2: Evaluation of myocardial ischaemia

Published on 02/03/2015 by admin

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Last modified 22/04/2025

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Topic 2 Evaluation of myocardial ischaemia

Markers of myocardial injury and infarction

A universal classification system for myocardial infarction (MI) was published in 2007.

It defines five types of MI:

Myocardial damage results in release of proteins into the circulation that can be detected with laboratory assays. These include troponins, myoglobin and CK-MB. Cardiac troponins are currently the preferred biomarkers as their detection in blood is highly specific and sensitive for myocardial damage.

CK-MB is an isoenzyme of creatine kinase, which is present in skeletal and myocardial muscle. An elevated level is usually detectable within 4–6 h of myocardial injury. Reference range is 0–5 ng/mL.

Cardiac troponins are myocardial contractile proteins. An increased value for cardiac troponin is defined as a measurement exceeding the 99th percentile of a normal reference population upper reference limit, measured with a coefficient of variation <10%.

Cardiac troponin T (cTnT) assays have a relatively consistent sensitivity with a cutoff (including 10% coefficient of variation) of 0.03 μg/L. The lowest level of detectability is 0.01 μg/L. cTnT is expressed by skeletal muscle in patients with chronic renal failure, and therefore cTnT measurements during acute presentations must be compared to baseline values in this patient cohort.

Cardiac troponin I (cTnI) assays are more variable and therefore reference to local laboratory assay ranges and coefficient of variation is appropriate. As a guide, a serum cTnI value of >0.5 ng/ml is evidence of acute myocardial injury with significant prognostic implications. Serum cTnI levels <0.01 are normal. cTnI values between 0.01–0.04 ng/ml may reflect myocyte necrosis, but depend on specific sensitivities and variability of the local assay. cTnI values between 0.04 and 0.5 ng/ml are suggestive of acute myocardial injury, and need to be placed in clinical context.

Troponin values may remain elevated for 7–14 days following the onset of infarction.

Myocardial injury and troponin elevation can occur without coronary artery disease. Examples include:

Troponin levels may also be elevated in noncardiac conditions such as in acute pulmonary embolism, renal failure, sepsis and following brain injury or burns.

Stress tests

Nuclear imaging

Nuclear imaging techniques can be used for non-invasive assessment of coronary artery disease. Applications include perfusion assessment, viability assessment and measurement of left ventricular volume and function.

In these procedures, images are created from the emitted radiation of injected radiopharmaceuticals (radionuclides bound to marker molecules).

Single photon emission computed tomography (SPECT)

SPECT describes the use of a rotating gamma camera, which enables reconstruction to create a three dimensional image. Standard views are shown in Figure 2.4.

Radiopharmaceuticals in common use are: Thallium-201, Technetium-99m-sestamibi (cardiolite) and Technetium-99m-tetrofosmin (myoview).

After intravenous injection, the distribution of radiopharmaceutical represents regional blood flow. Distribution with stress and rest is then compared.

A perfusion defect that improves at rest indicates inducible ischaemia. A fixed perfusion defect represents infarction.

ECG-gated perfusion SPECT allows additional functional assessment including LV ejection fraction, wall thickening, wall motion and volumes. Technetium is more suited to gated SPECT than thallium.

Stress echocardiography

Disadvantages of exercise: 90 second time window after peak exercise for optimum sensitivity. Increased ventilation/respiratory excursion makes image acquisition more difficult.

Typical pharmacological agents: dobutamine (+/– atropine), adenosine, dipyridamole.

Dobutamine effects: Increased contractility and heart rate, reduced systemic vascular resistance; possible side effects: palpitations, flushing, arrhythmias, drop in blood pressure.

The dobutamine dose is 5–10 µg/kg/min increased in increments to max 40 µg/kg/min.

Atropine can be given in addition to increase heart rate to target.

Views:

A number can be assigned to each segment and a wall motion score can be calculated:

Interpretation: (Figure 2.5)

Cardiac magnetic resonance imaging (see Figure 2.6)

Magnetic resonance imaging (MRI) involves the application of a strong magnetic field to the body. Radio wave energy is then applied to the area of interest. The resulting signal is then processed to generate an image.

Techniques used in the assessment of coronary artery disease include the following:

Late gadolinium enhancement can be used to assess viability. Impaired contractility without wall thinning and without late enhancement indicates hibernating viable myocardium. Recovery of function with revascularisation can be predicted by the transmural extent of scarring. Transmural enhancement percentage is inversely related to the likelihood of functional recovery.

Advantages include:

Limitations include incompatibility with ferromagnetic substances and patient tolerance due to claustrophobia. Resolution of magnetic resonance coronary angiography is not sufficient to replace traditional methods of anatomic assessment.

Diagnostic adjuncts in angiography and percutaneous intervention

There are now technologies in common use that provide important supplementary information during invasive coronary angiography and can therefore aid decision making.