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Troponinerhöhung beim akuten ischämischen Schlaganfall – unspezifisch oder Ausdruck eines akuten Myokardinfarkts?

Diagnostik und klinische Implikationen

Troponin elevation in acute ischemic stroke—unspecific or acute myocardial infarction?

Diagnostics and clinical implications

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Zusammenfassung

Für alle Patienten mit akutem ischämischen Schlaganfall wird die routinemäßige Troponinbestimmung empfohlen. Bei 20–55 % dieser Patienten ist der Troponinwert erhöht, wobei hierfür neben der ischämischen auch die nichtischämische Myokardschädigung sowie im Besonderen der neurokardiogene Myokardschaden ursächlich sein können. Bei Patienten mit akutem ischämischen Schlaganfall wird die Prävalenz einer bisher nicht bekannten koronaren Herzkrankheit mit bis zu 27 % angegeben und ist für dieses Kollektiv prognosebestimmend. Allerdings können bei Schlaganfallpatienten mit Troponinerhöhung im Vergleich zu Patienten mit einem Nicht-ST-Strecken-Hebungs-Myokardinfarkt seltener relevante Koronarstenosen nachgewiesen werden. Das Risiko einer sekundären intrazerebralen Hämorrhagie durch die Notwendigkeit einer dualen Thrombozytenaggregationshemmung verdeutlicht die herausfordernde Indikationsstellung zur invasiven Koronardiagnostik und -revaskularisation. Daher sind eine der Dringlichkeit angemessene diagnostische Aufarbeitung und interdisziplinäre Risikoevaluation notwendig, um ein sinnvolles therapeutisches Vorgehen mit Zeitpunkt der Intervention sowie Art und Dauer der Blutverdünnung festlegen zu können. Neben konventionellen Untersuchungsmethoden steht hierfür immer häufiger auch eine erweiterte kardiale Bildgebung zur Verfügung. Diese Übersichtsarbeit möchte einen pragmatischen und klinisch orientierten Ansatz zum diagnostischen und therapeutischen Vorgehen unter Berücksichtigung der vorhandenen Evidenz aufzeigen.

Abstract

Routine determination of troponin levels is recommended for all patients with acute ischemic stroke. In 20–55% of these patients the troponin levels are elevated, which may be caused by ischemic as well as non-ischemic myocardial damage and particularly neurocardiogenic myocardial damage. In patients with acute ischemic stroke, the prevalence of previously unknown coronary heart disease is reported to be up to 27% and is prognostically relevant for these patients; however, relevant coronary stenoses are less frequently detected in stroke patients with troponin elevation compared to patients with non-ST elevation myocardial infarction. The risk of secondary intracerebral hemorrhage due to the necessity for dual platelet aggregation inhibition illustrates the challenging indication for invasive coronary diagnostics and revascularization. Therefore, a diagnostic work-up and interdisciplinary risk evaluation appropriate to the urgency are necessary in order to be able to determine a reasonable treatment approach with timing of the intervention, type and duration of blood thinning. In addition to conventional examination methods, multimodal cardiac imaging is increasingly used for this purpose. This review article aims to provide a pragmatic and clinically oriented approach to diagnostic and therapeutic procedures, taking into account the available evidence.

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Authors and Affiliations

  1. I. Medizinische Klinik, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Deutschland

    M. Kruska, C. Fastner, A. Kolb, M. Rutsch, T. Papavassiliu, M. Borggrefe, I. Akin &  S. Baumann

  2. DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Mannheim, Deutschland

    M. Kruska, C. Fastner, A. Kolb, M. Rutsch, M. Borggrefe, I. Akin &  S. Baumann

  3. Klinik für Neurologie mit Experimenteller Neurologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland

    J. F. Scheitz

  4. Centrum für Schlaganfallforschung Berlin, Berlin, Deutschland

    J. F. Scheitz

  5. Neurologische Klinik, Universitätsklinikum Mannheim, Universität Heidelberg, Mannheim, Deutschland

    A. Kolb, A. Alonso & K. Szabo

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M. Kruska, C. Fastner, J.F. Scheitz, A. Kolb, M. Rutsch, T. Papavassiliu, M. Borggrefe, A. Alonso, I. Akin, K. Szabo und S. Baumann geben an, dass kein Interessenkonflikt besteht.

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Die Autoren M. Kruska und C. Fastner teilen sich die Erstautorschaft.

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Kruska, M., Fastner, C., Scheitz, J.F. et al. Troponinerhöhung beim akuten ischämischen Schlaganfall – unspezifisch oder Ausdruck eines akuten Myokardinfarkts?. Herz 46, 342–351 (2021). https://doi.org/10.1007/s00059-020-04967-3

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