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Mechanism of Elevated Cardiac Troponin in Acute Ischemic Stroke
Study Questions:
What is the coronary vessel status in acute ischemic stroke (AIS) patients with elevated cardiac troponin (cTn), compared to patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS)?
Methods:
TRELAS (TRoponin ELevation in Acute ischemic Stroke) was a prospective, observational study with blinded endpoint assessment of AIS patients presenting within 72 hours after symptom onset. AIS was defined as a sudden neurological deficit caused by cerebral ischemia, as confirmed by neuroimaging. Patients with elevated cTn levels (>50 ng/L) on presentation or during the following day underwent diagnostic coronary angiography within 72 hours. Patients with impaired kidney function (creatinine >1.20 mg/dl) were excluded. Twenty-nine AIS patients underwent conventional angiography and were compared to age- and gender-matched patients with NSTE-ACS. The primary outcome was the presence of a coronary culprit lesion on diagnostic coronary angiography.
Results:
Median cTn on presentation did not differ between patients with AIS or NSTE-ACS. Compared to patients with NSTE-ACS, AIS patients were less likely to have coronary culprit lesions (7/29 vs. 23/29, p < 0.001) or any obstructive coronary artery disease (15/29 vs. 25/29, p = 0.02). Angioplasty with stenting of the culprit lesion was performed in the same session in three AIS patients. In three other AIS patients, a staged intervention after neurological rehabilitation was recommended. In contrast, 20 patients with NSTE-ACS received immediate revascularization and three underwent coronary artery bypass graft surgery.
Conclusions:
Despite similar baseline cTn levels, coronary culprit lesions are significantly less frequent in AIS patients compared to age- and gender-matched patients with NSTE-ACS.
Perspective:
This is an important study, albeit limited by a small sample size of 29 AIS patients compared to age- and gender-matched patients with NSTE-ACS, that helps clarify coronary vessel status in AIS patients with elevated cTn. Indeed, elevation of cTn in AIS is a common finding and often presents a dilemma. The majority of AIS patients with elevated cTn do not have coincident ACS and about 50% of patients do not have evidence of obstructive coronary artery disease. As the authors opine, ‘Clinical conditions provoking coronary demand ischemia (i.e., Type 2 MI) and non-coronary causes are more likely to be the source of cTn release in the majority of AIS patients.’
Keywords: Acute Coronary Syndrome, Angiography, Brain Ischemia, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Creatinine, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Neuroimaging, Stroke, Troponin, Vascular Diseases
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