] findings associated with [[myocardial injury]]. However, [[cardiovascular]] evaluation and [[systemic]] organs assessment is warranted as follows:
* Check of [[vital signs]]
* [[Cardiovascular]] system: [[heart rate]] and [[rhythm]], [[murmurs]], presence of [[congestion]]
* [[Pulmonary system]]: [[wheezing]], [[rhonchi]], [[crackles]]
* Detecting origin of [[infection]]
 
===Laboratory Findings===
Laboratory investigation consistent with the diagnosis of [[myocardial injury]] include: <ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
* Serial cardiac [[troponin]] measurement
* [[Renal function]] testing ([[chronic kidney disease]])
* [[Natriuretic peptide]] ([[heart failure]])
* [[Complete blood cell count]] ([[anemia]] or [[infection]])
* [[D-dimer]] ([[pulmonary embolism]], [[aortic dissection]])
* [[C-reactive protein]] ([[infectious]] and [[inflammatory]] markers)
 
 
 
*Serial cardiac [[troponin]] samples should be obtained for differentiating between acute or chronic [[myocardial injury]].
* In [[patients]] suspected [[MI]], given a third sample of [[troponin]] without the pattern of rising and falling (in 26% of [[patients]]) and also [[ECG]] changes may be helpful to differentiate from [[myocardial injury]].<ref name="BjurmanLarsson2013">{{cite journal|last1=Bjurman|first1=Christian|last2=Larsson|first2=Mårten|last3=Johanson|first3=Per|last4=Petzold|first4=Max|last5=Lindahl|first5=Bertil|last6=Fu|first6=Michael L.X.|last7=Hammarsten|first7=Ola|title=Small Changes in Troponin T Levels Are Common in Patients With Non–ST-Segment Elevation Myocardial Infarction and Are Linked to Higher Mortality|journal=Journal of the American College of Cardiology|volume=62|issue=14|year=2013|pages=1231–1238|issn=07351097|doi=10.1016/j.jacc.2013.06.050}}</ref>
 
===Electrocardiogram===
There are no specific [[ECG]] findings associated with [[myocardial injury]]. Findings on an [[ECG]] suggestive of [[myocardial injury]] may include:<ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
* Evidence of [[ischemia]], [[infarction]]
* [[Arrhythmias]]
* Acute [[right ventricular]] strain
* [[Conduction disease]]
* [[Structural disease]] ( [[left ventricular hypertrophy]]).
 
===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]].
* Findings on an [[echocardiography]] associated with [[myocardial injury]] include:
*::Assessment of  [[systolic]] and [[diastolic function]]
*:: [[Left ventricular hypertrophy]]
*:: [[Regional wall motion abnormalities]]
*:: [[Valvular abnormalities]].
 
===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===
*There is no established consensus regarding the routine management of [[myocardial injury]]. However, treating the underlying precipitant factors such as [[heart failure]], [[chronic kidney disease]] is recommended.
* [[WOSCOPS]] study showed that [[pravastatin]] reduced [[hs-cTnI]] in [[patients]] without previous [[MI]] by the means of 13%  leading to reduced future risk of [[MI]] .However, the role of [[pravastatin]] in acute phase of nonischemic [[myocardial injury]] is uncertain.<ref name="FordShah2016">{{cite journal|last1=Ford|first1=Ian|last2=Shah|first2=Anoop S.V.|last3=Zhang|first3=Ruiqi|last4=McAllister|first4=David A.|last5=Strachan|first5=Fiona E.|last6=Caslake|first6=Muriel|last7=Newby|first7=David E.|last8=Packard|first8=Chris J.|last9=Mills|first9=Nicholas L.|title=High-Sensitivity Cardiac Troponin, Statin Therapy, and Risk of Coronary Heart Disease|journal=Journal of the American College of Cardiology|volume=68|issue=25|year=2016|pages=2719–2728|issn=07351097|doi=10.1016/j.jacc.2016.10.020}}</ref>
 
