)NTRODUCTION

Pollenls wllh chronlc kldney dlseose [CKD| ore ol hlgh rlsk lor ocule
coronory syndrome [ACS| lncludlng ocule myocordlol lnlorcllon
[AMl| ond cordlovosculor deolh, os lhey ore predlsposed lo
occeleroled olherosclerosls compored lo lhe generol populo
llon.
13
An AMl ls ollen o lelhol evenl ln pollenls wllh CKD, lwo
yeor poslmyocordlol lnlorcllon morlollly roles hove reporled lo
be up lo Z3 ln pollenls wllh end sloge renol dlseose.
4
Cordloc
blomorkers ol necrosls such os creollneklnose MB,

myoglobln,

ond cordloc lroponlns
Z
ore dllllcull lo lnlerprel ln pollenls wllh
CKD becouse lhey moy be elevoled ln lhe obsence ol AMl.
For pollenls wllh normol renol luncllon, lhe developmenl ol
cordloc lroponln l ond l hove helped revolullonlze lhe dlognosls
ond lreolmenl ol AMl. Becouse ol lhelr neor obsolule myocordlol
llssue speclllclly, os well os lhelr oblllly lo delecl mlcrolnlorcllons
desplle normol creollne klnoseMB levels, cordloc lroponln l ond l
hove become lhe prelerred cordloc blomorker lor lhe dlognosls ol
AMl.
8,P
Cordloc lroponln l ond l hove lhe oddlllonol prognosllc
oblllly lo predlcl odverse cordlovosculor oulcomes.
10
lhe dlognosllc oblllly ond prognosllc volue ol cordloc lroponln l
ond l ln pollenls wllh CKD ore uncerloln ln lhe emergency selllng.
Elevollons ln bolh cordloc lroponln l ond l hove been reporled ln
osymplomollc pollenls wllh CKD.
Z
As o resull, lhese elevollons hove
ollen been descrlbed os nonspeclllc lor myocordlol ln|ury
11
ond
dlsregorded by cllnlclons. nderslondlng lhe cllnlcol slgnlllconce
ol elevoled cordloc lroponln l ond l ln lhls pollenl populollon ls
exlremely lmporlonl os lndlvlduols wllh CKD hove o hlgher prelesl
llkellhood lor hovlng ACS.
2
lhe purpose ol lhls summory ls lo
brlelly revlew lhe currenl lllerolure concernlng lhe lnlerprelollon
ol cordloc lroponln l ond l resulls ln pollenls wllh CKD wllhln lhe
emergency selllng.
Deor Colleogues,

Pollenls wllh chronlc kldney dlseose ore ol very hlgh
rlsk lor ocule coronory syndrome ond ollen suller
cordlovosculor deolh. Dlseose processes such os
dlobeles mellllus ond hyperlenslon commonly couse
chronlc kldney dlseose. lhese some dlseoses olso
serve os rlsk loclors lor ocule coronory syndrome.
Delecllng ocule coronory syndrome ln o pollenl wllh
chronlc kldney dlseose ls o slgnlhconl chollenge
lor ony physlclon corlng lor lhese pollenls oculely.
Cordloc blomorkers such os lroponln l or l ore
senslllve ond speclhc lndlcolors ol ocule myocordlol
necrosls. ln some pollenls wllh chronlc kldney dlseose,
lhe lroponlns moy show sllghl elevollon obove lhe
lyplcol loborolory cul oll volue, moklng lhe evoluollon
ol lhese pollenls problemollc.
Dr. )ln Hon, Asslslonl Prolessor ol Emergency Medlclne
ol lhe nlverslly ol Clnclnnoll, provldes o delolled
dlscusslon ol lhe lnlerprelollon ol elevoled volues
ln pollenls wllh chronlc kldney dlseose ond ocule
coronory syndrome lor lhls EMCREGlnlernollonol
newsleller. ll ls our hope lhol lhe reoders ol lhls
newsleller wlll hnd lhelr evoluollon ol pollenls wllh
chronlc kldney dlseose ond ocule coronory syndrome
more ellecllve, resulllng ln lmproved pollenl core.
Slncerely,
Andro L. Blomkolns, MD V. Brlon Glbler, MD
Dlreclor ol CME, Presldenl,
EMCREGlnlernollonol EMCREGlnlernollonol
Interpretation of Cardiac Troponins in Patients with
Chronic Kidney Disease and Suspected Acute Coronary
Syndrome in the Emergency Setting
A SUMMARY FOR EMERGENCY PHYSICIANS
1in H. Hon, MD, Assis|on| Prolossor, Dopor|mon| ol Emorgoncy Modicino
Univorsi|y ol Cincinno|i Collogo ol Modicino, Cincinno|i, hio
VAY 2005 VOLUVE 3
COLLABORATE l I NVESTI GATE l EDUCATE
VAY 2005 VOLUVE 3 EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge 2
#ARDIAC4ROPONIN4
5ource ol Cordioc Iroponin I Elevolions
Cver lhe posl decode, lhe role ol cordloc lroponln l [clnl|
ln pollenls wllh CKD hos been sludled exlenslvely. Vhen
clnl wos llrsl lnlroduced, elevollons were observed ln up
lo Z0 ol osymplomollc dlolysls pollenls.
12
lhe source
ol lhese elevollons wos lhoughl lo be secondory lo uremlc
myopolhy,
13
whlch led lo reexpresslon ol clnl lsolorms ln
regenerollng skelelol muscle.
14,1

