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June 28, 1995, Vol 273, No. 24 >
ARTICLE | June 28, 1995

Myocardial Injury in Critically Ill Patients: Title and subTitle BreakA Frequently Unrecognized Complication FREE

Thomas M. Guest, MD; Anand V. Ramanathan, MD; Peter G. Tuteur, MD; Kenneth B. Schechtman, PhD; Jack H. Ladenson, PhD; Allan S. Jaffe, MD
[+] Author Affiliations

Dr Ladenson is a consultant to Baxter Diagnostics Inc, Miami, Fla, and there are licensing agreements between Baxter Diagnostics Inc and Washington University, St Louis, Mo, in the field of biochemical cardiovascular markers.

Reprint requests to the Cardiovascular Division, State University of New York Health Science Center at Syracuse College of Medicine, 750 E Adams St, Syracuse, NY 13210 (Dr Jaffe).

Concepts in Emergency and Critical Care section editor: Roger C. Bone, MD, Consulting Editor, JAMA.

Advisory Panel: Bart Chernow, MD, Baltimore, Md; David Dantzker, MD, New Hyde Park, NY; Jerrold Leiken, MD, Chicago, Ill; Joseph E. Parrillo, MD, Chicago, Ill; William J. Sibbald, MD, London, Ontario; and Jean-Louis Vincent, MD, PhD, Brussels, Belgium.


JAMA. 1995;273(24):1945-1949. doi:10.1001/jama.1995.03520480065042
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Article
References

Objective.  —To determine the incidence and effect of unrecognized cardiac injury in critically ill patients.

Design.  —Prospective, blinded, single-center study.

Setting.  —The medical and respiratory intensive care unit of an academic health center.

Patients.  —Two hundred nine patients (224 admissions).

Main Outcome Measures.  —Daily measurement of levels of cardiac troponin I, a sensitive, highly specific, and long-lived marker of myocardial injury. Concurrently, signs and symptoms potentially related to myocardial ischemia were tabulated by blinded investigators. All clinical evaluation and management decisions were made by the physicians responsible for the care of the patient.

Results.  —Thirty-two (15%) of the 209 patients had evidence of myocardial damage based on elevated levels of cardiac troponin I. Only 12(37%) of these 32 patients were diagnosed as having acute myocardial infarction by the intensive care unit staff. Cardiac damage was unrecognized in the other 20 (63%). Unrecognized cardiac injury was more common in young patients and in blacks. Mortality in patients with myocardial injury that was recognized (42%) or unrecognized (40%) was higherthan in those without myocardial injury (15%) (P<.001). Patients with cardiac injury were more frequently hypotensive (75% vs 50%; P=.007) and in need of mechanical ventilation (66% vs 27%; P<.001) and had longer intensive care unit stays (5.3 vs 3.1 days; P<.007) than patients without cardiac injury.

Conclusion.  —The incidence of myocardial injury defined by elevated levels of cardiac troponin I was unexpectedly high and associated with increased morbidity and mortality. Clinically, it was often unrecognized.(JAMA. 1995;273:1945-1949)

