Dolor torácico, electrocardiograma y enzimas cardiacas: una propuesta práctica de manejo hospitalario

La presentación clínica de la enfermedad arterioesclerótica coronaria abarca un espectro amplio: desde el paciente totalmente asintomático, a pesar de la existencia de lesiones obstructivas de grado variable en el árbol coronario, o bien, el paciente que refiere opresión precordial relacionada de manera exclusiva a esfuerzo físico, hasta el paciente que aqueja dolor precordial opresivo intenso de reposo, y acude a la sala de urgencias. En cada uno de estos contextos, existe una secuencia fisiopatológica distinta, a pesar de su origen común. Se presenta una propuesta práctica para el manejo del paciente con dolor torácico en la sala de urgencias, en diferentes contextos clínicos cuyo origen fisiopatológico es distinto; se comenta la utilidad y forma de interpretación del dosaje de las "enzimas cardiacas".

The clinical presentation of coronary arteriosclerotic disease covers a broad spectrum: from the patient totally asymptomatic, despite the existence of obstructive lesions of variable degree in the coronary tree, or the patient who refers precordial oppression related exclusively to physical activity, even the patient who suffers severe oppressive precordial pain at rest, and goes to the emergency room. In each of these contexts, there is a distinct physiopathological sequence, despite its common origin. A practical proposal for the management of patients with chest pain in the emergency room, in different clinical contexts with a different pathophysiology is presented. The usefulness and interpretation of the dosage of the "cardiac enzymes" is discussed.

To estimate the serum level of N-terminal pro-brain natriuretic peptide levels in acute coronary syndrome

Background: Acute coronary syndromes caused by a sudden blockage of a coronary artery. According to degree and location of the blockage, it ranges from unstable angina to non–STsegment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction (STEMI), and sudden cardiac death. The levels of serum cardiac markers get elevated during myocardial necrosis in ACS. B-type natriuretic peptide (BNP), cardiac neurohormone, and its Nterminal fragment (NT-proBNP) are synthesized and secreted from the ventricular myocardium. It is well known that the stimulus for their release is the increase in left ventricular wall stress. Aim and objectives: To estimate the serum level of N-terminal pro-Brain natriuretic peptide levels in acute coronary syndrome, to assess the levels of NT-pro-BNP and its relationship between STEMI, NSTEMI and Unstable angina patients. Materials and methods: The study included 40 patients admitted in the medicine ward of RMMCH. The study period was from January 2018- July 2018. Patients with acute coronary syndromes were identified over a period according to the criteria and were included in the study. The patients were completely evaluated and their serum NT-pro BNP levels were noted. Killips Class was recorded if the patient was in acute MI. In NSTEMI, STEMI and unstable angina, TIMI scoring was also calculated. Results: The common age of the patients was 51 to 60 years (50%). In the age group of 41 to 50 years, 30% was observed. In the age category of 31 to 40 years, 20% was observed. The mean age was 49.10 years. There was 55% of patients with NT pro BNP > 500 in the age category 51- 60 years whereas only 16.7% in this range in the age category 41 to 50 years and again only 8% Mohamed Yasar Arafath, K. Babu Raj. To estimate the serum level of N-terminal pro-brain natriuretic peptide levels in acute coronary syndrome. IAIM, 2019; 6(1): 8-15. Page 9 in the age category 30 to 40 years. The Majority of 30 to 40 years had NT pro-BNP of 100 to 500 (62.5%). In the age category of 41 to 50 years, 50% had NT Pro BNP of 100 to 500 while only 35% was in this range in the age group of 51-60 years. In the age category of 41 to 50 years, 33.3% had NT pro-BNP of < 100 whereas only 10% of 51 to 60 years had NT pro-BNP of < 100 and in the age category of 30 to 40 years, no one had NT pro-BNP of <100. The chi-square test of association was insignificant. Cardiac enzymes (Troponin T and CKMB) was elevated for the majority of the patients (N=27, 67.5%). Cardiac enzymes (Troponin T and CKMB) were normal for only 32.5% of the patients. The correlation of TIMI score with NT pro-BNP was peak positive i.e. if NT pro-BNP is higher, TIMI score was also higher and vice versa but the correlation was insignificant (r=2.54, p = .64). Conclusion: Even though the study is done in patients without clinical signs of heart failure, the levels of NT-proBNP had an inverse relationship with Ejection Fraction. Low NT-proBNP levels at the time of admission rule out high-risk patients or patients with heart failure.