Currenlly, crossreocllon wllh lhe skelelol muscle clnl
lsolorms ls no longer lound wllh more speclllc second
ond lhlrdgenerollon clnl lmmunoossoys.
14
Serum clnl
elevollons obove 0.10 ng,ml, however, ore sllll observed
ln up lo 20 ol osymplomollc dlolysls pollenls
Z
suggesllng
lhol elevoled clnl ls cordloc speclllc ln pollenls wllh CKD.
ln dlolysls pollenls, elevoled clnl ls ossocloled wllh mulll
vessel coronory orlery dlseose.
1
Even ln lhe obsence ol
coronory orlery dlseose, elevollons ln clnl moy represenl
cllnlcolly occull, mlnor myocordlol ln|ury exocerboled by
uremlo.
1Z
Proposed mechonlsms ol clnl level elevollon
ln pollenls recelvlng hemodlolysls hove lncluded sllenl
lschemlc ln|ury ond on opoplollc process.
1
l00
90
80
70
60
50
40
30
0
0.5 l.0 2.0 l.5 2.5 3.0
Time Since 8lood Draw (years)
cTnT<0.0l g/L
cTnT0.0l to <0.04 g/L
cTnT0.04 to <0.l0 g/L
cTnT0.l0 g/L
C
u
m
u
l
a
t
i
v
e

S
u
r
v
i
v
a
l

(
%
)
Figure J. KoplonMoior survivol curvos lor ollcouso mor|oli|y bosod upon |ho
dilloron| cTnT cu|olls in osymp|omo|ic homodiolysis po|ion|s. Highor cTnT is ossocio|od
wi|h worsoning prognosis. Roprin|od wi|h pormission lrom Applo o| ol. Circulo|ion
2002,10:244.
Cordioc Iroponin I in Asymplomolic
Polienls wilh CKD
Recenlly, lhere hove been numerous publlshed reporls
observlng on ossoclollon belween elevoled clnl ond
morlollly ln pollenls wllh CKD. Mosl ol lhese sludles hove
been perlormed wllh osymplomollc dlolysls pollenls.
lhere ls slrong evldence lo supporl lhe oblllly ol clnl
lo predlcl longlerm ollcouse morlollly. Apple ond
colleogues perlormed lhe lorgesl sludy lo dole conslsllng
ol Z33 osymplomollc dlolysls pollenls uslng o lhlrd
generollon clnl lmmunoossoy.
Z
lhey lound lhol elevoled
serum clnl levels ere ossocloled wllh worsenlng oll
couse morlollly roles, even wllh elevollons os llllle os
0.01 ng,ml (Fgure 1|.
Z
Sub|ecls wllh clnl elevollons
obove lhe 0.01 ng,ml, 0.04 ng,ml, ond 0.10 ng,ml
culolls hod lncreosed rlsk ol deolh, wllh od|usled relollve
rlsks ol 4.3, 2.1, ond 2.2, respecllvely.
Z
Addlllonolly,
elevoled clnl wos olso ossocloled wllh cordlovosculor
morlollly (Fgure 2|.
1P
Dlerkes ond colleogues sludled
102 dlolysls pollenls ond lound lhol clnl elevollons
obove 0.0 ng,ml were ossocloled wllh o Zlold lncreose
ln rlsk ol cordloc deolh.
20
lhese llndlngs hove been
"Even n Ihe
cbsence e|
cerencry crIery
dsecse, e|evcIens
n cn mcy
represenI c|ncc||y
eccu|I, mner
myeccrdc| njury
exccerbcIed by
uremc."
EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI VAY 2005 VOLUVE 3
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge 3
100
90
80
70
60
0 200 400 600 800
50
p<0.0001
S
u
r
v
i
v
a
l