REFERENCES

1 +
Campion EW, Mulley AG, Goldstein RL, Barnett O, Thibault GE.  Medical intensive care for the elderly. JAMA . 1981;;246:2052-2056.
2 +
Detsky AS, Stricker SC, Mulley AG, Thibault GE.  Prognosis, survival, and the expenditure of hospital resources for patients in an intensive care unit. N Engl J Med . 1981;;305:667-672.
3 +
Fedullo AJ, Swinburne AJ.  Relationship of patient age to cost and survival in a medical ICU. Crit Care Med . 1983;;11:155-159.
4 +
Girard K, Raffin TA.  The chronically critically ill: to save or let die? Respir Care . 1985;;30:339-347.
5 +
Le Gall J, Loirat P, Alperovitch A, et al.  A simplified acute physiology score for ICU patients. Crit Care Med . 1984;;12:975-977.
6 +
Young RKB, Campbell D, Reid JM, Telfer ABM.  Respiratory intensive care: a 10-year survey. BMJ . 1974;;1:307-310.
7 +
Cheitlin MD, McAllister HA, deCastro CM.  Myocardial infarction without atherosclerosis. JAMA . 1975;;231:951-959.
8 +
Parmley WW, Tyberg JV.  Determination of myocardial oxygen demand. Prog Cardiol . 1976;;5:19.
9 +
Schneider DJ, Sobel BE.  Effect of diabetes on the coagulation and fibrinolytic systems and its implications for atherogenesis. Coron Artery Dis . 1992;;3:26-32.
10 +
Gram J.  The haemostatic balance in groups of thrombosis-prone patients with particular reference to fibrinolysis in patients with myocardial infarction. Dan Med Bull . 1990;;37:210-234.
11 +
Parry G, Goudevenos J, Williams DO.  Coronary thrombosis postpartum in a young woman with Still's disease. Clin Cardiol . 1992;;15:305-307.
12 +
Gosalakkal JA, Neligan MC.  Coronary artery bypass grafting for coronary thrombosis complicating polycythaemia rubra vera: case report. Scand J Thorac Cardiovasc Surg . 1991;;25:159-160.
13 +
Kutom AH, Gibbs HR.  Myocardial infarction due to intracoronary thrombi without significant coronary artery disease in systemic lupus erythematosus. Chest . 1991;;100:571-572.
14 +
Travis KW, Carson HS III, Uhl RR, Bendixen HH.  Report on the first year's activities of a multidisciplinary respiratory intensive care unit. Crit Care Med . 1973;;1:235-238.
15 +
Uretsky BF, Farquhar DS, Berezin AF, Hood WB.  Symptomatic myocardial infarction without chest pain: prevalence and clinical course. Am J Cardiol . 1977;;40:498-503.
16 +
Pingleton SK, Hall JB.  Prevention and early detection of complications of critical care.  In: Hall JB, Schmidt GA, Wood LDH, eds. Principles of Critical Care . New York, NY: McGraw-Hill International Book Co; 1992;:599.
17 +
Julkunen H, Kataja J, Lahdensuu M, Rokkanen P.  Electrocardiographic changes in severely injured patients treated at the intensive care unit. Ann Chir Gynaecol Fenniae . 1972;;60:107-111.
18 +
Adams JE III, Abendschein DR, Jaffe AS.  Biochemical markers of myocardial injury: is MB creatine kinase the choice for the 1990's? Circulation . 1993;;88:750-763.
19 +
Wilhelm AH, Albers KM, Todd JK.  Creatine phosphokinase isoenzyme distribution in human skeletal and heart muscles. Int Res Commun Sci J Med Sci . 1976;;4:418-420.
20 +
Trask RV, Billadello JJ.  Tissue-specific distribution and developmental regulation of M and B creatine kinase mRNAs. Biochim Biophys Acta . 1990;;1049:182-188.
21 +
Tsung SH.  Several conditions causing elevation of serum CK-MB and CK-BB. Am J Clin Pathol . 1981;;75:711-715.
22 +