Enfermedad renal crónica en hemodiálisis: concentración de enzimas cardíacas en ausencia de evidencia de cardiopatía isquémica aguda / Chronic Kidney Disease in hemodialysis: cardiac enzymes concentrations without evidence of acute coronary disease

Se trata de un estudio observacional, analítico y prospectivo cuyo objetivo es analizar la concentración de enzimas cardíacas en pacientes con enfermedad renal crónica en hemodiálisis sin evidencia clínica de cardiopatía isquémica aguda, hospitalizados en el Servicio de Medicina Interna del Hospital Universitario de Caracas, Venezuela durante el período 2014-2015. Métodos: Se tomó muestra de suero a 48 pacientes con enfermedad renal crónica en hemodiálisis sin evidencia de cardiopatía isquémica aguda, y se midieron las concentraciones de creatin quinasa (CK), creatin quinasa fracción MB (CK-MB) y Troponina I (Tn-I) antes y después de la diálisis. Resultados: la mediana de los valores obtenidos de CK fue 42 prediálisis y 38 postdiálisis (p = 0,434), CK-MB: 10 pre y postdiálisis (p = 0,629), con respecto a troponina I, la mediana fue 0,00 pre y postdiálisis (p = 0,586). Se obtuvo valores dentro de límites normales de CK en 91,1% pre y 93,3% postdiálisis, CKMB 93,3% prediálisis y postdiálisis y Troponina I en 97,67% pre y 95,35% postdiálisis. Conclusiones: no se evidenciaron cambios significativos en las concentraciones de CK, CK-MB y Troponina I tanto pre como postdiálisis, encontrándose dentro de la normalidad en más de 90% de los casos. No se encontró relación entre concentración Troponina I, CK y CK-MB según edad, sexo, factores de riesgo cardiovasculares (diabetes mellitus e hipertensión arterial) y tiempo de hemodiálisis. Cualquiera de las enzimas puede tener utilidad clínica, siendo de preferencia las más cardioespecíficas, individualizando cada caso según su clínica y sus valores basales de enzimas cardíacas(AU)

This is an observational, analytical prospective study aimed to analyze cardiac enzymes concentrations in chronic kidney disease patients in hemodialysis without evidence of acute coronary disease at Internal Medicine Service of Hospital Universitario de Caracas, Venezuela during 2014-2015. Methods: serum samples were taken in 46 patients' with chronic kidney disease in hemodialysis without evidence of acute coronary disease and creatin kinase (CK), creatin kinase fraction MB (CK-MB) and Troponin I (Tn-I) were measured before and after hemodialysis. Results: was 42 predialysis and 38 postdialysis (p = 0.434), CK-MB 10 predialysis and post-dialysis (p = 0.629) the median value of troponin I, was 0.00 before and after dialysis (p = 0.586). It was obtained values within normal range of CK in 91.1% and 93.3% pre and post-dialysis, CK-MB in 93.3% predialysis and postdialysis and Troponin I in 97.67% pre and 95.35 % postdialysis. Conclusions: No significant changes were found in concentrations of CK, CK-MB and Troponin I bothpre and post-dialysis, with normal values in over 90% of cases. No relationship between concentration of Troponin I, CK and CK-MB and age, sex, cardiovascular risk factors (diabetes and hypertension) or time in hemodialysis were found. Any of the enzymes may have clinical utility, being the cardiospecific ones preferably, individualizing each case based on clinical and baseline cardiac enzymes(AU)

Study of pectin-adriamycin conjugate to cardiac toxicity in rats / 中国药理学通报

Aim To study the effect of pectin-adriamy-cin conjugate ( PAC) on cardiac toxicity .Methods 50 female SD rats were randomly divided into 5 groups with 10 animals in each group .Adriamycin ( ADM ) group received 3 mg? kg -1 , ip, every other day for 6 times.PAC group received ADM equivalent 1.5,3 and 6 mg? kg -1 , ip, every other day for 6 times.Control group received normal saline parallel to ADM .Rats were sacrificed and the echocardiogram , cardiac en-zymes , the oxidative stress levels in myocardial cells and histopathological changes after 48 h administration were detected.S180 ascites tumor bearing mice models were established to investigate the antitumor activity of PAC.Results The survival rate of ADM group was 50% and that of PAC each group was 100%.PAC could significantly increase body weight ,heart index and immune index and increase HR ,EF,FS,reduce LVIDd, LVIDs.PAC could also significantly increase the AST , LDH, CK, CK-MB level in serum .GSH-Px and SOD activities of PAC group were significantly increased and MDA contents were reduced , and histopathological changes decreased .PAC could effectively inhibit the growth of tumor cells and extend the survival period of mice.Conclusion PAC induces a significant reduc-tion in cardiotoxicity by increasing survival rate , im-mune and cardiac function , improving cardiac en-zymes ,oxidative stress and myocardial cell injury , and also PAC has obvious antitumor effect .