(
%
)
Days
cTnT > 0.054 ng/mL
cTnT > 0.054 ng/mL
repllcoled by numerous olher sludles ond suggesl lhol clnl moy
hove o posslble role lor rlsk ossessmenl ln osymplomollc pollenls
wllh CKD.
1,2123
Cordioc Iroponin I in Polienls wilh CKD ond
Possible AC5
lnlerprelollon ol clnl levels ln pollenls wllh CKD ond suspecled
ACS ln lhe emergency selllng remolns dllllcull. Becouse mosl
sludles hove been perlormed ln osymplomollc pollenls on dlolysls,
ll moy be dllllcull lo exlropolole lhese resulls lo o symplomollc
ED populollon, ocross lhe enllre speclrum ol renol dysluncllon.
However, ll would be reosonoble lo ossume lhol on elevoled clnl
ln pollenls wllh CKD ond suspecled ACS porlends o hlgh rlsk lor
odverse cordlovosculor evenls.
Avlles ond colleogues sludled over Z000
pollenls wllh suspecled ACS, ond lound lhol
elevoled bosellne clnl meosuremenls were
slrongly predlcllve ol deolh ond AMl.
24
lhey
lound lhol lhose pollenls wllh creollnlne
cleoronces less lhon 8 ml,mlnule ond o
serum clnl level > 0.10 ng,ml hod o 2.
lold lncreose ln lhe odds ol 30doy deolh
ond AMl.
24
However, only odds rollos were
reporled ond lhese hove llmlled ullllly ol lhe
bedslde. lhe speclllclly ol on elevoled bosellne
clnl meosuremenl ln lhls hlgh rlsk populollon
hos been queslloned. Von Lenle prospecllvely
sludled 1 pollenls wllh CKD molched by 102
pollenls wllh normol renol luncllon. slng
o composlle endpolnl ol deolh, coronory
surgery, recurrenl lschemlo, relnlorcllon,
congesllve heorl lollure, ond poslllve cordloc
colhelerlzollon wllh or wllhoul perculoneous
coronory lnlervenllon, lound o decreose ln
lesl perlormonce ol clnl ln pollenls wllh CKD
compored lo pollenls wllh normol renol luncllon
(Fgure 3|.
2
lhe oulhors olso lound lhol rolslng
lhe culoll lrom 0.10 ng,mL lo 0.0 ng,mL
lmproved speclllclly lrom 3 lo 8Z whlle
decreoslng senslllvlly lrom 43 lo 2P.
2

Figure 2. KoplonMoior survivol curvos lor cordiovosculor mor|oli|y in
osymp|omo|ic homodiolysis po|ion|s using cTnT cu|oll ol 0.054 ng/ml. Roprin|od
wi|h pormission lrom Hochor o| ol. 1 Am Soc Mophrol 2003, 14:2333.
"Hewever, I weu|d
be recsencb|e Ie
cssume IhcI cn
e|evcIed cn n
pcIenIs wIh CKD
cnd suspecIed AC5
perIends c hgh
rsk |er cdverse
ccrdevcscu|cr
evenIs."
VAY 2005 VOLUVE 3 EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge 4
Meosurlng chonges ln clnl lmproves dlognosllc speclllclly ln lhe
emergency selllng. Aculely, serum clnl levels os o resull ol AMl
ln CKD pollenls should hove lyplcol elevollon ond releose klnellcs,
regordless ol lhe pollenls creollnlne cleoronce.
P
A relrospecllve
cohorl sludy ol pollenls wllh serum creollnlnes greoler lhon 2.0
mg,dl, suspecled ACS, ond on lnlllol clnl volue ol 0.10 ng,mL
lndlcoled lhol on lncreose ln serum clnl ol os llllle os 0.10 ng,
mL over o perlod ol severol hours lncreosed
lhe llkellhood ol odverse cordloc evenls ol
hospllollzollon, 30doys, ond monlhs.
2
Adverse cordloc evenls ln lhls sludy were
dellned os ACS, revosculorlzollon, cordloc
dysrhylhmlos, ollcouse deolh, or congesllve
heorl lollure.
2
Vhen comporlng clnl belween ED vlslls, on
lncreose ln clnl moy be ossocloled wllh ocule
myocordlol ln|ury secondory lo olherosclerollc
ploque ruplure. However, lhe number ol
sludles evoluollng lhls phenomenon ls llmlled.
ln osymplomollc dlolysls pollenls, Col ond
colleogues reporled o relollve rlsk ol 2.0 lor
ollcouse morlollly when clnl rose greoler lhon
0 lrom serum drown ol leosl o yeor oporl.
2Z
Vllhln lhe ED selllng, one sludy evoluoled 10
pollenls wllh CKD ln pollenls hovlng mulllple
ED vlslls lor suspecled ACS.
28
For lndlvlduol
pollenls, on ED vlsll wllh on lnhospllol odverse
cordloc evenl wos ossocloled wllh hlgher serum
clnl levels when compored lo clnl levels drown
durlng ED vlslls nol ossocloled wllh on odverse
cordloc evenl.
28
Addlllonol prospecllve sludles
ore needed lo clorlly lhe slgnlllconce ol long
lerm lncreoses ln clnl wllhln lhe emergency
selllng.
AUC = 0.56 0.07
AUC = 0.75 0.07
Non-RenaI cTnT
RenaI cTnT
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
1-SPECIFICITY
S
E
N
S
I
T
I
V
I
T
Y