Tsung JS, Tsung SS.  Creatine kinase isoenzymes in extracts of various human skeletal muscles. Clin Chem . 1986;;32:1568-1570.
23 +
Jaffe AS, Ritter C, Meltzer V, Harter H, Roberts R.  Unmasking artifactual increases in creatine kinase isoenzymes in patients with renal failure. J Lab Clin Med . 1984;;104:193-202.
24 +
Perry SV.  The regulation of contractile activity in muscle. Biochem Soc Trans . 1979;;7:593-617.
25 +
Toyota N, Shimada Y.  Differentiation of troponin in cardiac and skeletal muscles in chicken embryos as studied by immunofluorescence microscopy. J Cell Biol . 1981;;91:497-504.
26 +
Larue C, Calzolari C, Bertinchant JP, Leclercq F, Grolleau R, Pau B.  Cardiac-specific immunoenzymometric assay of troponin I in the early phase of acute myocardial infarction. Clin Chem . 1993;; 39:972-979.
27 +
Cummins B, Young A, Auckland ML, Michie CA, Stone PCW, Shepstone BJ.  Comparison of serum cardiac specific troponin-I with creatine kinase, creatine kinase-MB isoenzyme, tropomyosin, myoglobin, and C-reactive protein release in marathon runners: cardiac or skeletal muscle damage? Eur J Clin Invest . 1987;;17:317-324.
28 +
Adams JE III, Bodor GS, Davilla-Roman VG, et al.  Cardiac troponin I: a marker with high specificity for cardiac injury. Circulation . 1993;;88:101-106.
29 +
Adams JE III, Sicard GA, Allen BT, et al.  Diagnosis of perioperative myocardial infarction with measurement of cardiac troponin I. N Engl J Med . 1994;;330:670-674.
30 +
Cummins B, Auckland ML, Cummins P.  Cardiacspecific troponin-I radioimmunoassay in the diagnosis of acute myocardial infarction. Am Heart J . 1987;;113:1333-1344.
31 +
Bodor GS, Porter S, Landt Y, Ladenson JH.  Development of monoclonal antibodies for an assay of cardiac troponin I and preliminary results in suspected cases of myocardial infarction. Clin Chem . 1992;;38:2203-2214.
32 +
Adams JE III, Schechtman K, Landt V, Ladenson JH, Jaffe AS.  Equivalent sensitivities of MB creatine kinase (MBCK) and cardiac troponin I for detection of acute myocardial infarction. Clin Chem . 1994;;40:1291-1295.
33 +
Rosalki SB.  An improved procedure for serum creatine phosphokinase determination. J Lab Clin Med . 1967;;69:696-705.
34 +
Vaidya HC, Maynard Y, Dietzler DN, Ladenson JH.  Direct measurement of creatine kinase-MB activity in serum after extraction with a monoclonal antibody specific to the MB isoenzyme. Clin Chem . 1986;;32:657-663.
35 +
Drasner K, Katz JA, Schapera A.  Control of pain and anxiety.  In: Hall JB, Schmidt GA, Wood LDH, eds. Principles of Critical Care . New York, NY: McGraw-Hill International Book Co; 1992;:959.
36 +
Hayes MA, Timmins AC, Yau EHS, Palazzo M, Hinds CJ, Watson D.  Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med . 1994;;330:1717-1722.
37 +
Hamm CW, Ravkilde J, Gerhardt W, et al.  The prognostic value of serum troponin T in unstable angina. N Engl J Med . 1992;;327:146-150.
38 +
Scheinman MM, Abott JA.  Clinical significance of transmural versus nontransmural electrocardiographic changes in patients with acute myocardial infarction. Am J Med . 1973;;55:602-606.
39 +
Madias JE, Chahine RA, Gorlin R, Blacklow DJ.  A comparison of transmural and nontransmural myocardial infarction. Circulation . 1973;;49:448-450.
40 +
Nicod P, Gilpin E, Dittrich H, et al.  Short- and long-term clinical outcome after q wave and non-q wave myocardial infarction in a large patient population. Circulation . 1989;;79:528-536.

