Myocardial injury

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List of terms related to Myocardial injury

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Synonyms and keywords:

Overview

myocardial injury is defined as elevated troponin concentrations without sign and symptom indicating overt myocardial ischemia. Traditionally, elevated troponin level was eqaul to myocardial infarction. By improving the laboratory method and clinical approach to diagnosis the ischemia, patients with myocardial injury due to underlying diseases were excluded and treated. Evaluation and treatment of percipitant factors related to myocardial injury including sepsis, anemia, chronic kidney disease, cardiomyopathy are practically indicated. However, patients with evidence of myocardial injury and myocardial ischemia both have poor short term outcome.

Historical Perspective

[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].

The association between [important risk factor/cause] and [disease name] was made in/during [year/event].

In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].

In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].

There have been several outbreaks of [disease name], including -----.

In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].

Classification

Classification	Definition
Acute myocardial injury	Dynamic rise and/or fall of troponin concentration associated with cardiovascular or noncardiovascular causes
Chronic myocardial injury	Stable elevated troponin concentration related to cardiovascular or noncardiovascular causes
Myocardial infarction type 1	Myocardial infarction due to plaque rupture, ulceration, or dissection
Myocardial infarction type 2	Myocardial infarction attributable to oxygen supply-demand mismatch
Myocardial infarction type 3	Sudden cardiac death associated with myocardial infarction
Myocardial infarction type 4	Myocardial infarction associated with percutaneous intervention or stent thrombosis
Myocardial infarction type 5	Myocardial infarction related to cardiac surgery

There is no established system for the classification of [disease name].

OR

[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].

OR

[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3]. [Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].

OR

Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.

OR

If the staging system involves specific and characteristic findings and features: According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].

OR

The staging of [malignancy name] is based on the [staging system].

OR

There is no established system for the staging of [malignancy name].

Pathophysiology

The exact pathogenesis of [disease name] is not fully understood.

OR

It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].

OR

[Pathogen name] is usually transmitted via the [transmission route] route to the human host.

OR

Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.

OR

[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].

OR

The progression to [disease name] usually involves the [molecular pathway].

OR

The pathophysiology of [disease/malignancy] depends on the histological subtype.

Causes

• Cardiovascular causes of chronic myocardial injury include:
• Chronic heart failure
• Infiltrative cardiomyopathies (amyloidosis, hemochromatosis, sarcoidosis)

• Hypertrophic cardiomyopathy

• Stable coronary artery disease

• Hypertension

• Valvular heart disease

• Persistent arrhythmias (eg, atrial fibrillation)
• Noncardiovascular causes of chronic myocardial injury include:
• Chronic renal disease
• Pulmonary hypertension
• Toxins
• Diabetes mellitus
• Neurologic condition

Differentiating ((Page name)) from other Diseases

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Epidemiology and Demographics

The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.

OR

In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.

OR

Between 2010 to 2011, the incidence of myocardial injury was approximately 29,000 per 100,000 individuals with a mortality rate of 39%.

The incidence of myocardial injury]] increases with age; the median age at diagnosis is [#] years.

There is no racial predilection to myocardial injury.

women are more commonly affected by myocardial injury than men. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.

The majority of [disease name] cases are reported in [geographical region].

OR

[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].

Risk Factors

There are no established risk factors for [disease name].

OR

The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].

OR

Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

OR

Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.

Screening

There is insufficient evidence to recommend routine screening for [disease/malignancy].

OR

According to the [guideline name], screening for [disease name] is not recommended.

OR

According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].

Natural History, Complications, and Prognosis

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally poor, and the 5-year mortality rate of patients with myocardial injury is approximately 70%. 60% of cases of abnormal troponin concentrations when obtained for clinical indications, and 1 in 8 patients presenting to the hospital will have evidence of myocardial injury

Diagnosis

Diagnostic Study of Choice

Myocardial injury Elevated cardiac troponin value >99th percentile

Acute myocardial injury Rising and/or falling troponin

Chronic myocardial injury Stable but elevated troponin

History and physical examination Evaluation for myocardial ischemia: Symptoms New electrocardiographic changes New wall-motion abnormalities on imaging Coronary occlusion at angiography

History and physician examination Laboratory findings Creatinine, glomerular filtration rate Natriuretic peptide Complete blood cell count C-reactive protein, erythrocyte sedimentation rate, D-dimer testing Electrocardiogram Transthoracic echocardiography Cardiac magnetic resonance imaging

