Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism

L La Vecchia; F Ottani; L Favero; G L Spadaro; A Rubboli; C Boanno; G Mezzena; A Fontanelli; A S Jaffe

doi:10.1136/hrt.2003.019745

Responses

Cardiovascular medicine

Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism

Compose a Response to This Article

Compose Response

Title *

Author Information

Contributors
First Name and Middle Initial * First or given name, e.g. 'Peter'. Last Name * Your last, or family, name, e.g. 'MacMoody'. Email Address * Your email address, e.g. higgs-boson@gmail.com Occupation * Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Affiliation * Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

PLEASE NOTE:

A rapid response is a moderated but not peer reviewed online response to a published article in a BMJ journal; it will not receive a DOI and will not be indexed unless it is also republished as a Letter, Correspondence or as other content. Find out more about rapid responses.
We intend to post all responses which are approved by the Editor, within 14 days (BMJ Journals) or 24 hours (The BMJ), however timeframes cannot be guaranteed. Responses must comply with our requirements and should contribute substantially to the topic, but it is at our absolute discretion whether we publish a response, and we reserve the right to edit or remove responses before and after publication and also republish some or all in other BMJ publications, including third party local editions in other countries and languages
Our requirements are stated in our rapid response terms and conditions and must be read. These include ensuring that: i) you do not include any illustrative content including tables and graphs, ii) you do not include any information that includes specifics about any patients,iii) you do not include any original data, unless it has already been published in a peer reviewed journal and you have included a reference, iv) your response is lawful, not defamatory, original and accurate, v) you declare any competing interests, vi) you understand that your name and other personal details set out in our rapid response terms and conditions will be published with any responses we publish and vii) you understand that once a response is published, we may continue to publish your response and/or edit or remove it in the future.
By submitting this rapid response you are agreeing to our terms and conditions for rapid responses and understand that your personal data will be processed in accordance with those terms and our privacy notice.

I agree to and have read the terms and conditions for rapid responses and BMJ Privacy Notice *

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Other responses

Jump to comment:

Paradoxic coronary embolism as an alternative explanation for increased cardiac troponin in acute PE
Tsung O Cheng
Published on: 23 November 2015
Authors Reply
Allan S. Jaffe
Published on: 23 November 2015
Paradoxical Coronary Embolism - an Alternative explanation for increased cardiac troponin in acutePE
Tsung O Cheng
Published on: 23 November 2015

Published on: 23 November 2015
Paradoxic coronary embolism as an alternative explanation for increased cardiac troponin in acute PE
- Tsung O Cheng, Professor of Medicine
- Other Contributors:
  n.a.
Dear Editor,
La Vecchia et al [1] considered increased cardiac troponin on admission to be the strongest independent predictor of mortality in acute pulmonary embolism. They attributed the increased troponin to right ventricular involvement, because they excluded patients with known or prior coronary artery disease in their study. The criteria they used for exclusion were documented angina, previous my...
Show More

Dear Editor,
La Vecchia et al [1] considered increased cardiac troponin on admission to be the strongest independent predictor of mortality in acute pulmonary embolism. They attributed the increased troponin to right ventricular involvement, because they excluded patients with known or prior coronary artery disease in their study. The criteria they used for exclusion were documented angina, previous myocardial infarction, coronary angioplasty or bypass surgery.
But they have not excluded coronary embolism which can occur in patients without prior, known coronary artery disease. As a matter of fact, paradoxical coronary embolism has been reported in patients with increased pulmonary artery pressure, e.g., pulmonary embolism [2,3] or increased right atrial pressure, e.g. Valsalva maneuver or cough [2-4]. It also accounts for ST segment elevation in right precordial leads on ECG in patients with acute pulmonary embolism [5,6]. Paradoxical coronary embolism may contribute to the increased mortality in patients with acute pulmonary embolism [7,8].
Finally, the diagnosis of paradoxical embolism in acute pulmonary embolism carries an important therapeutic implication, because patent foramen ovale, the commonest cause of paradoxical embolism, can now be closed nonsurgically [9].
References
(1). La Vecchia L, Ottani F, Favero L, Spadaro GL, Rubboli A, Boanno C, Mezzena G, Fontanelli A, Jaffe AS: Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism. Heart 2004;90:633-637.
(2). Cheng TO: Paradoxical embolism. A diagnostic challenge and its detection during life. Circulation 1976;53:565-568.
(3). Cheng, TO: Paradoxic embolism. Am Heart J 1996;131:1238.
(4). Cheng TO: Paradoxical embolism: diagnosis and management. J Emerg Med 2001;20:416-417.
(5). Cheng TO: Right-sided chest-lead abnormalities on EKG in acute pulmonary embolism. J Nat Med Assoc 2003;95:862.
(6). Cheng TO: Brugada syndrome vs pulmonary embolism vs paradoxical embolism. What are we to believe? Int J Cardiol 2004;94:119.
(7). Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, Rauber K, Iversen S, Redecker M, Kienast J: Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997;30:1165-1171.
(8). Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H: Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998;97:1946-1951.
(9). Cheng TO: Percutaneous closure of patent foramen ovale is the procedure of choice for paradoxical embolism. Circulation 2003;108:e126.
Show Less

Conflict of Interest:
None declared.
- Back to top
Published on: 23 November 2015
Authors Reply
- Allan S. Jaffe, M.D.
- Other Contributors:
  Luigi LaVecchia
Dear Editor
Dr. O Cheng raises the possibility that some elevations of troponin we attribute to pulmonary emboli [1] may be due to paradoxical coronary emboli [2].
We cannot, since all of the patients were not cathed acutely, exclude this possibility with data although we did not observe in this series focal ST segment elevation as one might expect from a paradoxical embolism.
We did angiogram...
Show More