Prevalence of myocarditis in pediatric intensive care unit cases presenting with other system involvement / Prevalência de miocardite em casos pediátricos na unidade de terapia intensiva, com envolvimento de outros sistemas

OBJECTIVE: To assess children with myocarditis, the frequency of various presenting symptoms, and the accuracy of different investigations in the diagnosis. METHODS: This was an observational study of 63 patients admitted to PICU with non-cardiac diagnosis. Cardiac enzymes, chest-X ray, echocardiography, and electrocardiogram were performed to diagnose myocarditis among those patients. RESULTS: There were 16 cases of definite myocarditis. The age distribution was non-normal, with median of 5.5 months (3.25-21). Of the 16 patients who were diagnosed with myocarditis, 62.5% were originally diagnosed as having respiratory problems, and there were more females than males. Among the present cases, the accuracy of cardiac enzymes (cardiac troponin T [cTn] and creatine phosphokinase MB [CKMB]) in the diagnosis of myocarditis was only 63.5%, while the accuracy of low fractional shortening and of chest-X ray cardiomegaly was 85.7 and 80.9%; respectively. Cardiac troponin folds 2.02 had positive predictive value of 100%, negative predictive value of 88.7%, specificity of 100%, sensitivity of 62.5%, and accuracy of 90.5%. CONCLUSIONS: Children with myocarditis present with symptoms that can be mistaken for other types of illnesses. When clinical suspicion of myocarditis exists, chest-X ray and echocardiography are sufficient as screening tests. Cardiac troponins confirm the diagnosis in screened cases, with specificity of 100%. .

OBJETIVO: Determinar as crianças com miocardite, a frequência de sintomas apresentados e a precisão de investigações no diagnóstico. MÉTODOS: Estudo observacional de 63 pacientes internados na UTIP com diagnóstico de problemas não cardíacos. Os exames de enzimas cardíacas, raios-X do tórax, ecocardiograma e eletrocardiograma (ECG) foram feitos para diagnosticar miocardite entre os pacientes. RESULTADOS: Houve 16 casos de miocardite definida. A distribuição etária não foi normal, com média de 5,5 meses (3,25-21). Dos 16 pacientes, 62,5% foram originalmente diagnosticados com problemas respiratórios e a mulheres estavam em maior número do que os homens. Dentre nossos casos, a precisão das enzimas cardíacas (cTn e CKMB) no diagnóstico da miocardite foi de apenas 63,5%, apesar de a precisão da baixa fração de encurtamento (FS) e dos raios-X de tórax que revelaram cardiomegalia ter sido 85,7% e 80,9%; respectivamente. A troponina cardíaca em 2,02 vezes apresentou valor preditivo positivo = 100%, valor preditivo negativo = 88,7%, especificidade = 100%, sensibilidade = 62,5% e precisão = 90,5%. CONCLUSÕES: As crianças com miocardite apresentam sintomas que podem ser confundidos com outros tipos de doenças. Quando há suspeita clínica de miocardite, raios-X de tórax e ecocardiografia são testes de rastreamento suficientes. As troponinas cardíacas confirmam o diagnóstico em casos examinados, com especificidade de 100%. .

Correlation of serum cardiac enzymes activities and schizophrenia / 中国基层医药

Objective To investigate the changes of serum myocardial enzyme in schizophrenia patients spectrum and its clinical significance.Methods 405 patients with schizophrenia hospitalized patients serum myocar-dial enzyme (CK,CK-MB,LDH,α-HBDH level,) on admission and 4 weeks after treatment the serum myocardial enzyme level,analyze its relationship with the disease, and 100 healthy people ( control group) were compared. Results the positive symptoms of schizophrenia patients before treatment,serum CK,CK-MB,LDH,α-HBDH were (1 286.52 ±714.38) U/L,(40.72 ±27.38) U/L,(143.06 ±33.24) U/L,(115.75 ±22.74) U/L,CK,CK-MB were higher than those in the control group (t=10.35,9.29,all P0.05).Conclusion Serum myocardial enzyme CK and CK-MB increased level was related with diseasein the patients with acute exacerbation of schizophrenia.

