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{{CMG}}; {{AE}} {{Sara.Zand}}
{{CMG}}; {{AE}} {{Sara.Zand}}


{{SK}}  
{{SK}} Acute myocardial injury, Chronic myocardial injury, Myocardial ischemia, troponin concentration, systemic illness


==Overview==
==Overview==
[[myocardial injury]] is defined as elevated [[troponin]] concentrations without [[sign]] and [[symptom]] indicating overt [[myocardial ischemia]] and is the most common causes of increased [[troponin]] level. Traditionally, elevated [[troponin]] level was eqaul to [[myocardial infarction]]. Diagnosis of [[myocardial injury]] is a challange for clinicians. By improving the laboratory method for detecting high sensitive [[troponin]] 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 of [[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 and [[long term outcome]].
[[Myocardial injury]] is defined as elevated [[troponin]] concentrations without [[sign]] and [[symptom]] indicating overt [[myocardial ischemia]] and is the most common cause of increased [[troponin]] level. Traditionally, elevated [[troponin]] level was eqaul to [[myocardial infarction]]. Diagnosis of [[myocardial injury]] is a challange for clinicians. By improving the laboratory method for detecting high sensitive [[troponin]] and clinical approach to diagnosis of myocardial [[ischemia]], [[patients]] with [[myocardial injury]] due to underlying [[diseases]] were excluded and treated. Evaluation and treatment of  [[percipitant]] factors of [[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 and [[long term outcome]].


==Historical Perspective==
==Historical Perspective==
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==Classification==
==Classification==
*[[Myocardial injury]] may be classified into acute and chronic based on the pattern of [[troponin]] concentration.<ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
*[[Myocardial injury]] may be classified into acute and chronic based upon the pattern of [[troponin]] concentration.<ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
* [[Acute]] [[myocardial injury]] is considered when there is a rise and/or fall of [[cardiac]] [[troponin]] concentrations exceeding the biological and/or analytical variation.<ref name="TwerenboldJaffe2012">{{cite journal|last1=Twerenbold|first1=R.|last2=Jaffe|first2=A.|last3=Reichlin|first3=T.|last4=Reiter|first4=M.|last5=Mueller|first5=C.|title=High-sensitive troponin T measurements: what do we gain and what are the challenges?|journal=European Heart Journal|volume=33|issue=5|year=2012|pages=579–586|issn=0195-668X|doi=10.1093/eurheartj/ehr492}}</ref>
* [[Acute]] [[myocardial injury]] is considered when there is a rise and/or fall of [[cardiac]] [[troponin]] concentrations exceeding the biological and/or analytical variation.<ref name="TwerenboldJaffe2012">{{cite journal|last1=Twerenbold|first1=R.|last2=Jaffe|first2=A.|last3=Reichlin|first3=T.|last4=Reiter|first4=M.|last5=Mueller|first5=C.|title=High-sensitive troponin T measurements: what do we gain and what are the challenges?|journal=European Heart Journal|volume=33|issue=5|year=2012|pages=579–586|issn=0195-668X|doi=10.1093/eurheartj/ehr492}}</ref>
* [[Chronic]] [[myocardial injury]] may occur when [[cardiac]] [[troponin]] is greater than 99th-percentile URL without a rise and/or fall over a period of serial [[measurements]] ( more than 8 hours) in the [[condition]]s such as [[structural heart disease]] ([[hypertensive heart disease]], [[ischemic cardiomyopathy]], [[dilated cardiomyopathy]]) or secondary to non-[[cardiac]] causes such as [[chronic renal failure]].
* [[Chronic]] [[myocardial injury]] may occur when [[cardiac]] [[troponin]] is greater than 99th-percentile URL without a rise and/or fall over a period of serial [[measurements]] ( more than 8 hours) in the [[condition]]s such as [[structural heart disease]] ([[hypertensive heart disease]], [[ischemic cardiomyopathy]], [[dilated cardiomyopathy]]) or secondary to non-[[cardiac]] causes such as [[chronic renal failure]].
* Table below shown the classification of [[myocardial injury]] and also different types of [[myocardial infarction]]:
* Table below shown the classification of [[myocardial injury]] and also different types of [[myocardial infarction]]:
{| style="border: 2px solid #4479BA; align="left"
{| style="border: 2px solid #4479BA; align="left"
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* [[Extreme]] [[exertion]]
* [[Extreme]] [[exertion]]


==Differentiating ((Page name)) from other Diseases==
==Differentiating [[myocardial injury]] 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
*[[Myocardial injury]] must be differentiated from [[myocardial ischemia]] based on the [[troponin]] concentration changes, [[ECG]] changes and [[clinical approach]].


[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
==Epidemiology and Demographics==
*The [[prevalence]] of [[myocardial injury]] is approximately 12,400 per 100,000 individuals presented in [[emergency department]].<ref name="LeeNoaman2019">{{cite journal|last1=Lee|first1=Kuan Ken|last2=Noaman|first2=Ala|last3=Vaswani|first3=Amar|last4=Gibbins|first4=Matthew|last5=Griffiths|first5=Megan|last6=Chapman|first6=Andrew R.|last7=Strachan|first7=Fiona|last8=Anand|first8=Atul|last9=McAllister|first9=David A.|last10=Newby|first10=David E.|last11=Gray|first11=Alasdair J.|last12=Mills|first12=Nicholas L.|last13=Shah|first13=Anoop S.V.|title=Prevalence, Determinants, and Clinical Associations of High-Sensitivity Cardiac Troponin in Patients Attending Emergency Departments|journal=The American Journal of Medicine|volume=132|issue=1|year=2019|pages=110.e8–110.e21|issn=00029343|doi=10.1016/j.amjmed.2018.10.002}}</ref>