* Use of [[dabigatran]] in [[patients]] with [[myocardial injury]] after [[noncardiac surgery ]] was associated with reduced risk of major [[vascular event rate]]. 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* The efficacy of [[Sodium-glucose cotransporter 2 inhibitors]] such as [[canagliflozin]] in [[patients]] with [[diabetes mellitus]] type 2 and [[myocardial injury]] was a delay of the rise in [[troponin]] over 2 years as well as [[diuresis]], reduce [[blood pressure]], and improve [[left ventricular remodeling]].<ref name="JanuzziButler2017">{{cite journal|last1=Januzzi|first1=James L.|last2=Butler|first2=Javed|last3=Jarolim|first3=Petr|last4=Sattar|first4=Naveed|last5=Vijapurkar|first5=Ujjwala|last6=Desai|first6=Mehul|last7=Davies|first7=Michael J.|title=Effects of Canagliflozin on Cardiovascular Biomarkers in Older Adults With Type 2 Diabetes|journal=Journal of the American College of Cardiology|volume=70|issue=6|year=2017|pages=704–712|issn=07351097|doi=10.1016/j.jacc.2017.06.016}}</ref>
 
 
===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==
{{reflist|2}}
 
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Latest revision as of 19:06, 10 March 2022

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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

    1. ↑ Perry SV (April 2008). "Background to the discovery of troponin and Setsuro Ebashi's contribution to our knowledge of the mechanism of relaxation in striated muscle". Biochem Biophys Res Commun. 369 (1): 43–8. doi:10.1016/j.bbrc.2007.11.185. PMID 18365325.
    2. ↑ Antman, Elliott; Bassand, Jean-Pierre; Klein, Werner; Ohman, Magnus; Lopez Sendon, Jose Luis; Rydén, Lars; Simoons, Maarten; Tendera, Michal (2000). "Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction". Journal of the American College of Cardiology. 36 (3): 959–969. doi:10.1016/S0735-1097(00)00804-4. ISSN 0735-1097.
    3. ↑ 3.0 3.1 3.2 3.3 3.4 McCarthy, Cian P.; Raber, Inbar; Chapman, Andrew R.; Sandoval, Yader; Apple, Fred S.; Mills, Nicholas L.; Januzzi, James L. (2019). "Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays". JAMA Cardiology. 4 (10): 1034. doi:10.1001/jamacardio.2019.2724. ISSN 2380-6583.
    4. ↑ Twerenbold, R.; Jaffe, A.; Reichlin, T.; Reiter, M.; Mueller, C. (2012). "High-sensitive troponin T measurements: what do we gain and what are the challenges?". European Heart Journal. 33 (5): 579–586. doi:10.1093/eurheartj/ehr492. ISSN 0195-668X.
    5. ↑ Januzzi, James; Gaggin, Hanna; Wolf, Myles; Christenson, Robert H; Hise, Michael; Duh, Show-Hong; Kelley, Walter; Seliger, Stephen L; deFilippi, Christopher (2012). "Interpreting Cardiac Troponin Results from High-Sensitivity Assays in Chronic Kidney Disease without Acute Coronary Syndrome". Clinical Chemistry. 58 (9): 1342–1351. doi:10.1373/clinchem.2012.185322. ISSN 0009-9147.
    6. ↑ Chin, C. W. L.; Shah, A. S. V.; McAllister, D. A.; Joanna Cowell, S.; Alam, S.; Langrish, J. P.; Strachan, F. E.; Hunter, A. L.; Maria Choy, A.; Lang, C. C.; Walker, S.; Boon, N. A.; Newby, D. E.; Mills, N. L.; Dweck, M. R. (2014). "High-sensitivity troponin I concentrations are a marker of an advanced hypertrophic response and adverse outcomes in patients with aortic stenosis". European Heart Journal. 35 (34): 2312–2321. doi:10.1093/eurheartj/ehu189. ISSN 0195-668X.