Figures

Tables

Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Campion EW, Mulley AG, Goldstein RL, Barnett O, Thibault GE.  Medical intensive care for the elderly. JAMA . 1981;;246:2052-2056.
2 +
Detsky AS, Stricker SC, Mulley AG, Thibault GE.  Prognosis, survival, and the expenditure of hospital resources for patients in an intensive care unit. N Engl J Med . 1981;;305:667-672.
3 +
Fedullo AJ, Swinburne AJ.  Relationship of patient age to cost and survival in a medical ICU. Crit Care Med . 1983;;11:155-159.
4 +
Girard K, Raffin TA.  The chronically critically ill: to save or let die? Respir Care . 1985;;30:339-347.
5 +
Le Gall J, Loirat P, Alperovitch A, et al.  A simplified acute physiology score for ICU patients. Crit Care Med . 1984;;12:975-977.
6 +
Young RKB, Campbell D, Reid JM, Telfer ABM.  Respiratory intensive care: a 10-year survey. BMJ . 1974;;1:307-310.
7 +
Cheitlin MD, McAllister HA, deCastro CM.  Myocardial infarction without atherosclerosis. JAMA . 1975;;231:951-959.
8 +
Parmley WW, Tyberg JV.  Determination of myocardial oxygen demand. Prog Cardiol . 1976;;5:19.
9 +
Schneider DJ, Sobel BE.  Effect of diabetes on the coagulation and fibrinolytic systems and its implications for atherogenesis. Coron Artery Dis . 1992;;3:26-32.
10 +
Gram J.  The haemostatic balance in groups of thrombosis-prone patients with particular reference to fibrinolysis in patients with myocardial infarction. Dan Med Bull . 1990;;37:210-234.
11 +
Parry G, Goudevenos J, Williams DO.  Coronary thrombosis postpartum in a young woman with Still's disease. Clin Cardiol . 1992;;15:305-307.
12 +
Gosalakkal JA, Neligan MC.  Coronary artery bypass grafting for coronary thrombosis complicating polycythaemia rubra vera: case report. Scand J Thorac Cardiovasc Surg . 1991;;25:159-160.
13 +
Kutom AH, Gibbs HR.  Myocardial infarction due to intracoronary thrombi without significant coronary artery disease in systemic lupus erythematosus. Chest . 1991;;100:571-572.
14 +
Travis KW, Carson HS III, Uhl RR, Bendixen HH.  Report on the first year's activities of a multidisciplinary respiratory intensive care unit. Crit Care Med . 1973;;1:235-238.
15 +
Uretsky BF, Farquhar DS, Berezin AF, Hood WB.  Symptomatic myocardial infarction without chest pain: prevalence and clinical course. Am J Cardiol . 1977;;40:498-503.
16 +
Pingleton SK, Hall JB.  Prevention and early detection of complications of critical care.  In: Hall JB, Schmidt GA, Wood LDH, eds. Principles of Critical Care . New York, NY: McGraw-Hill International Book Co; 1992;:599.
17 +
Julkunen H, Kataja J, Lahdensuu M, Rokkanen P.  Electrocardiographic changes in severely injured patients treated at the intensive care unit. Ann Chir Gynaecol Fenniae . 1972;;60:107-111.
18 +
Adams JE III, Abendschein DR, Jaffe AS.  Biochemical markers of myocardial injury: is MB creatine kinase the choice for the 1990's? Circulation . 1993;;88:750-763.
19 +
Wilhelm AH, Albers KM, Todd JK.  Creatine phosphokinase isoenzyme distribution in human skeletal and heart muscles. Int Res Commun Sci J Med Sci . 1976;;4:418-420.
20 +
Trask RV, Billadello JJ.  Tissue-specific distribution and developmental regulation of M and B creatine kinase mRNAs. Biochim Biophys Acta . 1990;;1049:182-188.
21 +
Tsung SH.  Several conditions causing elevation of serum CK-MB and CK-BB. Am J Clin Pathol . 1981;;75:711-715.
22 +
Tsung JS, Tsung SS.  Creatine kinase isoenzymes in extracts of various human skeletal muscles. Clin Chem . 1986;;32:1568-1570.
23 +
Jaffe AS, Ritter C, Meltzer V, Harter H, Roberts R.  Unmasking artifactual increases in creatine kinase isoenzymes in patients with renal failure. J Lab Clin Med . 1984;;104:193-202.
24 +
Perry SV.  The regulation of contractile activity in muscle. Biochem Soc Trans . 1979;;7:593-617.
25 +
Toyota N, Shimada Y.  Differentiation of troponin in cardiac and skeletal muscles in chicken embryos as studied by immunofluorescence microscopy. J Cell Biol . 1981;;91:497-504.
26 +
Larue C, Calzolari C, Bertinchant JP, Leclercq F, Grolleau R, Pau B.  Cardiac-specific immunoenzymometric assay of troponin I in the early phase of acute myocardial infarction. Clin Chem . 1993;; 39:972-979.
27 +
Cummins B, Young A, Auckland ML, Michie CA, Stone PCW, Shepstone BJ.  Comparison of serum cardiac specific troponin-I with creatine kinase, creatine kinase-MB isoenzyme, tropomyosin, myoglobin, and C-reactive protein release in marathon runners: cardiac or skeletal muscle damage? Eur J Clin Invest . 1987;;17:317-324.
28 +
Adams JE III, Bodor GS, Davilla-Roman VG, et al.  Cardiac troponin I: a marker with high specificity for cardiac injury. Circulation . 1993;;88:101-106.
29 +
Adams JE III, Sicard GA, Allen BT, et al.  Diagnosis of perioperative myocardial infarction with measurement of cardiac troponin I. N Engl J Med . 1994;;330:670-674.
30 +
Cummins B, Auckland ML, Cummins P.  Cardiacspecific troponin-I radioimmunoassay in the diagnosis of acute myocardial infarction. Am Heart J . 1987;;113:1333-1344.
31 +
Bodor GS, Porter S, Landt Y, Ladenson JH.  Development of monoclonal antibodies for an assay of cardiac troponin I and preliminary results in suspected cases of myocardial infarction. Clin Chem . 1992;;38:2203-2214.
32 +
Adams JE III, Schechtman K, Landt V, Ladenson JH, Jaffe AS.  Equivalent sensitivities of MB creatine kinase (MBCK) and cardiac troponin I for detection of acute myocardial infarction. Clin Chem . 1994;;40:1291-1295.
33 +
Rosalki SB.  An improved procedure for serum creatine phosphokinase determination. J Lab Clin Med . 1967;;69:696-705.
34 +
Vaidya HC, Maynard Y, Dietzler DN, Ladenson JH.  Direct measurement of creatine kinase-MB activity in serum after extraction with a monoclonal antibody specific to the MB isoenzyme. Clin Chem . 1986;;32:657-663.
35 +
Drasner K, Katz JA, Schapera A.  Control of pain and anxiety.  In: Hall JB, Schmidt GA, Wood LDH, eds. Principles of Critical Care . New York, NY: McGraw-Hill International Book Co; 1992;:959.
36 +
Hayes MA, Timmins AC, Yau EHS, Palazzo M, Hinds CJ, Watson D.  Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med . 1994;;330:1717-1722.
37 +
Hamm CW, Ravkilde J, Gerhardt W, et al.  The prognostic value of serum troponin T in unstable angina. N Engl J Med . 1992;;327:146-150.
38 +
Scheinman MM, Abott JA.  Clinical significance of transmural versus nontransmural electrocardiographic changes in patients with acute myocardial infarction. Am J Med . 1973;;55:602-606.
39 +
Madias JE, Chahine RA, Gorlin R, Blacklow DJ.  A comparison of transmural and nontransmural myocardial infarction. Circulation . 1973;;49:448-450.
40 +
Nicod P, Gilpin E, Dittrich H, et al.  Short- and long-term clinical outcome after q wave and non-q wave myocardial infarction in a large patient population. Circulation . 1989;;79:528-536.

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