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


*Between 2010 to 2011, the incidence of [[myocardial injury]] was approximately 29,000 per 100,000 individuals with a [[mortality rate]] of 39%.<ref name="SarkisianSaaby2016">{{cite journal|last1=Sarkisian|first1=Laura|last2=Saaby|first2=Lotte|last3=Poulsen|first3=Tina S.|last4=Gerke|first4=Oke|last5=Jangaard|first5=Nikolaj|last6=Hosbond|first6=Susanne|last7=Diederichsen|first7=Axel C.P.|last8=Thygesen|first8=Kristian|last9=Mickley|first9=Hans|title=Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins|journal=The American Journal of Medicine|volume=129|issue=4|year=2016|pages=446.e5–446.e21|issn=00029343|doi=10.1016/j.amjmed.2015.11.006}}</ref>
*Between 2010 to 2011, the incidence of [[myocardial injury]] was approximately 29,000 per 100,000 individuals with a [[mortality rate]] of 39%.<ref name="SarkisianSaaby2016">{{cite journal|last1=Sarkisian|first1=Laura|last2=Saaby|first2=Lotte|last3=Poulsen|first3=Tina S.|last4=Gerke|first4=Oke|last5=Jangaard|first5=Nikolaj|last6=Hosbond|first6=Susanne|last7=Diederichsen|first7=Axel C.P.|last8=Thygesen|first8=Kristian|last9=Mickley|first9=Hans|title=Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins|journal=The American Journal of Medicine|volume=129|issue=4|year=2016|pages=446.e5–446.e21|issn=00029343|doi=10.1016/j.amjmed.2015.11.006}}</ref>
*The incidence of myocardial injury]] increases with age.
*The incidence of [[myocardial injury]] increases with age.
*There is no racial predilection to [[myocardial injury]].
*There is no racial predilection to [[myocardial injury]].
*[[women]] are more commonly affected by [[myocardial injury]] than [[men]].
*[[women]] are more commonly affected by [[myocardial injury]] than [[men]].
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==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
*60% of cases of abnormal [[troponin]] concentrations , and 1 in 8 [[patients]] presenting to the [[hospital]] will have evidence of [[myocardial injury]].
*60% of cases of abnormal [[troponin]] concentrations , and 1 in 8 [[patients]] presenting to the [[hospital]] will have evidence of [[myocardial injury]].
* Evidence of [[myocardial injury]] in [[chronic heart failure]] [[disease]] was associated with increased [[all-cause mortality]], [[cardiovascular death]], [[cardiovascular hospitalization]].<ref name="AimoJanuzzi2018">{{cite journal|last1=Aimo|first1=Alberto|last2=Januzzi|first2=James L.|last3=Vergaro|first3=Giuseppe|last4=Ripoli|first4=Andrea|last5=Latini|first5=Roberto|last6=Masson|first6=Serge|last7=Magnoli|first7=Michela|last8=Anand|first8=Inder S.|last9=Cohn|first9=Jay N.|last10=Tavazzi|first10=Luigi|last11=Tognoni|first11=Gianni|last12=Gravning|first12=Jørgen|last13=Ueland|first13=Thor|last14=Nymo|first14=Ståle H.|last15=Brunner-La Rocca|first15=Hans-Peter|last16=Genis|first16=Antoni Bayes|last17=Lupón|first17=Josep|last18=de Boer|first18=Rudolf A.|last19=Yoshihisa|first19=Akiomi|last20=Takeishi|first20=Yasuchika|last21=Egstrup|first21=Michael|last22=Gustafsson|first22=Ida|last23=Gaggin|first23=Hanna K.|last24=Eggers|first24=Kai M.|last25=Huber|first25=Kurt|last26=Tentzeris|first26=Ioannis|last27=Tang|first27=Wai H.W.|last28=Grodin|first28=Justin|last29=Passino|first29=Claudio|last30=Emdin|first30=Michele|title=Prognostic Value of High-Sensitivity Troponin T in Chronic Heart Failure|journal=Circulation|volume=137|issue=3|year=2018|pages=286–297|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031560}}</ref>
* Evidence of [[myocardial injury]] in [[chronic heart failure]] [[disease]] was associated with increased [[all-cause mortality]], [[cardiovascular death]], [[cardiovascular hospitalization]].<ref name="AimoJanuzzi2018">{{cite journal|last1=Aimo|first1=Alberto|last2=Januzzi|first2=James L.|last3=Vergaro|first3=Giuseppe|last4=Ripoli|first4=Andrea|last5=Latini|first5=Roberto|last6=Masson|first6=Serge|last7=Magnoli|first7=Michela|last8=Anand|first8=Inder S.|last9=Cohn|first9=Jay N.|last10=Tavazzi|first10=Luigi|last11=Tognoni|first11=Gianni|last12=Gravning|first12=Jørgen|last13=Ueland|first13=Thor|last14=Nymo|first14=Ståle H.|last15=Brunner-La Rocca|first15=Hans-Peter|last16=Genis|first16=Antoni Bayes|last17=Lupón|first17=Josep|last18=de Boer|first18=Rudolf A.|last19=Yoshihisa|first19=Akiomi|last20=Takeishi|first20=Yasuchika|last21=Egstrup|first21=Michael|last22=Gustafsson|first22=Ida|last23=Gaggin|first23=Hanna K.|last24=Eggers|first24=Kai M.|last25=Huber|first25=Kurt|last26=Tentzeris|first26=Ioannis|last27=Tang|first27=Wai H.W.|last28=Grodin|first28=Justin|last29=Passino|first29=Claudio|last30=Emdin|first30=Michele|title=Prognostic Value of High-Sensitivity Troponin T in Chronic Heart Failure|journal=Circulation|volume=137|issue=3|year=2018|pages=286–297|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031560}}</ref>
*Increases in [[cTnI]] [[concentration]]s in [[patient]]s undergoing high-dose [[chemotherapy]] for [[aggressive]] [[malignant]] [[conditions]] have been correlated with future decreases in [[left ventricular]] [[ejection fraction]].
*Increases in [[cTnI]] [[concentration]]s in [[patient]]s undergoing high-dose [[chemotherapy]] for [[aggressive]] [[malignant]] [[conditions]] have been correlated with future decreases in [[left ventricular]] [[ejection fraction]].
* In [[patients]] with [[chronic kidney disease]] and [[end stage renal disease]], [[amyloidosis]], [[pulmonary embolism]], increased level of [[troponin]] was associated with increased  all-cause [[mortality]].<ref name="AppleLer2016">{{cite journal|last1=Apple|first1=Fred S|last2=Ler|first2=Ranka|last3=Young|first3=Amy|last4=Brunelli|first4=Steven M|last5=Gilbertson|first5=David|last6=Wu|first6=Alan H B|last7=Hu|first7=Yan|last8=Cao|first8=Jing|last9=Love|first9=Sara A|last10=Herzog|first10=Charles A|last11=Sandoval|first11=Yader|title=Prognostic Value of Serial Changes in High-Sensitivity Cardiac Troponin I and T over 3 Months Using Reference Change Values in Hemodialysis Patients|journal=Clinical Chemistry|volume=62|issue=4|year=2016|pages=631–638|issn=0009-9147|doi=10.1373/clinchem.2015.251835}}</ref><ref name="La Vecchia2004">{{cite journal|last1=La Vecchia|first1=L|title=Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism|journal=Heart|volume=90|issue=6|year=2004|pages=633–637|issn=0007-0769|doi=10.1136/hrt.2003.019745}}</ref>
* In [[patients]] with [[chronic kidney disease]] and [[end stage renal disease]], [[amyloidosis]], [[pulmonary embolism]], increased level of [[troponin]] was associated with increased  all-cause [[mortality]].<ref name="AppleLer2016">{{cite journal|last1=Apple|first1=Fred S|last2=Ler|first2=Ranka|last3=Young|first3=Amy|last4=Brunelli|first4=Steven M|last5=Gilbertson|first5=David|last6=Wu|first6=Alan H B|last7=Hu|first7=Yan|last8=Cao|first8=Jing|last9=Love|first9=Sara A|last10=Herzog|first10=Charles A|last11=Sandoval|first11=Yader|title=Prognostic Value of Serial Changes in High-Sensitivity Cardiac Troponin I and T over 3 Months Using Reference Change Values in Hemodialysis Patients|journal=Clinical Chemistry|volume=62|issue=4|year=2016|pages=631–638|issn=0009-9147|doi=10.1373/clinchem.2015.251835}}</ref><ref name="La Vecchia2004">{{cite journal|last1=La Vecchia|first1=L|title=Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism|journal=Heart|volume=90|issue=6|year=2004|pages=633–637|issn=0007-0769|doi=10.1136/hrt.2003.019745}}</ref>
*Among [[patients]] admitted in [[emergency department]], evidence of acute myocardial injury was associated with higher rate of all cause [[mortality]] and [[heart failure]] compared with chronic [[myocardial injury]].<ref name="KadesjoRoos2019">{{cite journal|last1=Kadesjo|first1=Erik|last2=Roos|first2=Andreas|last3=Siddiqui|first3=Anwar J.|last4=Desta|first4=Liyew|last5=Lundback|first5=Magnus|last6=Holzmann|first6=Martin|title=ACUTE VERSUS CHRONIC MYOCARDIAL INJURY AND OUTCOMES|journal=Journal of the American College of Cardiology|volume=73|issue=9|year=2019|pages=105|issn=07351097|doi=10.1016/S0735-1097(19)30713-2}}</ref>
*Among [[patients]] admitted in [[emergency department]], evidence of acute [[myocardial injury ]] was associated with higher rate of all cause [[mortality]] and [[heart failure]] compared with chronic [[myocardial injury]].<ref name="KadesjoRoos2019">{{cite journal|last1=Kadesjo|first1=Erik|last2=Roos|first2=Andreas|last3=Siddiqui|first3=Anwar J.|last4=Desta|first4=Liyew|last5=Lundback|first5=Magnus|last6=Holzmann|first6=Martin|title=ACUTE VERSUS CHRONIC MYOCARDIAL INJURY AND OUTCOMES|journal=Journal of the American College of Cardiology|volume=73|issue=9|year=2019|pages=105|issn=07351097|doi=10.1016/S0735-1097(19)30713-2}}</ref>