    7. ↑ 7.0 7.1 Sandoval, Yader; Smith, Stephen W.; Sexter, Anne; Thordsen, Sarah E.; Bruen, Charles A.; Carlson, Michelle D.; Dodd, Kenneth W.; Driver, Brian E.; Hu, Yan; Jacoby, Katherine; Johnson, Benjamin K.; Love, Sara A.; Moore, Johanna C.; Schulz, Karen; Scott, Nathaniel L.; Apple, Fred S. (2017). "Type 1 and 2 Myocardial Infarction and Myocardial Injury: Clinical Transition to High-Sensitivity Cardiac Troponin I". The American Journal of Medicine. 130 (12): 1431–1439.e4. doi:10.1016/j.amjmed.2017.05.049. ISSN 0002-9343.
    8. ↑ 8.0 8.1 Aimo, Alberto; Januzzi, James L.; Vergaro, Giuseppe; Ripoli, Andrea; Latini, Roberto; Masson, Serge; Magnoli, Michela; Anand, Inder S.; Cohn, Jay N.; Tavazzi, Luigi; Tognoni, Gianni; Gravning, Jørgen; Ueland, Thor; Nymo, Ståle H.; Brunner-La Rocca, Hans-Peter; Genis, Antoni Bayes; Lupón, Josep; de Boer, Rudolf A.; Yoshihisa, Akiomi; Takeishi, Yasuchika; Egstrup, Michael; Gustafsson, Ida; Gaggin, Hanna K.; Eggers, Kai M.; Huber, Kurt; Tentzeris, Ioannis; Tang, Wai H.W.; Grodin, Justin; Passino, Claudio; Emdin, Michele (2018). "Prognostic Value of High-Sensitivity Troponin T in Chronic Heart Failure". Circulation. 137 (3): 286–297. doi:10.1161/CIRCULATIONAHA.117.031560. ISSN 0009-7322.
    9. ↑ . doi:10.3969/j.issn.1671-5411.2014.02.011. Missing or empty |title= (help)
    10. ↑ Kubo, Toru; Kitaoka, Hiroaki; Yamanaka, Shigeo; Hirota, Takayoshi; Baba, Yuichi; Hayashi, Kayo; Iiyama, Tatsuo; Kumagai, Naoko; Tanioka, Katsutoshi; Yamasaki, Naohito; Matsumura, Yoshihisa; Furuno, Takashi; Sugiura, Tetsuro; Doi, Yoshinori L. (2013). "Significance of High-Sensitivity Cardiac Troponin T in Hypertrophic Cardiomyopathy". Journal of the American College of Cardiology. 62 (14): 1252–1259. doi:10.1016/j.jacc.2013.03.055. ISSN 0735-1097.
    11. ↑ Januzzi, James L.; Suchindran, Sunil; Coles, Adrian; Ferencik, Maros; Patel, Manesh R.; Hoffmann, Udo; Ginsburg, Geoffrey S.; Douglas, Pamela S. (2019). "High-Sensitivity Troponin I and Coronary Computed Tomography in Symptomatic Outpatients With Suspected CAD". JACC: Cardiovascular Imaging. 12 (6): 1047–1055. doi:10.1016/j.jcmg.2018.01.021. ISSN 1936-878X.
    12. ↑ Aeschbacher, Stefanie; Schoen, Tobias; Bossard, Matthias; van der Lely, Stephanie; Glättli, Kathrin; Todd, John; Estis, Joel; Risch, Martin; Mueller, Christian; Risch, Lorenz; Conen, David (2015). "Relationship Between High-Sensitivity Cardiac Troponin I and Blood Pressure Among Young and Healthy Adults". American Journal of Hypertension. 28 (6): 789–796. doi:10.1093/ajh/hpu226. ISSN 0895-7061.
    13. ↑ Røsjø, Helge; Andreassen, Johanna; Edvardsen, Thor; Omland, Torbjørn (2011). "Prognostic Usefulness of Circulating High-Sensitivity Troponin T in Aortic Stenosis and Relation to Echocardiographic Indexes of Cardiac Function and Anatomy". The American Journal of Cardiology. 108 (1): 88–91. doi:10.1016/j.amjcard.2011.02.346. ISSN 0002-9149.
    14. ↑ van den Bos, E. J.; Constantinescu, A. A.; van Domburg, R. T.; Akin, S.; Jordaens, L. J.; Kofflard, M. J. M. (2011). "Minor elevations in troponin I are associated with mortality and adverse cardiac events in patients with atrial fibrillation". European Heart Journal. 32 (5): 611–617. doi:10.1093/eurheartj/ehq491. ISSN 0195-668X.
    15. ↑ Apple, Fred S.; Murakami, MaryAnn M.; Pearce, Lesly A.; Herzog, Charles A. (2002). "Predictive Value of Cardiac Troponin I and T for Subsequent Death in End-Stage Renal Disease". Circulation. 106 (23): 2941–2945. doi:10.1161/01.CIR.0000041254.30637.34. ISSN 0009-7322.
