This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Social Bookmarking   What's this?

A Frequently Unrecognized Complication

Thomas M. Guest, MD; Anand V. Ramanathan, MD; Peter G. Tuteur, MD; Kenneth B. Schechtman, PhD; Jack H. Ladenson, PhD; Allan S. Jaffe, MD

JAMA. 1995;273(24):1945-1949.

Abstract
Objective.
—To determine the incidence and effect of unrecognized cardiac injury in critically ill patients.

Design.
—Prospective, blinded, single-center study.

Setting.
—The medical and respiratory intensive care unit of an academic health center.

Patients.
—Two hundred nine patients (224 admissions).

Main Outcome Measures.
—Daily measurement of levels of cardiac troponin I, a sensitive, highly specific, and long-lived marker of myocardial injury. Concurrently, signs and symptoms potentially related to myocardial ischemia were tabulated by blinded investigators. All clinical evaluation and management decisions were made by the physicians responsible for the care of the patient.

Results.
—Thirty-two (15%) of the 209 patients had evidence of myocardial damage based on elevated levels of cardiac troponin I. Only 12(37%) of these 32 patients were diagnosed as having acute myocardial infarction by the intensive care unit staff. Cardiac damage was unrecognized in the other 20 (63%). Unrecognized cardiac injury was more common in young patients and in blacks. Mortality in patients with myocardial injury that was recognized (42%) or unrecognized (40%) was higherthan in those without myocardial injury (15%) (P<.001). Patients with cardiac injury were more frequently hypotensive (75% vs 50%; P=.007) and in need of mechanical ventilation (66% vs 27%; P<.001) and had longer intensive care unit stays (5.3 vs 3.1 days; P<.007) than patients without cardiac injury.

Conclusion.
—The incidence of myocardial injury defined by elevated levels of cardiac troponin I was unexpectedly high and associated with increased morbidity and mortality. Clinically, it was often unrecognized.

(JAMA. 1995;273:1945-1949)

Author Affiliations
From the Department of Medicine (Drs Guest and Ramanathan), the Pulmonary and Critical Care Divisions (Dr Tuteur), the Department of Biostatistics (Dr Schechtman), the Departments of Medicine and Pathology, Division of Laboratory Medicine (Dr Ladenson), and the Cardiovascular Division (Dr Jaffe), Washington University School of Medicine, St Louis, Mo. Dr Jaffe is now with the Cardiovascular Division, State University of New York Health Science Center at Syracuse College of Medicine.

Footnotes
Dr Ladenson is a consultant to Baxter Diagnostics Inc, Miami, Fla, and there are licensing agreements between Baxter Diagnostics Inc and Washington University, St Louis, Mo, in the field of biochemical cardiovascular markers.

Reprint requests to the Cardiovascular Division, State University of New York Health Science Center at Syracuse College of Medicine, 750 E Adams St, Syracuse, NY 13210 (Dr Jaffe).

Concepts in Emergency and Critical Care section editor: Roger C. Bone, MD, Consulting Editor, JAMA.

Advisory Panel: Bart Chernow, MD, Baltimore, Md; David Dantzker, MD, New Hyde Park, NY; Jerrold Leiken, MD, Chicago, Ill; Joseph E. Parrillo, MD, Chicago, Ill; William J. Sibbald, MD, London, Ontario; and Jean-Louis Vincent, MD, PhD, Brussels, Belgium.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Interpreting troponin elevations: do we need multiple diagnoses?
Pierpont and McFalls
Eur Heart J 2009;30:135-138.
FULL TEXT  

Requiem for a Heavyweight: The Demise of Creatine Kinase-MB
Saenger and Jaffe
Circulation 2008;118:2200-2206.
FULL TEXT  

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: Use of Cardiac Troponin and B-Type Natriuretic Peptide or N-Terminal proB-Type Natriuretic Peptide for Etiologies Other than Acute Coronary Syndromes and Heart Failure
NACB WRITING GROUP MEMBERS et al.
Clin. Chem. 2007;53:2086-2096.
ABSTRACT | FULL TEXT  

Elevated Cardiac Troponin Measurements in Critically Ill Patients
Lim et al.
Arch Intern Med 2006;166:2446-2454.
ABSTRACT | FULL TEXT  

Cardiovascular dysfunction in dogs associated with critical illnesses.
Nelson and Thompson
Journal of the American Animal Hospital Association 2006;42:344-349.
ABSTRACT | FULL TEXT  

Early and long-term prognostic value of Troponin-I after cardiac surgery in newborns and children.
Bottio et al.
Eur. J. Cardiothorac. Surg. 2006;30:250-255.
ABSTRACT | FULL TEXT  

Neuroanatomic correlates of stroke-related myocardial injury
Ay et al.
Neurology 2006;66:1325-1329.
ABSTRACT | FULL TEXT  

Elevated Cardiac Troponin Levels in Critically Ill Patients: Prevalence, Incidence, and Outcomes
Lim et al.
Am J Crit Care 2006;15:280-288.
ABSTRACT | FULL TEXT  

Sepsis-Associated Myocardial Dysfunction: Diagnostic and Prognostic Impact of Cardiac Troponins and Natriuretic Peptides
Maeder et al.
Chest 2006;129:1349-1366.
ABSTRACT | FULL TEXT  