*[[Prognosis]] is generally poor especially in non-cardiac causes of [[myocardial injury]] which have higher [[in-hospital]] [[mortality rate]] ( compared with [[cardiac]] causes of chronic [[myocardial injury]]).<ref name="IlvaEskola2010">{{cite journal|last1=Ilva|first1=Tuomo J.|last2=Eskola|first2=Markku J.|last3=Nikus|first3=Kjell C.|last4=Voipio-Pulkki|first4=Liisa-Maria|last5=Lund|first5=Juha|last6=Pulkki|first6=Kari|last7=Mustonen|first7=Harri|last8=Niemelä|first8=Kari O.|last9=Karhunen|first9=Pekka J.|last10=Porela|first10=Pekka|title=The Etiology and Prognostic Significance of Cardiac Troponin I Elevation in Unselected Emergency Department Patients|journal=The Journal of Emergency Medicine|volume=38|issue=1|year=2010|pages=1–5|issn=07364679|doi=10.1016/j.jemermed.2007.09.060}}</ref>
*[[Prognosis]] is generally poor especially in non-[[cardiac]] causes of [[myocardial injury]] which have higher [[in-hospital]] [[mortality rate]] ( compared with [[cardiac]] causes of chronic [[myocardial injury]]).<ref name="IlvaEskola2010">{{cite journal|last1=Ilva|first1=Tuomo J.|last2=Eskola|first2=Markku J.|last3=Nikus|first3=Kjell C.|last4=Voipio-Pulkki|first4=Liisa-Maria|last5=Lund|first5=Juha|last6=Pulkki|first6=Kari|last7=Mustonen|first7=Harri|last8=Niemelä|first8=Kari O.|last9=Karhunen|first9=Pekka J.|last10=Porela|first10=Pekka|title=The Etiology and Prognostic Significance of Cardiac Troponin I Elevation in Unselected Emergency Department Patients|journal=The Journal of Emergency Medicine|volume=38|issue=1|year=2010|pages=1–5|issn=07364679|doi=10.1016/j.jemermed.2007.09.060}}</ref>
* The 5-year [[mortality rate]] of [[patients]] with [[myocardial injury]] is approximately 70%.<ref name="ChapmanShah2018">{{cite journal|last1=Chapman|first1=Andrew R.|last2=Shah|first2=Anoop S.V.|last3=Lee|first3=Kuan Ken|last4=Anand|first4=Atul|last5=Francis|first5=Oliver|last6=Adamson|first6=Philip|last7=McAllister|first7=David A.|last8=Strachan|first8=Fiona E.|last9=Newby|first9=David E.|last10=Mills|first10=Nicholas L.|title=Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury|journal=Circulation|volume=137|issue=12|year=2018|pages=1236–1245|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031806}}</ref>
* The 5-year [[mortality rate]] of [[patients]] with [[myocardial injury]] is approximately 70%.<ref name="ChapmanShah2018">{{cite journal|last1=Chapman|first1=Andrew R.|last2=Shah|first2=Anoop S.V.|last3=Lee|first3=Kuan Ken|last4=Anand|first4=Atul|last5=Francis|first5=Oliver|last6=Adamson|first6=Philip|last7=McAllister|first7=David A.|last8=Strachan|first8=Fiona E.|last9=Newby|first9=David E.|last10=Mills|first10=Nicholas L.|title=Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury|journal=Circulation|volume=137|issue=12|year=2018|pages=1236–1245|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031806}}</ref>
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