    16. ↑ Heresi, G.A.; Tang, W.H.W.; Aytekin, M.; Hammel, J.; Hazen, S.L.; Dweik, R.A. (2012). "Sensitive cardiac troponin I predicts poor outcomes in pulmonary arterial hypertension". European Respiratory Journal. 39 (4): 939–944. doi:10.1183/09031936.00067011. ISSN 0903-1936.
    17. ↑ Riley, Elise D.; Hsue, Priscilla Y.; Vittinghoff, Eric; Wu, Alan H.B.; Coffin, Phillip O.; Moore, Peter K.; Lynch, Kara L. (2017). "Higher prevalence of detectable troponin I among cocaine-users without known cardiovascular disease". Drug and Alcohol Dependence. 172: 88–93. doi:10.1016/j.drugalcdep.2016.11.039. ISSN 0376-8716.
    18. ↑ Segre, Carlos Alexandre Wainrober; Hueb, Whady; Garcia, Rosa Maria Rahmi; Rezende, Paulo Cury; Favarato, Desiderio; Strunz, Celia Maria Cassaro; Sprandel, Marília da Costa Oliveira; Roggério, Alessandra; Carvalho, Ana Luiza de Oliveira; Maranhão, Raul Cavalcante; Ramires, José Antonio Franchini; Filho, Roberto Kalil (2015). "Troponin in diabetic patients with and without chronic coronary artery disease". BMC Cardiovascular Disorders. 15 (1). doi:10.1186/s12872-015-0051-z. ISSN 1471-2261.
    19. ↑ Bellotto, Fabio; Fagiuoli, Stefano; Pavei, Andrea; Gregory, Shawn A.; Cati, Arianna; Silverj, Elisabetta; Plebani, Mario; Zaninotto, Martina; Mancuso, Tommaso; Iliceto, Sabino (2005). "Anemia and ischemia: Myocardial injury in patients with gastrointestinal bleeding". The American Journal of Medicine. 118 (5): 548–551. doi:10.1016/j.amjmed.2005.01.026. ISSN 0002-9343.
    20. ↑ Puelacher, Christian; Lurati Buse, Giovanna; Seeberger, Daniela; Sazgary, Lorraine; Marbot, Stella; Lampart, Andreas; Espinola, Jaqueline; Kindler, Christoph; Hammerer, Angelika; Seeberger, Esther; Strebel, Ivo; Wildi, Karin; Twerenbold, Raphael; du Fay de Lavallaz, Jeanne; Steiner, Luzius; Gurke, Lorenz; Breidthardt, Tobias; Rentsch, Katharina; Buser, Andreas; Gualandro, Danielle M.; Osswald, Stefan; Mueller, Christian; Seeberger, Manfred; Christ-Crain, Mirjam; Cuculi, Florim; Badertscher, Patrick; Nestelberger, Thomas; Wussler, Desiree; Flores, Dayana; Boeddinghaus, Jasper; Sabti, Zaid; Giménez, Maria Rubini; Kozhuharov, Nikola; Shrestha, Samyut; Kloos, Wanda; Lohrmann, Jens; Reichlin, Tobias; Freese, Michael; Meissner, Kathrin; Kaiser, Christoph; Buser, Andreas (2018). "Perioperative Myocardial Injury After Noncardiac Surgery". Circulation. 137 (12): 1221–1232. doi:10.1161/CIRCULATIONAHA.117.030114. ISSN 0009-7322.
    21. ↑ Lim, Wendy (2006). "Elevated Cardiac Troponin Measurements in Critically Ill Patients". Archives of Internal Medicine. 166 (22): 2446. doi:10.1001/archinte.166.22.2446. ISSN 0003-9926.
    22. ↑ Punukollu, Gopikrishna; Gowda, Ramesh M; Khan, Ijaz A; Mehta, Nirav J; Navarro, Victor; Vasavada, Balendu C; Sacchi, Terrence J (2004). "Elevated serum cardiac troponin I in rhabdomyolysis". International Journal of Cardiology. 96 (1): 35–40. doi:10.1016/j.ijcard.2003.04.053. ISSN 0167-5273.
    23. ↑ Lee, Kuan Ken; Noaman, Ala; Vaswani, Amar; Gibbins, Matthew; Griffiths, Megan; Chapman, Andrew R.; Strachan, Fiona; Anand, Atul; McAllister, David A.; Newby, David E.; Gray, Alasdair J.; Mills, Nicholas L.; Shah, Anoop S.V. (2019). "Prevalence, Determinants, and Clinical Associations of High-Sensitivity Cardiac Troponin in Patients Attending Emergency Departments". The American Journal of Medicine. 132 (1): 110.e8–110.e21. doi:10.1016/j.amjmed.2018.10.002. ISSN 0002-9343.