AUC = 0.59 0.07

AUC = 0.74 0.07
Non-RenaI cTnT
RenaI cTnT
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
1-SPECIFICITY
S
E
N
S
I
T
I
V
I
T
Y

Figure 3. Rocoivor oporo|ing choroc|oris|ic curvos lor cTnT in po|ion|s wi|h

ond wi|hou| CKD. An oroo undor |ho curvo [AUCJ closor |o 1 indico|os bo||or
|os| porlormonco. [AJ roproson|s inhospi|ol ovon|s ond [BJ roproson|s mon|h
ovon|s. Roprin|od lrom Von Lon|o o| ol. 1 Am Coll Cordiol 1,33:4Z5,4ZZ wi|h
pormission lrom Amoricon Collogo ol Cordiology Foundo|ion.
"Mecsurng
chcnges n
cn mpreves
dcgnesIc
spechcIy n
Ihe emergency
seIIng."
A
B
EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI VAY 2005 VOLUVE 3
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge 5
#ARDIAC4ROPONIN)
Cordioc Iroponin l Elevolions in
Asymplomolic Polienls
ln osymplomollc dlolysls pollenls, elevollons obove lhe
dlognosllc culoll lor AMl ore only observed ln 0.4
ol lhe pollenls uslng clnl compored lo 20 lor clnl.
Z
lnsleod, mlnor elevollons ore more prevolenl, bul lhelr
cllnlcol slgnlllconce ls uncleor.
2P
lheorellcolly, lhese
elevollons ore lrom lhe myocordlol llssue, os clnl ls nol
lound ln lhe skelelol muscle ol pollenls wllh CKD.
30
lhese
elevollons ore llkely lo be cllnlcolly slgnlllconl, lor lhe
generol populollon wllh suspecled ACS, mlnor elevollons
ln clnl below lhe AMl culoll level hove been ossocloled
wllh poor oulcomes.
31
lhere ls o lock ol preclslon ln
ossoys lor clnl ol lhe lower ronge ol clnl elevollons ond
lhese mlnor elevollons moy represenl orlllocls coused by
onolyllcol lnlerlerence.
32

l00
90
80
70
60
50
40
30
0
0.5 l.0 2.0 l.5 2.5 3.0
Time Since lood raw (years)
cTn0.l g/L
cTn0.l g/L

u
m
u
l
a
t
i
v
e

S
u
r
v
i
v
a
l

(
%
)
Figure 4. KoplonMoior survivol curvos lor ollcouso mor|oli|y in osymp|omo|ic homodiolysis
po|ion|s bosod upon |ho dilloron| |h porcon|ilo cu|oll lor cTnl. Roprin|od wi|h pormission
lrom Applo o| ol. Circulo|ion 2002,10:244.
lhere hove been dlscordonl resulls, perhops due lo lhls
ossoy lmpreclslon, lor mulllple sludles evoluollng lhe
oblllly ol clnl lo predlcl morlollly ln osymplomollc pollenls
wllh CKD. Khon ond colleogues lound no ossoclollon
wllh serum clnl levels greoler lhon lhe lower delecllon
llmll [0.03 ng,ml| ond ollcouse or cordloc morlollly.
33

