Neurological update: use of cardiac troponin in patients with stroke

Jan F Scheitz, Helena Stengl, Christian H Nolte, Ulf Landmesser, Matthias Endres, Jan F Scheitz, Helena Stengl, Christian H Nolte, Ulf Landmesser, Matthias Endres

Abstract

Cardiac troponin is a specific and sensitive biomarker to identify and quantify myocardial injury. Myocardial injury is frequently detected after acute ischemic stroke and strongly associated with unfavorable outcomes. Concomitant acute coronary syndrome is only one of several possible differential diagnoses that may cause elevation of cardiac troponin after stroke. As a result, there are uncertainties regarding the correct interpretation and optimal management of stroke patients with myocardial injury in clinical practice. Elevation of cardiac troponin may occur as part of a 'Stroke-Heart Syndrome'. The term 'Stroke-Heart Syndrome' subsumes a clinical spectrum of cardiac complications after stroke including cardiac injury, dysfunction, and arrhythmia which may relate to disturbances of autonomic function and the brain-heart axis. In this review, we provide an up-to-date overview about prognostic implications, mechanisms, and management of elevated cardiac troponin levels in patients with acute ischemic stroke.

Keywords: Brain–heart interaction; Cardiac biomarker; Cardiac troponin; Ischemic stroke; Myocardial infarction; Myocardial injury; Stroke-heart-syndrome.

Conflict of interest statement

ME reports grants from Bayer and fees paid to the Charité from Bayer, Boehringer Ingelheim, BMS, Daiichi Sankyo, Amgen, GSK, Sanofi, Covidien, Novartis, Pfizer, all outside the submitted work. Dr Nolte received speaker and/or consultation fees from Boehringer Ingelheim, Bristol-Myers Squibb, Pfizer Pharma, Abbott and W.L. Gore and Associates, all outside the submitted work. The other authors report no conflicts of interest.

Figures

Fig. 1
Fig. 1
Taxonomy of myocardial injury and possible impact of stroke. Myocardial injury can be acute or chronic. In case of evidence of cardiac ischemia (clinical symptoms, ischemic ECG alterations, evidence of new wall motion abnormalities) myocardial infarction can be suspected (see Info-Box for definitions). Stroke-associated alterations in the central autonomic network lead to autonomic imbalance with activation of the sympathetic nervous system (SNS) and hypothalamic–pituitary–adrenal axis (HPA). In addition, stroke results in a pro-inflammatory response. Thereby, stroke can trigger both ischemic and non-ischemic myocardial injury
Fig. 2
Fig. 2
Interpretation and management of troponin elevation after acute ischemic stroke. Systematic approach to the interpretation, classification, and diagnostic steps of elevated cardiac troponin levels in patients with acute ischemic stroke. (Algorithm is based on literature [4, 10, 11] and has not been validated). CMR cardiovascular magnetic resonance tomography, cTn cardiac troponin, DAPT dual antiplatelet therapy, ECG electrocardiogram, MI myocardial infarction, SHS stroke heart syndrome, TTE transthoracic echocardiography, URL upper reference limit

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