Cardioprotective and Antilipidemic Effect of Gemmotherapeutically Treated Glycyrrhiza glabra against Isoproterenol Induced Myocardial Injury.

Aims: To evaluate preventive (pre- treated) and curative (post treated) potential of gemmomodified and native extract of Glycyrrhiza glabra for alleviating harmful changes in lipid profile (HDL, LDL, TG, TC) and cardiac enzymes (CK-MB, LDH, SGOT, SGPT) against isoproterenol (ISO) induced myocardial injury in rabbits. Study Design: In vivo study. Place and Duration of Study: Department of Chemistry and Biochemistry, University of Agriculture, Faisalabad, Pakistan, between February 2011 and April 2011. Methodology: Thirty six rabbits weighing 1.25 ± 0.2 Kg were allocated into six groups (Control, Ischemia, Gemmo curative, Native curative, Gemmo preventive and Native preventive) having six animals each. Rabbits were fed normal diet for 20 days. Gemmo preventive and Native preventive groups were also given gemmo modified and native extract (100 mg kg-1). On 20th day and 21st day rabbits were given ISO (50 mg kg-1). Five days after the ischemia the Gemmo curative and Native curative groups were given gemmo and native extracts (100 mg kg-1). Serum activities of lipid profile and cardiac enzymes were determined. Results: ISO administration significantly lowered (P=.05) HDL level and increased (P=.05) LDL, TG and TC as compared with control rabbits. ISO injury significantly increased (P=.05) the levels of cardiac enzymes CK-MB. LDH, SGOT and SGPT as compared with control rabbits. Curative treatment with gemmo and native extracts of Glycyrrhiza glabra significantly increased (P=.05) level of HDL and lowered (P=.05) the level of LDL, TG, TC and cardiac enzymes as compared with ischemic rabbits. Pre treatment with gemmo and native extracts prevented the reduction (P=.05) in HDL level and resisted the rise (P=.05) in other lipid parameters and cardiac enzymes as after ISO induced myocardial injury. Pretreatment with extracts was significantly better (P=.05) than curative treatment. Gemmo extract was significantly better (P=.05) than native extract in preventive and curative treatment in normalizing serum levels of lipid parameters and cardiac enzymes in ISO injured rabbits. Conclusion: The results provide evidence for the first time that gemmo extract of Glycyrrhiza glabra prevents myocardial injury induced by ISO in rabbits.

The clinical study of exhaustive heart damage in a military region for training staff / 中国中西医结合急救杂志

Objective To investigate the incidence and clinical characteristics and look for assay or examination indexes or indicators with higher sensitivity and specificity of heart damage induced by exhaustive exercise in order to establish its preliminary clinical classification and diagnostic criteria. Methods In a military region for training staff,the clinical data of 88 soldiers who were admitted to the departments of cardiology in 6 general or central hospitals because of exhaustive exercise from January 2000 to December 2010 were analyzed. The myocardial enzyme, electrocardiogram(ECG),echocardiography and other related examination indexes or indicators were observed,and the changes of symptoms,signs and other relevant assay and examination indexes before and after treatment were recorded. Results Exhaustive exercise could cause the symptoms such as chest tightness,palpitations,chest pain, dizziness,shortness of breath,fatigue,syncope and other symptoms,as well as cardiac auscultation abnormalities. After treatment, aspartate aminotransferase〔AST(U/L):20.34±6.33 vs. 35.43±25.25〕,α-hydroxybutyrate dehydrogenase〔α-HBDH(U/L):130.47±9.04 vs. 168.93±62.69〕,lactate dehydrogenase〔LDH(μmol?s-1?L-1):2.48±0.62 vs. 3.58±1.34〕,creatine kinase〔CK(U/L):125.58±67.56 vs. 556.42±381.89〕,creatine kinase isoenzyme〔CK-MB(U/L):11.20±4.08 vs. 23.09±15.61〕were significantly lower than those before treatment(P<0.05 or P<0.01);cardiac troponin T(cTnT)was detected in 5 patients,its level after treatment was significantly lower than that before treatment(μg/L:0.07±0.05 vs. 1.26±0.78,P<0.05). The ECG abnormalities included primarily sinus bradycardia (16 cases),sinus arrhythmia (13 cases) and premature ventricular contractions (11 cases). Echocardiographic abnormalities appeared in 18 cases,they were chiefly as follows:valvular regurgitation, cardiac dysfunction,cardiac enlargement,etc,among which the most common one was valvular regurgitation(all the refluxes were of small amount). Based on the above clinical manifestations and examination results,the exhaustive cardiac injuries were preliminarily divided into common type(20 cases),arrhythmia type(56 cases),heart failure type(2 cases)and sudden death(10 cases). Conclusions The clinical manifestations of exhaustive heart damage may appear in different types. Abnormal changes of myocardial enzymes,ECG and echocardiography are the strong evidences for the damage. Clinicians should pay attention to its prevention and treatment.