==Diagnosis==
==Diagnosis==
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* [[Toxin]] exposure}}
* [[Toxin]] exposure}}
{{Family tree| |!| | | |`|V|-|-|'| | | | |}}
{{Family tree| |!| | | |`|V|-|-|'| | | | |}}
{{Family tree| |A9 | | |  A10| | | | | | | |A9=Management based on the type| A10=Management based on the causes of [[myocardial injury]] and [[clinical]] course }}
{{Family tree| |A9 | | |  A10| | | | | | | |A9=Management based on the type of [[myocardial infarction]]| A10=Management based on the causes of [[myocardial injury]] and [[clinical]] course }}
{{Family tree| | | | | | | | | | | | | | |}}
{{Family tree| | | | | | | | | | | | | | |}}
{{Family tree/end}}
{{Family tree/end}}
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*The initial workup includes an evaluation for [[myocardial ischemia]].
*The initial workup includes an evaluation about [[myocardial ischemia]].<ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
* If [[myocardial infarction]] is ruled out, further assessment involves a detailed [[history]], [[physical examination]], [[laboratory testing]], a 12-lead [[electrocardiogram]], and an [[echocardiogram]].
* If [[myocardial infarction]] is ruled out, further assessment involves a detailed [[history]], [[physical examination]], [[laboratory testing]], a 12-lead [[electrocardiogram]], and an [[echocardiogram]].
*Medical history should be taken about:
*Medical history should be taken about:
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*There are no specific physical examination findings associated with [[myocardial injury]]. However, cardiovascular evaluation about evidence of [[ischemia]] and [[nonischemic]] causes and [[systemic]] organs assessment is warranted as follows:
*There are no specific [[physical examination]] findings associated with [[myocardial injury]]. However, [[cardiovascular]] evaluation and [[systemic]] organs assessment is warranted as follows:
* Check of [[vital signs]]
* Check of [[vital signs]]
* [[Cardiovascular]] system: [[heart rate]] and [[rhythm]], [[murmurs]], presence of [[congestion]]
* [[Cardiovascular]] system: [[heart rate]] and [[rhythm]], [[murmurs]], presence of [[congestion]]
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===Laboratory Findings===
===Laboratory Findings===
Laboratory investigation consistent with the diagnosis of [[myocardial injury]] include:  
Laboratory investigation consistent with the diagnosis of [[myocardial injury]] include: <ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
* Serial cardiac [[troponin]] measurement
* Serial cardiac [[troponin]] measurement
* [[Renal function]] testing ([[chronic kidney disease]])
* [[Renal function]] testing ([[chronic kidney disease]])
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===Electrocardiogram===
===Electrocardiogram===
There are no specific [[ECG]] findings associated with [[myocardial injury]]. Findings on an [[ECG]] suggestive of [[myocardial injury]] may include:
There are no specific [[ECG]] findings associated with [[myocardial injury]]. Findings on an [[ECG]] suggestive of [[myocardial injury]] may include:<ref name="McCarthyRaber2019">{{cite journal|last1=McCarthy|first1=Cian P.|last2=Raber|first2=Inbar|last3=Chapman|first3=Andrew R.|last4=Sandoval|first4=Yader|last5=Apple|first5=Fred S.|last6=Mills|first6=Nicholas L.|last7=Januzzi|first7=James L.|title=Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays|journal=JAMA Cardiology|volume=4|issue=10|year=2019|pages=1034|issn=2380-6583|doi=10.1001/jamacardio.2019.2724}}</ref>
* Evidence of [[ischemia]], [[infarction]]
* Evidence of [[ischemia]], [[infarction]]
* [[Arrhythmias]]  
* [[Arrhythmias]]  
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===X-ray===
===X-ray===
There are no x-ray findings associated with [[myocardial injury]].
There are no [[x-ray]] findings associated with [[myocardial injury]].
 
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 or Ultrasound===
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===CT scan===
===CT scan===
There are no [[CT scan]] findings associated with [[myocardial injury]]. However, a [[CT scan]] may be helpful in suspicion of  [[pulmonary thromboembolism]] or [[aorta dissection]].
There are no [[CT scan]] findings associated with [[myocardial injury]]. However, a [[CT scan]] may be helpful in suspicion of  [[pulmonary thromboembolism]] or [[aortic dissection]].


