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Unrecognised myocardial infarction and its relationship to outcome in critically ill patients with cardiovascular disease

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Abstract

Purpose

To establish the incidence of myocardial infarction (MI) in ICU patients with co-existing cardiovascular disease (CVD), and explore its association with long-term survival.

Methods

In a multi-centre prospective cohort study in 11 UK ICUs, we enrolled 273 critically ill patients with co-existing CVD. We measured troponin I (cTnI) with a high sensitivity assay for 10 days; ECGs were carried out daily for 5 days and analysed by blinded cardiologists for dynamic changes. Data were combined to diagnose myocardial ‘infarction’, ‘injury’ or ‘no injury’ according to the third universal definition of MI. Patients were followed-up for 6 months. Regression and mediation analyses were used to explore relationships between acute physiological derangements, MI, and mortality.

Results

cTnI was detected in all patients, with a rise/fall pattern consistent with an acute hit. In 73% of patients, this peaked on days 1–3 [median 114 ng/l (first, third quartiles: 27, 393)]. Serial ECGs indicated 24.2% (n = 66) of patients experienced MI, but > 95% were unrecognized by clinical teams. Type 2 MI was the most likely aetiology in all cases. A further 46.1% (n = 126) experienced injury (no ECG changes). Injury and MI were both associated with 6-month mortality (reference: no injury): OR injury 2.28 (95% CI 1.06–4.92, p = 0.035), OR MI 2.70 (95% CI 1.11–6.55, p = 0.028). Mediation analysis suggested MI partially mediated the relationship between acute physiological derangement and 6-month mortality (p = 0.002), suggesting a possible causal association.

Conclusions

Undiagnosed MI occurs in around a quarter of critically ill patients with co-existing CVD and is associated with lower long-term survival.

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Acknowledgements

TROPICCAL Investigators: Stephen Wright, Newcastle Hospitals; Stuart McKechnie, Oxford University Hospitals; Marlies Ostermann, Guys and St Thomas’ London; David Pogson, Portsmouth Hospitals NHS Trust; Dan Horner, Salford Royal Infirmary, Madhu Balasubramaniam, Royal Bolton Hospital; Jon Hopper, University Hospital South Manchester; Owen Boyd, Brighton and Sussex University Hospitals; Robert Shawcross, East Lancashire Hospitals Trust; Malcolm Sim, Queen Elizabeth University Hospital Glasgow.

Funding

This study was undertaken as part of ABD’s PhD, which was funded by the National Blood Service, and the Scottish National Blood Transfusion Service.

Author information

Authors and Affiliations

  1. Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, 2nd Floor Anaesthetics Corridor, Royal Infirmary Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SA, UK

    Annemarie B. Docherty, Nazir I. Lone & Timothy S. Walsh

  2. Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK

    Annemarie B. Docherty & Timothy S. Walsh

  3. Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK

    Shirjel Alam, Anoop S. Shah, Alastair Moss, David E. Newby & Nicholas L. Mills

  4. Radcliffe Department of Medicine, University of Oxford, Oxford, UK

    Simon J. Stanworth

  5. Transfusion Medicine, NHS Blood and Transplant, Oxford, UK

    Simon J. Stanworth

  6. The Usher Institute, University of Edinburgh, Edinburgh, UK

    Annemarie B. Docherty & Nazir I. Lone

Authors
  1. Annemarie B. Docherty
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  2. Shirjel Alam
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  3. Anoop S. Shah
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  4. Alastair Moss
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  5. David E. Newby
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  6. Nicholas L. Mills
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  7. Simon J. Stanworth
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  8. Nazir I. Lone
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  9. Timothy S. Walsh
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Consortia

the TROPICCAL Investigators

  • Stephen Wright
  • , Stuart McKechnie
  • , Marlies Ostermann
  • , David Pogson
  • , Dan Horner
  • , Madhu Balasubramaniam
  • , Jon Hopper
  • , Owen Boyd
  • , Robert Shawcross
  •  & Malcolm Sim

Contributions

All authors were involved in the design of the study. ABD: Ran the study. SA, ASS, and AM: Performed the ECG analysis. ABD, NIL and TSW: Undertook the data analysis. All authors were involved in the interpretation of the data and the drafting of the manuscript.

Corresponding author

Correspondence to Annemarie B. Docherty.

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Conflicts of interest

Dr. Shah has received speaker fees from Abbott Diagnostics. Professor Mills has acted as a consultant for Abbott Diagnostics, Beckman-Coulter, Roche and Singulex who manufacture troponin assays, and has received research grants from Abbott Diagnostics.

Additional information

TROPICCAL Investigators members details are given in the Acknowledgement section.

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Docherty, A.B., Alam, S., Shah, A.S. et al. Unrecognised myocardial infarction and its relationship to outcome in critically ill patients with cardiovascular disease. Intensive Care Med 44, 2059–2069 (2018). https://doi.org/10.1007/s00134-018-5425-0

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