Evidence of myocardial ischemia Type 1 Myocardial infarction associated with Plaque rupture, ulceration, or dissection leading to coronary thrombus Type 2 Myocardial infarction related to supply-demand mismatch Type 3 Sudden cardiac death secondary to myocardial infarction Type 4 Myocardial infarction attributable with percutaneous coronary intervention or stent thrombosis Type 5 Myocardial infarction associated with cardiac surgery

NO evidence of ischemia Causes of Nonischemic myocardial injury: Cardiovascular causes: Hypertension Cardiac arrhythmias Acute valvular heart disease Takotsubo cardiomyopathy Cardiac contusions Acute heart failure Pulmonary embolism Myocarditis Aortic dissection Cardiac surgery or procedures Noncardiovascular causes: Acute renal failure Sepsis Anemia Hypotension Hypoxia Noncardiac surgery Critical illness Rhabdomyolysis Drug-induced Stroke, brain hemorrhage Extreme exertion

Cardiovascular causes of chronic myocardial injury Chronic heart failure Infiltrative cardiomyopathy Hypertrophic cardiomyopathy Stable coronary artery disease Hypertension Valvular heart disease Persistent arrhythmias Noncardiovascular causes of chronic myocardial injury Chronic renal disease Pulmonary hypertension Diabetes mellitus Drug-induced Toxin exposure

Management based on the type

Management based on the causes of myocardial injury and clinical course

The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].

OR

The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

OR

The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

OR

There are no established criteria for the diagnosis of [disease name].

History and Symptoms

• The initial workup includes an evaluation for myocardial ischemia.
• If myocardial infarction is ruled out, further assessment involves a detailed history, physical examination, laboratory testing, a 12-lead electrocardiogram, and an echocardiogram
• The most practical approach is identifying and treating the underlying causes of myocardial injury.

The majority of patients with [disease name] are asymptomatic.

OR

The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

Physical Examination

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Laboratory Findings

Laboratory investigation consistent with the diagnosis of myocardial injury include:

• Serial cardiac troponin measurement
• Renal function testing (chronic kidney disease)
• Natreriuretic peptide (heart failure)
• Complete blood cell count (anemia or infection)
• D-dimer (pulmonary embolism, aortic dissection)
• C-reactive protein (infectious and inflammatory markers)

• Serial cardiac troponin samples should be obtained for differentiating between acute or chronic myocardial injury.
• In patients suspected MI, given a third sample of troponin without the pattern of rising and falling (in 26% of patients) and also ECG changes may be helpful to differentiate from myocardial injury.

Electrocardiogram

There are no specific ECG findings associated with myocardial injury. Findings on an ECG suggestive of myocardial injury may include:

• Evidence of ischemia, infarction
• Arrhythmias
• Acute right ventricular strain
• Conduction disease
• Structural disease ( left ventricular hypertrophy).

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

Echocardiography may be helpful in the diagnosis of underlying causes of myocardial injury.

• Findings on an echocardiography associated with myocardial injury include:

  Assessment of systolic and diastolic function

  Left ventricular hypertrophy

  Regional wall motion abnormalities

  Valvular abnormalities.

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

Cardiac MRI may be helpful when there is clinically suspicion of myocarditis or infiltrative cardiomyopathy as the underlying causes of myocardial injury.

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

OR

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no established consensus regarding the routine management of myocardial injury. However, treating the underlying precipitant factors such as heart failure, chronic kidney disease is recommended.
• WOSCOPS study showed that pravastatin reduced hs-cTnI in patients without previous MI by the means of 13% leading to reduced future risk of MI .However, the role of pravastatin in acute phase of nonischemic myocardial injury is uncertain.

• Use of dabigatran in patients with myocardial injury after noncardiac surgery was associated with reduced risk of major vascular event rate. However, this trial was terminated early and medication discontinuation rates were high.

• The efficacy of Sodium-glucose cotransporter 2 inhibitors such as canagliflozin in patients with diabetes mellitus type 2 and myocardial injury was a delay of the rise in troponin over 2 years as well as diuresis, reduce blood pressure, and improve left ventricular remodeling.

Surgery

Surgical intervention is not recommended for the management of [disease name].

OR

Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]

OR

The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].

OR

The feasibility of surgery depends on the stage of [malignancy] at diagnosis.

OR

Surgery is the mainstay of treatment for [disease or malignancy].

Primary Prevention

There are no established measures for the primary prevention of [disease name].

OR

There are no available vaccines against [disease name].

OR

Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

OR

[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].

Secondary Prevention

There are no established measures for the secondary prevention of [disease name].

OR

Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].

References

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