===MRI===
===MRI===
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===Other Imaging Findings===
===Other Imaging Findings===
There are no other imaging findings associated with [[myocardial injury]].
There are no other imaging findings associated with [[myocardial injury]].
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===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [[myocardial injury]].
There are no other diagnostic studies associated with [[myocardial injury]].
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==
==Treatment==
Line 386: Line 329:
===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of [[myocardial injury]].
Surgical intervention is not recommended for the management of [[myocardial injury]].
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===
===Primary Prevention===
There are no established measures for the primary prevention of [[myocardial injury]].
There are no established measures for the [[primary prevention ]] of [[myocardial injury]].
 
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===
===Secondary Prevention===
There are no established measures for the secondary prevention of [[myocardial injury]].
There are no established measures for the [[secondary prevention]] of [[myocardial injury]].
 
OR
 
Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].


==References==
==References==

Latest revision as of 19:06, 10 March 2022

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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: Sara Zand, M.D.[2]

Synonyms and keywords: Acute myocardial injury, Chronic myocardial injury, Myocardial ischemia, troponin concentration, systemic illness

Overview

Myocardial injury is defined as elevated troponin concentrations without sign and symptom indicating overt myocardial ischemia and is the most common cause of increased troponin level. Traditionally, elevated troponin level was eqaul to myocardial infarction. Diagnosis of myocardial injury is a challange for clinicians. By improving the laboratory method for detecting high sensitive troponin and clinical approach to diagnosis of myocardial ischemia, patients with myocardial injury due to underlying diseases were excluded and treated. Evaluation and treatment of percipitant factors of 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 and long term outcome.

Historical Perspective

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

Pathophysiology

Causes





Differentiating myocardial injury from other Diseases

Epidemiology and Demographics


Risk Factors

Common risk factors in the development of myocardial injury include:

Screening

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice



 
 
 
 
Myocardial injury
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute myocardial injury
 
 
 
Chronic myocardial injury
  • Stable but elevated troponin
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		History and physical examination
     
     
     
    		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
     
    		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 of myocardial infarction
     
     
    		Management based on the causes of myocardial injury and clinical course
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

    History and Symptoms

    Common symptoms associated with underlying causes of myocardial injury include:

    Physical Examination

    Laboratory Findings

    Laboratory investigation consistent with the diagnosis of myocardial injury include: [3]


    Electrocardiogram

    There are no specific ECG findings associated with myocardial injury. Findings on an ECG suggestive of myocardial injury may include:[3]

    X-ray

    There are no x-ray findings associated with myocardial injury.

    Echocardiography or Ultrasound

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

    CT scan

    There are no CT scan findings associated with myocardial injury. However, a CT scan may be helpful in suspicion of pulmonary thromboembolism or aortic dissection.

    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 myocardial injury.

    Other Diagnostic Studies

    There are no other diagnostic studies associated with myocardial injury.

    Treatment

    Medical Therapy


    Surgery

    Surgical intervention is not recommended for the management of myocardial injury.

    Primary Prevention

    There are no established measures for the primary prevention of myocardial injury.

    Secondary Prevention

    There are no established measures for the secondary prevention of myocardial injury.

