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

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Cardiovascular medicine

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

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Paradoxic coronary embolism as an alternative explanation for increased cardiac troponin in acute PE
Tsung O Cheng
Published on: 4 November 2004
Authors Reply
Allan S. Jaffe
Published on: 13 July 2004
Paradoxical Coronary Embolism - an Alternative explanation for increased cardiac troponin in acutePE
Tsung O Cheng
Published on: 1 July 2004

Published on: 4 November 2004
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...
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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.
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Conflict of Interest:
None declared.
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Published on: 13 July 2004
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...
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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.
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Conflict of Interest:
None declared.
- Back to top
Published on: 1 July 2004
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

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