Case Study: 70-year old womanCase Study: 13-year male adolescentCase Study: 82-year woman
Case
70-year old woman
Key signs and symptoms
Progressive orthopnea and exertional dyspnea for 4 days, associated with chest tightness and palpitation.
Medical history/
Clinical examination
Medical history: Congestive heart failure, valvular heart disease, and third degree atrioventricular block, status post permanent pacemaker implantation. Clinical examination: BP 106/69mmHg, HR 106 BPM, RR 26BPM, temperature 36.7C, oxygen saturation 97%, Glasgow coma scale 15.
Laboratory test
results
Test
Value
Reference range
WBC (x103/μL)
6.05
3.54 – 9.06
Hemoglobin (g/dL)
12.1
10.8 – 14.9
NT-proBNP (pg/mL)
3319
Rule out of acute heart failure
(AHF): <300 pg/mL
Rule in AHF:
< 50 years: >450 pg/mL
50 – 75 years: >900 pg/mL
>75 years: >1800 pg/mL
ECG
Atrial fibrillation with rapid ventricular response; nonspecific ST and T wave abnormality
Although the hs-cTnT level was higher than the 99th percentile cutoff (14 ng/L), serial measurement did not disclose an significant kinetic change higher than 20%, acute myocardial infarction can be excluded
Author’s opinion
•
Acute heart failure is a common cause for troponin elevation. Serial measurement with an significant kinetic change would help rule in or rule out MI.
•
In addition, measurement of troponin is recommended as an initial laboratory test in patients presenting with suspected acute heart failure to investigate the trigger of acute heart failure. Potential trigger include: ACS (acute coronary syndrome), hypertension, atrial fibrillation, mechanical reasons such as aortic valve stenosis, pneumonia or pulmonary embolism. Highly elevated cTnT-hs or relevant rising values increase the probability for myocardial ischemia/NSTEMI as the relevant trigger.
Case
13-year male adolescent
Key signs and
symptoms
Chest pain located at the central chest. The pain was diffuse and persistent for 2-3 hours without radiation.
Medical history/
Clinical examination
Medical history: Past history of chest pain and asthma. Clinical examination: BP 129/87mmHg, HR 81 BPM, RR 20 BPM, temperature 36C, oxygen saturation 97%, Glasgow coma scale 15.
Laboratory test
results
Test
Value
Reference range
WBC (x103 /μL)
12.65
3.54 – 9.06
Segmented neutrophil (%)
83.2
50 – 70
Hemoglobin (g/dL)
14.1
10.8 – 14.9
CRP (mg/dL)
11.27
<1
Creatinine clearance (ml/min)
143
90 – 139
ECG at
admission
Concave ST elevation
at lead II, III, aVF
Subsequent
ECG
Evolutionary changes with normalisation of ST elevation and diffuse T-wave inversion
Troponin kinetic profile
Chest X-ray
Echocardiography
Normal LV size and function; no pericardial effusion
First ECG showed concave ST elevation at lead II, III, aVF. Subsequent ECG showed evolutionary
changes with normalisation of ST elevation and diffuse T-wave inversion.
•
Troponins does not follow the kinetics of peak and fall commonly seen in patients with MI.
•
Symptoms quickly subside after NSAID (nonsteroidal anti-inflammatory drugs) treatment.
Author’s opinion
•
Pericarditis and myocarditis are characterized by ECG changes and elevated cardiac enzymes,
respectively, and patients with perimyocarditis often complain of chest discomfort.
•
These findings are nonspecific and often lead to diagnostic difficulties, as ST-elevation myocardial
infarction commonly presents in a similar fashion.
•
Perimyocarditis usually manifest with concave ST elevations, which did not conform to a particular
coronary artery territory.
•
In this case, the ECG change was limited to inferior lead. However, due to the benign course with no
known risk factors, acute perimyocarditis is most likely the diagnosis.
Case
82-year woman
Key signs and
symptoms
Fever and fank pain.
Medical history/
Clinical examination
Medical history: Stroke, hypertension and parkinsonism. Clinical examination: BP 172/89mmHg, HR 88BPM, RR 20BPM, temperature 38.6C, oxygen saturation 93%, Glasgow coma scale 15.
Laboratory test
results
Test
Value
Reference range
WBC (x103/μL)
16.34
3.54 – 9.06
Segmented neutrophil (%)
89.2
50 – 70
Hemoglobin (g/dL)
14.2
10.8 – 14.9
CRP (mg/dL)
3.20
<1
Creatinine clearance (ml/min)
101.7
90 – 139
NT-proBNP (pg/mL)
240
Rule out of acute heart failure
(AHF): <300 pg/mL
Rule in AHF:
< 50 years: >450 pg/mL
50 – 75 years: >900 pg/mL
>75 years: >1800 pg/mL
The mild rise and fall of cardiac troponin with lateral lead ST-depression does not favor a occlusive coronary pathology.
Author’s opinion
•
This is a case with troponin elevation with relevant changes but without clear clinical context of ischemia. Troponin elevation is compatible with severe infection or sepsis.