    References

    1. ↑ Perry SV (April 2008). "Background to the discovery of troponin and Setsuro Ebashi's contribution to our knowledge of the mechanism of relaxation in striated muscle". Biochem Biophys Res Commun. 369 (1): 43–8. doi:10.1016/j.bbrc.2007.11.185. PMID 18365325.
    2. ↑ Antman, Elliott; Bassand, Jean-Pierre; Klein, Werner; Ohman, Magnus; Lopez Sendon, Jose Luis; Rydén, Lars; Simoons, Maarten; Tendera, Michal (2000). "Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction". Journal of the American College of Cardiology. 36 (3): 959–969. doi:10.1016/S0735-1097(00)00804-4. ISSN 0735-1097.
    3. ↑ 3.0 3.1 3.2 3.3 3.4 McCarthy, Cian P.; Raber, Inbar; Chapman, Andrew R.; Sandoval, Yader; Apple, Fred S.; Mills, Nicholas L.; Januzzi, James L. (2019). "Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays". JAMA Cardiology. 4 (10): 1034. doi:10.1001/jamacardio.2019.2724. ISSN 2380-6583.
    4. ↑ Twerenbold, R.; Jaffe, A.; Reichlin, T.; Reiter, M.; Mueller, C. (2012). "High-sensitive troponin T measurements: what do we gain and what are the challenges?". European Heart Journal. 33 (5): 579–586. doi:10.1093/eurheartj/ehr492. ISSN 0195-668X.
    5. ↑ Januzzi, James; Gaggin, Hanna; Wolf, Myles; Christenson, Robert H; Hise, Michael; Duh, Show-Hong; Kelley, Walter; Seliger, Stephen L; deFilippi, Christopher (2012). "Interpreting Cardiac Troponin Results from High-Sensitivity Assays in Chronic Kidney Disease without Acute Coronary Syndrome". Clinical Chemistry. 58 (9): 1342–1351. doi:10.1373/clinchem.2012.185322. ISSN 0009-9147.
    6. ↑ Chin, C. W. L.; Shah, A. S. V.; McAllister, D. A.; Joanna Cowell, S.; Alam, S.; Langrish, J. P.; Strachan, F. E.; Hunter, A. L.; Maria Choy, A.; Lang, C. C.; Walker, S.; Boon, N. A.; Newby, D. E.; Mills, N. L.; Dweck, M. R. (2014). "High-sensitivity troponin I concentrations are a marker of an advanced hypertrophic response and adverse outcomes in patients with aortic stenosis". European Heart Journal. 35 (34): 2312–2321. doi:10.1093/eurheartj/ehu189. ISSN 0195-668X.
    7. ↑ 7.0 7.1 Sandoval, Yader; Smith, Stephen W.; Sexter, Anne; Thordsen, Sarah E.; Bruen, Charles A.; Carlson, Michelle D.; Dodd, Kenneth W.; Driver, Brian E.; Hu, Yan; Jacoby, Katherine; Johnson, Benjamin K.; Love, Sara A.; Moore, Johanna C.; Schulz, Karen; Scott, Nathaniel L.; Apple, Fred S. (2017). "Type 1 and 2 Myocardial Infarction and Myocardial Injury: Clinical Transition to High-Sensitivity Cardiac Troponin I". The American Journal of Medicine. 130 (12): 1431–1439.e4. doi:10.1016/j.amjmed.2017.05.049. ISSN 0002-9343.
    8. ↑ 8.0 8.1 Aimo, Alberto; Januzzi, James L.; Vergaro, Giuseppe; Ripoli, Andrea; Latini, Roberto; Masson, Serge; Magnoli, Michela; Anand, Inder S.; Cohn, Jay N.; Tavazzi, Luigi; Tognoni, Gianni; Gravning, Jørgen; Ueland, Thor; Nymo, Ståle H.; Brunner-La Rocca, Hans-Peter; Genis, Antoni Bayes; Lupón, Josep; de Boer, Rudolf A.; Yoshihisa, Akiomi; Takeishi, Yasuchika; Egstrup, Michael; Gustafsson, Ida; Gaggin, Hanna K.; Eggers, Kai M.; Huber, Kurt; Tentzeris, Ioannis; Tang, Wai H.W.; Grodin, Justin; Passino, Claudio; Emdin, Michele (2018). "Prognostic Value of High-Sensitivity Troponin T in Chronic Heart Failure". Circulation. 137 (3): 286–297. doi:10.1161/CIRCULATIONAHA.117.031560. ISSN 0009-7322.
    9. ↑ . doi:10.3969/j.issn.1671-5411.2014.02.011. Missing or empty |title= (help)
    10. ↑ Kubo, Toru; Kitaoka, Hiroaki; Yamanaka, Shigeo; Hirota, Takayoshi; Baba, Yuichi; Hayashi, Kayo; Iiyama, Tatsuo; Kumagai, Naoko; Tanioka, Katsutoshi; Yamasaki, Naohito; Matsumura, Yoshihisa; Furuno, Takashi; Sugiura, Tetsuro; Doi, Yoshinori L. (2013). "Significance of High-Sensitivity Cardiac Troponin T in Hypertrophic Cardiomyopathy". Journal of the American College of Cardiology. 62 (14): 1252–1259. doi:10.1016/j.jacc.2013.03.055. ISSN 0735-1097.
    11. ↑ Januzzi, James L.; Suchindran, Sunil; Coles, Adrian; Ferencik, Maros; Patel, Manesh R.; Hoffmann, Udo; Ginsburg, Geoffrey S.; Douglas, Pamela S. (2019). "High-Sensitivity Troponin I and Coronary Computed Tomography in Symptomatic Outpatients With Suspected CAD". JACC: Cardiovascular Imaging. 12 (6): 1047–1055. doi:10.1016/j.jcmg.2018.01.021. ISSN 1936-878X.
    12. ↑ Aeschbacher, Stefanie; Schoen, Tobias; Bossard, Matthias; van der Lely, Stephanie; Glättli, Kathrin; Todd, John; Estis, Joel; Risch, Martin; Mueller, Christian; Risch, Lorenz; Conen, David (2015). "Relationship Between High-Sensitivity Cardiac Troponin I and Blood Pressure Among Young and Healthy Adults". American Journal of Hypertension. 28 (6): 789–796. doi:10.1093/ajh/hpu226. ISSN 0895-7061.
    13. ↑ Røsjø, Helge; Andreassen, Johanna; Edvardsen, Thor; Omland, Torbjørn (2011). "Prognostic Usefulness of Circulating High-Sensitivity Troponin T in Aortic Stenosis and Relation to Echocardiographic Indexes of Cardiac Function and Anatomy". The American Journal of Cardiology. 108 (1): 88–91. doi:10.1016/j.amjcard.2011.02.346. ISSN 0002-9149.
