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Observational Study
. 2024 Jul 1;81(7):703-711.
doi: 10.1001/jamaneurol.2024.1552.

Type 1 Myocardial Infarction in Patients With Acute Ischemic Stroke

Christian H Nolte  1   2   3   4 , Regina von Rennenberg  1   2   5 , Simon Litmeier  1   2   5 , David M Leistner  6 , Kristina Szabo  7 , Stefan Baumann  8 , Annerose Mengel  9 , Dominik Michalski  10 , Timo Siepmann  11 , Stephan Blankenberg  12   13 , Gabor C Petzold  14   15 , Martin Dichgans  16   17   18   19 , Hugo Katus  20 , Burkert Pieske  21 , Vera Regitz-Zagrosek  22 , Tim Bastian Braemswig  1   2   3   4 , Ida Rangus  1   2 , Amra Pepic  23 , Eik Vettorazzi  23 , Andreas M Zeiher  24   25 , Jan F Scheitz  1   2   3   4 , Karl Wegscheider  13   23 , Ulf Landmesser  4   26 , Matthias Endres  1   2   3   4   5   27
Affiliations
Observational Study

Type 1 Myocardial Infarction in Patients With Acute Ischemic Stroke

Christian H Nolte et al. JAMA Neurol. .

Abstract

Importance: Elevated values of high-sensitivity cardiac troponin (hs-cTn) are common in patients with acute ischemic stroke and are associated with poor prognosis. However, diagnostic and therapeutic implications in patients with ischemic stroke remain unclear.

Objective: To identify factors indicative of myocardial infarction (MI) in patients with acute ischemic stroke and hs-cTn elevation. The primary hypothesis was that a dynamic change of hs-cTn values (>50% change) in patients with acute ischemic stroke indicates MI.

Design, setting, and participants: This cross-sectional study was a prospective, observational study with blinded end-point assessment conducted across 26 sites in Germany. Patients were included if they had acute ischemic stroke within 72 hours and either (1) highly elevated hs-cTn values on admission (>52 ng/L) or (2) hs-cTn levels above the upper limit of normal and a greater than 20% change at repeated measurements. Patients were enrolled between August 2018 and October 2020 and had 1 year of follow-up. Statistical analysis was performed between April 2022 and August 2023.

Exposure: Standardized electrocardiography, echocardiography, and coronary angiography.

Main outcome and measures: Diagnosis of MI as adjudicated by an independent end-point committee based on the findings of electrocardiography, echocardiography, and coronary angiography.

Results: In total, 254 patients were included. End points were adjudicated in 247 patients (median [IQR] age, 75 [66-82] years; 117 were female [47%] and 130 male [53%]). MI was present in 126 of 247 patients (51%) and classified as type 1 MI in 50 patients (20%). Dynamic change in hs-cTn value was not associated with MI in univariable (32% vs 38%; χ2 P = .30) or adjusted comparison (odds ratio, 1.05; 95% CI, 0.31-3.33). The baseline absolute hs-cTn value was independently associated with type 1 MI. The best cutoffs for predicting type 1 MI were at hs-cTn values 5 to 10 times the upper limit normal.

Conclusions and relevance: This study found that in patients with acute ischemic stroke, a dynamic change in hs-cTn values did not identify MI, underscoring that dynamic changes do not identify the underlying pathophysiological mechanism. In exploratory analyses, very high absolute hs-cTn values were associated with a diagnosis of type 1 MI. Further studies are needed how to best identify patients with stroke who should undergo coronary angiography.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Nolte reported lecture fees and/or consultancies from Abbott, Alexion, Astra Zeneca, Bayer Pharma, Bristol Myers Squibb, Daiichi Sankyo, Novartis, Pfizer Pharma, Portola, and Takeda. Dr Siepmann reported grants from the German Federal Ministry of Health and Kurt Goldstein Institute, royalties from Thieme, and speaker fees from Astra Zeneca and Dresden International University outside the submitted work. Dr Blankenberg reported lecture fees from Abbott Diagnostics and Roche Diagnostics during the conduct of the study and advisory board fees from Thermo Fisher, lecture fees from Amgen, Bayer, Bristol Myers Squibb, Boehringer Ingelheim, Daiichi, GSK, Lumira Dx, Novartis, and Amarin outside the submitted work; and a contract with Siemens Helathineers within the Hamburg City Health Study. Dr Pieske reported steering committee, advisory, and/or speaking honoraria from Bayer, Astra Zeneca, Bristol Myers Squibb, and Lilly outside the submitted work and minor shares in Imaging in Clinical Trials (ICTS) GmbH. Dr Vettorazzi reported grants from Charite University, Berlin, during the conduct of the study. Dr Zeiher reported scientific advisory board fees from Boehringer Ingelheim, Astra Zeneca, and Novo Nordisk outside the submitted work. Dr Scheitz reported lecture fees from Bristol Myers Squib, Pfizer, and Astra Zeneca outside the submitted work. Dr Wegscheider reported grants from Charite Berlin for statistical analysis during the conduct of the study. Dr Landmesser reported grants from Abbott outside the submitted work; grants to Charité from Bayer, Novartis, and Amgen; and lecture or consultant fees from Abbott, Boston Scientific, Amgen, Novartis, Bayer, Sanofi, and Pfizer. Dr Endres reported grants to their institution from Bayer or MonDAFIS study and Berlin AFib registry; fees paid to institution for their role as country principal investigatory for the Naviate-ESUS trial, and lecture, advisory board, and/or trial participation fees paid to their institution other from Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, Amgen, GSK, Sanofi, Covidien, Novartis, Pfizer, Astra Zeneca, and Acticor Biotech outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Participant Flow in the PRAISE Study
TIA indicates transient ischemic attack.
Figure 2.
Figure 2.. Diagnostic Accuracy of Adding High-Sensitivity Cardiac Troponin (hs-cTn) Changes to a Predefined Regression Model for Myocardial Infarction (MI)
Predictive accuracy for different thresholds (x-axis) of relative hs-cTn changes (any cutoff between relative change of 0% and 100%) for the presence of MI as given by area under the curve (AUC). The higher the AUC, the better the predictive accuracy of the respective cutoff.
Figure 3.
Figure 3.. Diagnostic Accuracy of Adding Baseline Absolute High-Sensitivity Cardiac Troponin (hs-cTn) Values to a Predefined Regression Model for Type 1 Myocardial Infarction (MI)
Predictive accuracy for different thresholds (x-axis) of hs-cTn on admission (as a multiple of upper limits of normal [ULN]) for the presence of MI as given by the area under the curve (AUC). The higher the AUC, the better the predictive accuracy of the cutoff. The optimal cutoff hs-cTn to predict type 1 MI is at 5.39 times ULN with AUC = 0.608 (95% CI, 0.535-0.681) and at 10.42 times ULN with AUC = 0.608 (95% CI, 0.531-0.685).
See this image and copyright information in PMC

Comment on

References

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