lo lhe conlrory, olhers hove lound lhol smoll elevollons ol
clnl oppeor lo predlcl morlollly (Fgure 4|.
Z
Bouller ond
colleogues sludled 1P1 hemodlolysls pollenls ond lound
lhol elevollons ln clnl obove lhe PP
lh
percenllle volue
[0.04 ng,ml| were ossocloled wllh o lourlold lncreosed
rlsk ol ollcouse morlollly, oller od|usllng lor pollenl
demogrophlcs ond hlslory.
34

lnlerprelollon ol lhe resulls ol lhese sludles ls dllllcull,
os mulllple lmmunoossoys lor clnl exlsl. Apple ond
colleogues compored lwo clnl ossoys ln osymplomollc
dlolysls pollenls ond lound elevollons obove lhe lower
delecllon llmll ln 1P ond 4 ol lhe enrolled pollenls.
3,3

lhls dlsporlly moy be due lo lhe lmproved oblllly ol
cerloln lmmunoossoys lo delecl lower levels ol clnl.
3Z
"E|evcIens cbeve
Ihe dcgnesIc
cuIe|| |er AM| cre
en|y ebserved
n 0.4% e| Ihe
pcIenIs usng cn|
cempcred Ie 20%
|er cn."
VAY 2005 VOLUVE 3 EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge 6
AUC = 0.54 0.06
AUC = 0.71 0.07
Non-RenaI cTnI
RenaI cTnI
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
1-SPECIFICITY
S
E
N
S
I
T
I
V
I
T
Y

AUC = 0.53 0.06

AUC = 0.65 0.07
Non-RenaI cTnI
RenaI cTnI
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
1-SPECIFICITY
S
E
N
S
I
T
I
V
I
T
Y

Iroponin l in 5ymplomolic ED
Polienls
As noled prevlously, serum levels ol clnl obove
lhe dlognosllc culoll lor AMl ore rorely seen
ln pollenls wllh CKD nol hovlng symploms.
Morlln ond colleogues sludled pollenls
odmllled lor ACS evoluollon wllh CKD ond
ocule renol lollure. lhey lound lhol elevoled
clnl volues were 100 speclllc ond P4
senslllve lor AMl.
38
McCullough ond colleogues
sludled 808 pollenls ond lound lhol clnl lesl
perlormonce wos conslslenl lhroughoul vorlous
degrees ol renol lmpolrmenl.

Von Lenle,
however, lound lhol clnl dld nol hove lhe some
dlognosllc power lor lhe dlognosls ol odverse
cordloc evenls ln pollenls wllh chronlc kldney
dlseose compored lo pollenls wllh normol renol
luncllon (Fgure 5|.
2

lhere ore o number ol llmllollons wllh clnl
lmmunoossoys. nllke clnl, where lhere ls
o slngle lmmunoossoy monuloclurer, lhere
ore mulllple clnl lmmunoossoys ln exlslence,
eoch possesslng dlllerenl dlognosllc culolls
lor AMl. lhere ls no slondordlzollon belween
Figure 5. Rocoivor oporo|ing choroc|oris|ic curvos lor cTnl in po|ion|s wi|h
ond wi|hou| CKD. An oroo undor |ho curvo [AUCJ closor |o 1 indico|os bo||or
|os| porlormonco. [AJ roproson|s inhospi|ol ovon|s ond [BJ roproson|s mon|h
ovon|s. Roprin|od lrom Von Lon|o o| ol. 1 Am Coll Cordiol 1,33:4Z5,4ZZ wi|h
pormission lrom Amoricon Collogo ol Cordiology Foundo|ion.
clnl lmmunoossoys, eoch ossoy uses dlllerenl relerence molerlols
lo collbrole lhe ossoy ond dlllerenl onllbodles ore used lo delecl
speclllc porllons ol lhe clnl molecule. As o resull, meosuremenl ol
clnl belween dlllerenl clnl lmmunoossoys lor ldenllcol speclmens
moy vory up lo o hundredlold.
3P
Coullon musl be exerclsed by lhe
cllnlclon when exlropolollng resulls lrom one clnl lmmunoossoy lo
onolher. Currenlly, ellorls lo slondordlze lhe clnl lmmunoossoy ore
ln progress.
40
"CcuIen musI be
exercsed by Ihe
c|nccn when
exIrcpe|cIng
resu|Is |rem ene
cn| mmunecsscy
Ie cneIher."
A
B
EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI VAY 2005 VOLUVE 3
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge 7
Comporing Cordioc Iroponin I
versus Cordioc Iroponin l
ln lhe osymplomollc dlolysls pollenl, clnl
elevollons obove lhe AMl culoll ore observed
more ollen lhon clnl elevollons.
Z
lhe
mechonlsms lor lhls ore speculollve ond requlre
oddlllonol sludy. lhere ls evldence lo suggesl
lhol clnl moy be o superlor morker lo clnl ln
predlcllng odverse oulcomes ln osymplomollc
dlolysls pollenls. lshll ond colleogues compored
recelveroperollng choroclerlsllc curves belween
lhese lwo morkers, ond lound lhol clnl hod
slgnlllconlly greoler oreo under lhe curve
lhon clnl lor ollcouse ond cordloc morlollly
(Fgure |.
22