    14. ↑ van den Bos, E. J.; Constantinescu, A. A.; van Domburg, R. T.; Akin, S.; Jordaens, L. J.; Kofflard, M. J. M. (2011). "Minor elevations in troponin I are associated with mortality and adverse cardiac events in patients with atrial fibrillation". European Heart Journal. 32 (5): 611–617. doi:10.1093/eurheartj/ehq491. ISSN 0195-668X.
    15. ↑ Apple, Fred S.; Murakami, MaryAnn M.; Pearce, Lesly A.; Herzog, Charles A. (2002). "Predictive Value of Cardiac Troponin I and T for Subsequent Death in End-Stage Renal Disease". Circulation. 106 (23): 2941–2945. doi:10.1161/01.CIR.0000041254.30637.34. ISSN 0009-7322.
    16. ↑ Heresi, G.A.; Tang, W.H.W.; Aytekin, M.; Hammel, J.; Hazen, S.L.; Dweik, R.A. (2012). "Sensitive cardiac troponin I predicts poor outcomes in pulmonary arterial hypertension". European Respiratory Journal. 39 (4): 939–944. doi:10.1183/09031936.00067011. ISSN 0903-1936.
    17. ↑ Riley, Elise D.; Hsue, Priscilla Y.; Vittinghoff, Eric; Wu, Alan H.B.; Coffin, Phillip O.; Moore, Peter K.; Lynch, Kara L. (2017). "Higher prevalence of detectable troponin I among cocaine-users without known cardiovascular disease". Drug and Alcohol Dependence. 172: 88–93. doi:10.1016/j.drugalcdep.2016.11.039. ISSN 0376-8716.
    18. ↑ Segre, Carlos Alexandre Wainrober; Hueb, Whady; Garcia, Rosa Maria Rahmi; Rezende, Paulo Cury; Favarato, Desiderio; Strunz, Celia Maria Cassaro; Sprandel, Marília da Costa Oliveira; Roggério, Alessandra; Carvalho, Ana Luiza de Oliveira; Maranhão, Raul Cavalcante; Ramires, José Antonio Franchini; Filho, Roberto Kalil (2015). "Troponin in diabetic patients with and without chronic coronary artery disease". BMC Cardiovascular Disorders. 15 (1). doi:10.1186/s12872-015-0051-z. ISSN 1471-2261.
    19. ↑ Bellotto, Fabio; Fagiuoli, Stefano; Pavei, Andrea; Gregory, Shawn A.; Cati, Arianna; Silverj, Elisabetta; Plebani, Mario; Zaninotto, Martina; Mancuso, Tommaso; Iliceto, Sabino (2005). "Anemia and ischemia: Myocardial injury in patients with gastrointestinal bleeding". The American Journal of Medicine. 118 (5): 548–551. doi:10.1016/j.amjmed.2005.01.026. ISSN 0002-9343.
    20. ↑ Puelacher, Christian; Lurati Buse, Giovanna; Seeberger, Daniela; Sazgary, Lorraine; Marbot, Stella; Lampart, Andreas; Espinola, Jaqueline; Kindler, Christoph; Hammerer, Angelika; Seeberger, Esther; Strebel, Ivo; Wildi, Karin; Twerenbold, Raphael; du Fay de Lavallaz, Jeanne; Steiner, Luzius; Gurke, Lorenz; Breidthardt, Tobias; Rentsch, Katharina; Buser, Andreas; Gualandro, Danielle M.; Osswald, Stefan; Mueller, Christian; Seeberger, Manfred; Christ-Crain, Mirjam; Cuculi, Florim; Badertscher, Patrick; Nestelberger, Thomas; Wussler, Desiree; Flores, Dayana; Boeddinghaus, Jasper; Sabti, Zaid; Giménez, Maria Rubini; Kozhuharov, Nikola; Shrestha, Samyut; Kloos, Wanda; Lohrmann, Jens; Reichlin, Tobias; Freese, Michael; Meissner, Kathrin; Kaiser, Christoph; Buser, Andreas (2018). "Perioperative Myocardial Injury After Noncardiac Surgery". Circulation. 137 (12): 1221–1232. doi:10.1161/CIRCULATIONAHA.117.030114. ISSN 0009-7322.
    21. ↑ Lim, Wendy (2006). "Elevated Cardiac Troponin Measurements in Critically Ill Patients". Archives of Internal Medicine. 166 (22): 2446. doi:10.1001/archinte.166.22.2446. ISSN 0003-9926.
    22. ↑ Punukollu, Gopikrishna; Gowda, Ramesh M; Khan, Ijaz A; Mehta, Nirav J; Navarro, Victor; Vasavada, Balendu C; Sacchi, Terrence J (2004). "Elevated serum cardiac troponin I in rhabdomyolysis". International Journal of Cardiology. 96 (1): 35–40. doi:10.1016/j.ijcard.2003.04.053. ISSN 0167-5273.
    23. ↑ Lee, Kuan Ken; Noaman, Ala; Vaswani, Amar; Gibbins, Matthew; Griffiths, Megan; Chapman, Andrew R.; Strachan, Fiona; Anand, Atul; McAllister, David A.; Newby, David E.; Gray, Alasdair J.; Mills, Nicholas L.; Shah, Anoop S.V. (2019). "Prevalence, Determinants, and Clinical Associations of High-Sensitivity Cardiac Troponin in Patients Attending Emergency Departments". The American Journal of Medicine. 132 (1): 110.e8–110.e21. doi:10.1016/j.amjmed.2018.10.002. ISSN 0002-9343.
    24. ↑ Sarkisian, Laura; Saaby, Lotte; Poulsen, Tina S.; Gerke, Oke; Jangaard, Nikolaj; Hosbond, Susanne; Diederichsen, Axel C.P.; Thygesen, Kristian; Mickley, Hans (2016). "Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins". The American Journal of Medicine. 129 (4): 446.e5–446.e21. doi:10.1016/j.amjmed.2015.11.006. ISSN 0002-9343.
    25. ↑ Puelacher, Christian; Bollen Pinto, Bernardo; Mills, Nicholas L.; Duceppe, Emmanuelle; Popova, Ekaterine; Duma, Andreas; Nagele, Peter; Omland, Torbjørn; Hammerer-Lercher, Angelika; Lurati Buse, Giovanna (2021). "Expert consensus on peri-operative myocardial injury screening in noncardiac surgery". European Journal of Anaesthesiology. 38 (6): 600–608. doi:10.1097/EJA.0000000000001486. ISSN 0265-0215.
    26. ↑ Apple, Fred S; Ler, Ranka; Young, Amy; Brunelli, Steven M; Gilbertson, David; Wu, Alan H B; Hu, Yan; Cao, Jing; Love, Sara A; Herzog, Charles A; Sandoval, Yader (2016). "Prognostic Value of Serial Changes in High-Sensitivity Cardiac Troponin I and T over 3 Months Using Reference Change Values in Hemodialysis Patients". Clinical Chemistry. 62 (4): 631–638. doi:10.1373/clinchem.2015.251835. ISSN 0009-9147.