Dear Editor
Dr. O Cheng raises the possibility that some elevations of troponin we attribute to pulmonary emboli [1] may be due to paradoxical coronary emboli [2].
We cannot, since all of the patients were not cathed acutely, exclude this possibility with data although we did not observe in this series focal ST segment elevation as one might expect from a paradoxical embolism.
We did angiograms for a few patients who had confusing clinical presentations (n= 5) and did not find paradoxical emboli. Furthermore, our present understanding suggests that paradoxical coronary emboli are unusual and that most paradoxic emboli do not migrate to the coronary arteries [3,4].
We did not observe any systemic emboli. In addition, there is adequate experimental and clinical data to support the contention that the acute right heart strain caused by pulmonary emboli can cause RV dysfunction, ECG changes and troponin release [5,6].
It is certainly possible that in some patients there may left ventricular injury due to occult coronary artery disease and either hypotension, increased cardiac work or both [7]. It would be difficult for us to advocate coronary angiography in every patient with a pulmonary embolism and troponin release or ECG changes until Dr. O Cheng and others provide more data to suggest that this is a common occurrence.
Until that time, we and others should be aware of this rare complication, so that in the unusual case, it can be considered as part of the differential diagnosis in selected individuals.
References
(1). La Vecchia L, Ottani F, Favero L, Spadaro GL, Rubboli A, Bonanno C, Mezzena G, Fontanelli A, Jaffe AS: Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism. Heart 2004;90:633-637.
(2). Cheng TO, Paradoxical Coronary Embolism - an Alternative explanation for increased cardiac troponin in acutePE. Heart 2004; 90:
(3). Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H: Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998;97:1946-1951.
(4). Wachsman DE, Jacobs AK. Paradoxical coronary embolism: a rare cause of acute myocardial infarction. Reviews in Cardiovascular Medicine 2003; 4:107-11.
(5). Goldhaber SZ, Elliot CG: Acute pulmonary embolism. Part 2. Risk stratification, treatment and prevention. Circulation 2003; 108:2834-2838.
(6). Ammann P, Maggiorini M, Bertel O, Haenseler E, Joller-Jemelka HI, Oechslin E, Minder EI, Rickli H, Fehr T.Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes.Rev Cardiovasc Med. 2003;4:107-11.
(7). Kiryu S, Raptopoulos V, Baptista J, Hatabu H.Increased prevalence of coronary artery calcification in patients with suspected pulmonary embolism. Am Coll Cardiol. 2003;41:2004-9.
Show Less

Conflict of Interest:
None declared.
- Back to top
Published on: 23 November 2015
Paradoxical Coronary Embolism - an Alternative explanation for increased cardiac troponin in acutePE
- Tsung O Cheng, Professor of Medicine
Dear Editor
La Vecchia et al. [1] considered increased cardiac troponin on admission to be the strongest independent predictor of mortality in acute pulmonary embolism. They attributed the increased troponin to right ventricular involvement, because they excluded patients with known or prior coronary artery disease in their study. The criteria they used for exclusion were documented angina, previous myocardial...
Show More

Dear Editor
La Vecchia et al. [1] considered increased cardiac troponin on admission to be the strongest independent predictor of mortality in acute pulmonary embolism. They attributed the increased troponin to right ventricular involvement, because they excluded patients with known or prior coronary artery disease in their study. The criteria they used for exclusion were documented angina, previous myocardial infarction, coronary angioplasty or bypass surgery.
But they have not excluded coronary embolism which can occur in patients without prior, known coronary artery disease. As a matter of fact, paradoxical coronary embolism has been reported in patients with increased pulmonary artery pressure, e.g. pulmonary embolism [2,3] or increased right atrial pressure, e.g. Valsalva maneuver or cough.[2-4] It also accounts for ST segment elevation in right precordial leads on ECG in patients with acute pulmonary embolism.[5,6] Paradoxical coronary embolism may contribute to the increased mortality in patients with acute pulmonary embolism.[7,8] Finally, the diagnosis of paradoxical embolism in acute pulmonary embolism carries an important therapeutic implication, because patent foramen ovale, the commonest cause of paradoxical embolism, can now be closed nonsurgically.[9]
References
1. La Vecchia L, Ottani F, Favero L, Spadaro GL, Rubboli A, Boanno C, Mezzena G, Fontanelli A, Jaffe AS: Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism. Heart 2004;90:633-637.
2. Cheng TO: Paradoxical embolism. A diagnostic challenge and its detection during life. Circulation 1976;53:565-568.
3. Cheng, TO: Paradoxic embolism. Am Heart J 1996;131:1238.
4. Cheng TO: Paradoxical embolism: diagnosis and management. J Emerg Med 2001;20:416-417.
5. Cheng TO: Right-sided chest-lead abnormalities on EKG in acute pulmonary embolism. J Nat Med Assoc 2003;95:862.
6. Cheng TO: Brugada syndrome vs pulmonary embolism vs paradoxical embolism. What are we to believe? Int J Cardiol 2004;94:119.
7. Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, Rauber K, Iversen S, Redecker M, Kienast J: Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997;30:1165-1171.
8. Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H: Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998;97:1946-1951.
9. Cheng TO: Percutaneous closure of patent foramen ovale is the procedure of choice for paradoxical embolism. Circulation 2003;108:e126.
Show Less

Conflict of Interest:
None declared.
- Back to top

Main menu

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Log in using your username and password

Main menu

Log in using your username and password

You are here

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Read the full text or download the PDF:

Log in using your username and password