Importance of cardiac marker enzymes (Aspartate transaminase and troponin I) in acute myocardial infarction: A case-control study from South India .

Background: Cardiac marker enzymes are measured to evaluate the heart function. The diagnosis of acute myocardial infarction can be achieved by electrocardiogram (ECG) changes and elevation of cardiac marker enzymes like creatine kinase, lactate dehydrogenase (LDH), aspartate transaminase (AST) and troponin I. Objective: To estimates the levels of AST and troponin I among patients of acute myocardial infarction, and to compare with those among health controls. Materials and Methods: This study was carried out among 50 cases of acute myocardial infarction and 50 age and sex matched healthy individuals. Serum samples of cases, collected after 5 hours and within 24 hours from the onset of chest pain and of controls were analyzed for AST by modified IFCC method and for troponin I by chemiluminescence – sandwich method. Results: The mean levels of AST and troponin I in cases and controls revealed that mean levels of AST and cardiac troponin I in cases (296.02±SD 135.69 IU/L and 57.34±SD 12.83 ng/ml, erspectively) are significantly higher than among controls (25.50±SD 6.22 IU/L and 0.31±SD 0.15 ng/ml, respectively). The differences between cases and controls are statistically significant (p<0.0001). Conclusion: The diagnostic efficiency of AST and troponin I were superior because they are specific to myocardial injury.

The Clinical Significance of Cardiac Enzymes of Acute Cerebral Infarction / 医学研究杂志

Objective To study the clinical significance of cardiac enzymes of acute cerebral infarction(CI). Method The cardiac enzymes were determined in 92 patients with CI within 48 hours. The cardiac enzymes of CI group and control group,consciousness disturbance group and consciousness group were compared. Results The cardiac enzymes of CI were evaluated than the control group (P

Changes of Electrocardiogram and Cardiac Enzymes in Acute Ischemic Stroke

BACKGROUND: Cardiac arrhythmias and other cardiac dysfunctions occur in relation with acute cerebral ischemia. This study was undertaken to evaluate the sequential changes of electrocardiogram and cardiac enzymes after acute ischemic stroke, and to evaluate the incidence of cardiac arrhythmias. METHODS: Forty-three patients with acute ischemic stroke were recruited for this study. Electrocardiogram and cardiac enzymes were checked at 1, 3, 5, 7, 15, and 30 days after onset. RESULTS: Heart rates were decreased acutely after ischemic stroke and showed maximal decrease at day 3 (p<0.05). Heart rates were more significantly decreased in the right-sided lesions than the left (p<0.05) and in the supratentorial lesions than the infratentorial (p<0.05). PR intervals and durations of QRS complex were prolonged at day 3 and 5 but were not significant. The prolongation of the QTc interval was found in 21 patients (48.8%) and sustained QTc prolongation at day 30 were seen in 16 patients. Compared with controls, patients showed significantly higher incidence of arrhythmias (p<0.01). Creatine phosphokinase-MB (CK-MB) was significantly increased at day 5 (p<0.01) and lactic dehydrogenase (LDH) was increased at day 7 (p<0.01). CONCLUSIONS: In our study, the incidence of neurogenic cardiac abnormalities in acute ischemic stroke was higher than that of previous studies. Abnormalities peaked at days 3 and 5 were nearly similar to control levels at day 30. These periods of peak abnormalities coincided with those of increasing brain edema. Therefore, we postulate that cardiac autonomic controls are also influenced by acute brain edema. (J Korean Neurol Assoc 19(3):207~212, 2001)