    27. ↑ La Vecchia, L (2004). "Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism". Heart. 90 (6): 633–637. doi:10.1136/hrt.2003.019745. ISSN 0007-0769.
    28. ↑ Kadesjo, Erik; Roos, Andreas; Siddiqui, Anwar J.; Desta, Liyew; Lundback, Magnus; Holzmann, Martin (2019). "ACUTE VERSUS CHRONIC MYOCARDIAL INJURY AND OUTCOMES". Journal of the American College of Cardiology. 73 (9): 105. doi:10.1016/S0735-1097(19)30713-2. ISSN 0735-1097.
    29. ↑ Ilva, Tuomo J.; Eskola, Markku J.; Nikus, Kjell C.; Voipio-Pulkki, Liisa-Maria; Lund, Juha; Pulkki, Kari; Mustonen, Harri; Niemelä, Kari O.; Karhunen, Pekka J.; Porela, Pekka (2010). "The Etiology and Prognostic Significance of Cardiac Troponin I Elevation in Unselected Emergency Department Patients". The Journal of Emergency Medicine. 38 (1): 1–5. doi:10.1016/j.jemermed.2007.09.060. ISSN 0736-4679.
    30. ↑ Chapman, Andrew R.; Shah, Anoop S.V.; Lee, Kuan Ken; Anand, Atul; Francis, Oliver; Adamson, Philip; McAllister, David A.; Strachan, Fiona E.; Newby, David E.; Mills, Nicholas L. (2018). "Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury". Circulation. 137 (12): 1236–1245. doi:10.1161/CIRCULATIONAHA.117.031806. ISSN 0009-7322.
    31. ↑ Bjurman, Christian; Larsson, Mårten; Johanson, Per; Petzold, Max; Lindahl, Bertil; Fu, Michael L.X.; Hammarsten, Ola (2013). "Small Changes in Troponin T Levels Are Common in Patients With Non–ST-Segment Elevation Myocardial Infarction and Are Linked to Higher Mortality". Journal of the American College of Cardiology. 62 (14): 1231–1238. doi:10.1016/j.jacc.2013.06.050. ISSN 0735-1097.
    32. ↑ Ford, Ian; Shah, Anoop S.V.; Zhang, Ruiqi; McAllister, David A.; Strachan, Fiona E.; Caslake, Muriel; Newby, David E.; Packard, Chris J.; Mills, Nicholas L. (2016). "High-Sensitivity Cardiac Troponin, Statin Therapy, and Risk of Coronary Heart Disease". Journal of the American College of Cardiology. 68 (25): 2719–2728. doi:10.1016/j.jacc.2016.10.020. ISSN 0735-1097.
    33. ↑ Devereaux, P J; Duceppe, Emmanuelle; Guyatt, Gordon; Tandon, Vikas; Rodseth, Reitze; Biccard, Bruce M; Xavier, Denis; Szczeklik, Wojciech; Meyhoff, Christian S; Vincent, Jessica; Franzosi, Maria Grazia; Srinathan, Sadeesh K; Erb, Jason; Magloire, Patrick; Neary, John; Rao, Mangala; Rahate, Prashant V; Chaudhry, Navneet K; Mayosi, Bongani; de Nadal, Miriam; Iglesias, Pilar Paniagua; Berwanger, Otavio; Villar, Juan Carlos; Botto, Fernando; Eikelboom, John W; Sessler, Daniel I; Kearon, Clive; Pettit, Shirley; Sharma, Mukul; Connolly, Stuart J; Bangdiwala, Shrikant I; Rao-Melacini, Purnima; Hoeft, Andreas; Yusuf, Salim; Devereaux, P.J.; Duceppe, Emmanuelle; Bangdiwala, Shrikant I.; Connolly, Stuart; Eikelboom, John; Guyatt, Gordon; Kearon, Clive; Pettit, Shirley; Pogue, Janice; Rodseth, Reitze; Sessler, Daniel I.; Vincent, Jessica; Yusuf, Salim; Vincent, Jessica; Di Diodato, Sara; Gasic, Zora; Mastrangelo, Louise J.; Molnar, Sarah H.; Pettit, Shirley; Swanson, Jennifer L.; Tosh, Makayla L.; Wells, Jennifer R.; Botto, Fernando; Diaz, Rafael; Chow, Clara K.; Berwanger, Otavio; Gonzales, Beatriz; Devereaux, P.J.; Tandon, Vikas; Villar, Juan Carlos; Vásquez, Skarlet; Jansky, Petr; Dušek, Radovan; Meyhoff, Christian S.; Coriat, Pierre; Hoeft, Andreas; Wittmann, Maria; Yonga, Gerald; Xavier, Denis; Rao, Mangala; Mathur, Nandini; Franzosi, Maria Grazia; Seletti, Elena; Malaga, German; Tumanan-Mendoza, Bernadette A.; Tagle, Maria Pamela A.; Szczeklik, Wojciech; Biccard, Bruce M.; Alonso-Coello, Pablo; Popova, Ekaterine; Shields, Martin; Sessler, Daniel I.; Devereaux, P.J.; Biccard, Bruce M.; Connolly, Stuart; Duceppe, Emmanuelle; Eikelboom, John; Guyatt, Gordon; Hoeft, Andreas; Jansky, Petr; Kearon, Clive; Le Manach, Yannick; Moayyedi, Paul; Pettit, Shirley; Pogue, Janice; Rodseth, Reitze; Sessler, Daniel I.; van Zanten, Sander; Villar, Juan Carlos; Vincent, Jessica; Yusuf, Salim; Devereaux, P.J.; Alonso-Coello, Pablo; Berwanger, Otavio; Biccard, Bruce M.; Botto, Fernando; Chow, Clara K.; Connolly, Stuart; Coriat, Pierre; Diaz, Rafael; Duceppe, Emmanuelle; Eikelboom, John; Fleischmann, Edith; Franzosi, Maria Grazia; Garg, Amit; Guyatt, Gordon; Hoeft, Andreas; Jansky, Petr; Karaye, Kamilu; Kearon, Clive; Le Manach, Yannick; Malaga, German; McFalls, Edward; Meyhoff, Christian S.; Moayyedi, Paul; Pettit, Shirley; Pogue, Janice; Rodseth, Reitze; Sessler, Daniel I.; Sigamani, Alben; Shields, Martin; Szczeklik, Wojciech; Tumanan-Mendoza, Bernadette A.; van Zanten, Sander; Villar, Juan Carlos; Vincent, Jessica; Xavier, Denis; Yonga, Gerald; Yusuf, Salim; Connolly, Stuart; Belley-Côté, Emilie; Biedroń, Grzegorz; Borges, Flavia; Frosi Stella, Steffan; Haarmark Nielsen, Christian; Leong, Darryl P.; Meyhoff, Christian S.; Spence, Jessica; Tran, Allen; Wawrzycka-Adamczyk, Katarzyna; Yang, Stephen S.; Yung, Terence; Wyse, D. 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