    24. ↑ Sarkisian, Laura; Saaby, Lotte; Poulsen, Tina S.; Gerke, Oke; Jangaard, Nikolaj; Hosbond, Susanne; Diederichsen, Axel C.P.; Thygesen, Kristian; Mickley, Hans (2016). "Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins". The American Journal of Medicine. 129 (4): 446.e5–446.e21. doi:10.1016/j.amjmed.2015.11.006. ISSN 0002-9343.
    25. ↑ Puelacher, Christian; Bollen Pinto, Bernardo; Mills, Nicholas L.; Duceppe, Emmanuelle; Popova, Ekaterine; Duma, Andreas; Nagele, Peter; Omland, Torbjørn; Hammerer-Lercher, Angelika; Lurati Buse, Giovanna (2021). "Expert consensus on peri-operative myocardial injury screening in noncardiac surgery". European Journal of Anaesthesiology. 38 (6): 600–608. doi:10.1097/EJA.0000000000001486. ISSN 0265-0215.
    26. ↑ Apple, Fred S; Ler, Ranka; Young, Amy; Brunelli, Steven M; Gilbertson, David; Wu, Alan H B; Hu, Yan; Cao, Jing; Love, Sara A; Herzog, Charles A; Sandoval, Yader (2016). "Prognostic Value of Serial Changes in High-Sensitivity Cardiac Troponin I and T over 3 Months Using Reference Change Values in Hemodialysis Patients". Clinical Chemistry. 62 (4): 631–638. doi:10.1373/clinchem.2015.251835. ISSN 0009-9147.
    27. ↑ La Vecchia, L (2004). "Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism". Heart. 90 (6): 633–637. doi:10.1136/hrt.2003.019745. ISSN 0007-0769.
    28. ↑ Kadesjo, Erik; Roos, Andreas; Siddiqui, Anwar J.; Desta, Liyew; Lundback, Magnus; Holzmann, Martin (2019). "ACUTE VERSUS CHRONIC MYOCARDIAL INJURY AND OUTCOMES". Journal of the American College of Cardiology. 73 (9): 105. doi:10.1016/S0735-1097(19)30713-2. ISSN 0735-1097.
    29. ↑ Ilva, Tuomo J.; Eskola, Markku J.; Nikus, Kjell C.; Voipio-Pulkki, Liisa-Maria; Lund, Juha; Pulkki, Kari; Mustonen, Harri; Niemelä, Kari O.; Karhunen, Pekka J.; Porela, Pekka (2010). "The Etiology and Prognostic Significance of Cardiac Troponin I Elevation in Unselected Emergency Department Patients". The Journal of Emergency Medicine. 38 (1): 1–5. doi:10.1016/j.jemermed.2007.09.060. ISSN 0736-4679.
    30. ↑ Chapman, Andrew R.; Shah, Anoop S.V.; Lee, Kuan Ken; Anand, Atul; Francis, Oliver; Adamson, Philip; McAllister, David A.; Strachan, Fiona E.; Newby, David E.; Mills, Nicholas L. (2018). "Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury". Circulation. 137 (12): 1236–1245. doi:10.1161/CIRCULATIONAHA.117.031806. ISSN 0009-7322.
    31. ↑ Bjurman, Christian; Larsson, Mårten; Johanson, Per; Petzold, Max; Lindahl, Bertil; Fu, Michael L.X.; Hammarsten, Ola (2013). "Small Changes in Troponin T Levels Are Common in Patients With Non–ST-Segment Elevation Myocardial Infarction and Are Linked to Higher Mortality". Journal of the American College of Cardiology. 62 (14): 1231–1238. doi:10.1016/j.jacc.2013.06.050. ISSN 0735-1097.
    32. ↑ Ford, Ian; Shah, Anoop S.V.; Zhang, Ruiqi; McAllister, David A.; Strachan, Fiona E.; Caslake, Muriel; Newby, David E.; Packard, Chris J.; Mills, Nicholas L. (2016). "High-Sensitivity Cardiac Troponin, Statin Therapy, and Risk of Coronary Heart Disease". Journal of the American College of Cardiology. 68 (25): 2719–2728. doi:10.1016/j.jacc.2016.10.020. ISSN 0735-1097.
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