Use of Admission Troponin in Critically Ill Medical Patients
Minkin et al.
J Intensive Care Med 2005;20:286-290.
ABSTRACT  

Troponin: the biomarker of choice for the detection of cardiac injury
Babuin and Jaffe
CMAJ 2005;173:1191-1202.
ABSTRACT | FULL TEXT  

Myocardial Injury in Critically Ill Patients: Relation to Increased Cardiac Troponin I and Hospital Mortality
Quenot et al.
Chest 2005;128:2758-2764.
ABSTRACT | FULL TEXT  

Relationship Between B-Type Natriuretic Peptides and Pulmonary Capillary Wedge Pressure in the Intensive Care Unit
Forfia et al.
J Am Coll Cardiol 2005;45:1667-1671.
ABSTRACT | FULL TEXT  

Narrative Review: Alternative Causes for Elevated Cardiac Troponin Levels when Acute Coronary Syndromes Are Excluded
Jeremias and Gibson
ANN INTERN MED 2005;142:786-791.
ABSTRACT | FULL TEXT  

Cardiac troponin after major vascular surgery: The role of perioperative ischemia, preoperative thallium scanning, and coronary revascularization
Landesberg et al.
J Am Coll Cardiol 2004;44:569-575.
ABSTRACT | FULL TEXT  

Common Causes of Troponin Elevations in the Absence of Acute Myocardial Infarction: Incidence and Clinical Significance
Roongsritong et al.
Chest 2004;125:1877-1884.
ABSTRACT | FULL TEXT  

Identification, characterization, and gene expression profiling of endotoxin-induced myocarditis
Wong et al.
Proc. Natl. Acad. Sci. USA 2003;100:14241-14246.
ABSTRACT | FULL TEXT  

Frequency and Outcomes of Transient Myocardial Ischemia in Critically Ill Adults Admitted for Noncardiac Conditions
Booker et al.
Am J Crit Care 2003;12:508-517.
ABSTRACT | FULL TEXT  

Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes
Ammann et al.
J Am Coll Cardiol 2003;41:2004-2009.
ABSTRACT | FULL TEXT  

Differences of Creatine Kinase MB and Cardiac Troponin I Concentrations in Normal and Diseased Human Myocardium
Welsh et al.
Annals of Clinical & Laboratory Science 2002;32:44-49.
ABSTRACT | FULL TEXT  

Cardiac Involvement in Patients With Acute Neurologic Disease: Confirmation With Cardiac Troponin I
Dixit et al.
Arch Intern Med 2000;160:3153-3158.
ABSTRACT | FULL TEXT  

Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage
Parekh et al.
J Am Coll Cardiol 2000;36:1328-1335.
ABSTRACT | FULL TEXT  

It's Time for a Change to a Troponin Standard
Jaffe et al.
Circulation 2000;102:1216-1220.
FULL TEXT  

Troponin-I for prediction of early postoperative course after pediatric cardiac surgery
Immer et al.
J Am Coll Cardiol 1999;33:1719-1723.
ABSTRACT | FULL TEXT  

Perioperative Risk Stratification in Patients Undergoing Noncardiac Surgery: Kloehn, GC and O'Rourke, RA Perioperative Risk Stratification in Patients Undergoing Noncardiac Surgery J Intensive Care Med 1999,14 95-108
Kloehn and O'Rourke
J Intensive Care Med 1999;14:95-108.
ABSTRACT  

Cardiac troponin T and cardiac troponin I: relative values in short-term risk stratification of patients with acute coronary syndromes
Christenson et al.
Clin. Chem. 1998;44:494-501.
ABSTRACT | FULL TEXT  

Cardiac troponin I measurement with the ACCESS® immunoassay system: analytical and clinical performance characteristics
Christenson et al.
Clin. Chem. 1998;44:52-60.
ABSTRACT | FULL TEXT  

Circulating Cardiac Troponin I in Severe Congestive Heart Failure
Missov et al.
Circulation 1997;96:2953-2958.
ABSTRACT | FULL TEXT  

Improved detection of minor ischemic myocardial injury with measurement of serum cardiac troponin I
Apple et al.
Clin. Chem. 1997;43:2047-2051.
ABSTRACT | FULL TEXT  

Prevention of Analytical False-Positive Increases of Cardiac Troponin I on the Stratus II Analyzer • A representative of Dade International replies:
Roberts et al.
Clin. Chem. 1997;43:860-861.
FULL TEXT  

Cardiac-Specific Troponin I Levels to Predict the Risk of Mortality in Patients with Acute Coronary Syndromes
Antman et al.
NEJM 1996;335:1342-1349.
ABSTRACT | FULL TEXT  

Myocardial Injury in Critically III Patients
Beck
JAMA 1995;274:1672-1672.
ABSTRACT  

Myocardial Injury in Critically III Patients
Fromm and Varon
JAMA 1995;274:1672-1672.
ABSTRACT  

Unrecognized Myocardial Injury in ICU Patients
Journal Watch Cardiology 1995;1995:18-18.
FULL TEXT  

UNRECOGNIZED MYOCARDIAL INJURY IN ICU PATIENTS
JWatch General 1995;1995:4-4.
FULL TEXT