ln lhe emergency selllng, some oulhors hove
suggesled lhol clnl ls o superlor morker,
38
becouse elevollons obove lhe dlognosllc culoll
lor AMl ore rorely observed ln osymplomollc
pollenls.
Z
However, lhe )olnl Europeon
Soclely ol Cordlology,Amerlcon College ol
Cordlology Commlllee lor lhe redellnlllon ol
myocordlol lnlorcllon hos odvocoled uslng
lhe PP
lh
percenllle volue ol lhe ossoy os lhe
culoll level lor AMl.
P
A slgnlllconlly hlgher
proporllon ol osymplomollc dlolysls pollenls
wlll hove clnl elevollons obove lhls lower culoll
volue.
Z
As prevlously dlscussed, lnlerprelollon
ol such elevollons ls problemollc becouse ol
lmpreclslon ol lhe lower volues ol clnl.
32

#ARDIAC4ROPONIN4AND)$IRECTED
!#34HERAPYIN#+$
ln pollenls wllh normol renol luncllon ond
nonSl segmenl elevollon ACS, elevoled
cordloc lroponln l ond l levels hove ollowed
cllnlclons lo ldenllly lhose who would mosl
benelll lrom eorly lnvoslve monogemenl,
31
low
moleculor welghl heporln,
41
ond glycoproleln
llblllo lnhlbllor lheropy.
42
Subonolyses ol
lorge lrlols hove been perlormed suggesllng
1-SpeciIicity
S
e
n
s
i
t
i
v
i
t
y
0.75
0.50
0.25

0.08 g/L
0.15 g/L
0.10 g/L
0.20 g/L
0.07 g/L
0.10 g/L
0.20 g/L
cTnI
cTnT
1-SpeciIicity
S
e
n
s
i
t
i
v
i
t
y
0.75
0.50
0.25
0.05 g/L
0.10 g/L
0.20 g/L
0.06 g/L
0.10 g/L
0.20 g/L
P0.0001
cTnT
cTnI
Figure 6. Rocoivor oporo|ing choroc|oris|ic curvos lor cTnT ond cTnl in
osymp|omo|ic diolysis po|ion|s. [AJ roproson|s ollcouso mor|oli|y ond [BJ
roproson|s cordioc mor|oli|y. Roprin|od lrom lshii o| ol. Clin Chimico Ac|o.
2002,312:Z, wi|h pormission lrom Elsovior.
A
B
VAY 2005 VOLUVE 3 EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge 8
$)3#,/352%3
Dr. Hon hos no disclosuros |o ropor|.
#-%!##2%$)4!4)/.
lhe nlverslly ol Clnclnnoll College ol Medlclne dosigno|os |his oduco|ionol oc|ivi|y lor o moximum ol ono [1J Co|ogory 1 crodi| |oword |ho AMA Physicion's Rocogni|ion Aword. Eoch physicion
should cloim only |hoso crodi|s ho/sho oc|uolly spon| in |ho oduco|ionol oc|ivi|y. Tho Univorsi|y ol Cincinno|i Collogo ol Modicino is occrodi|od by |ho Accrodi|o|ion Council lor Con|inuing Modicol
Educo|ion [ACCMEJ |o sponsor con|inuing modicol oduco|ion lor physicions. Applico|ion hos boon modo |o |ho Amoricon Collogo ol Emorgoncy Physicions lor ACEP Colegory 1 crodi|.
$)3#,!)-%2
This documon| is |o bo usod os o summory ond clinicol roloronco |ool ond MT os o subs|i|u|o lor rooding |ho voluoblo ond originol sourco documon|s. EMCREG will no| bo lioblo |o you or
onyono olso lor ony docision modo or oc|ion |okon [or no| |okonJ by you in rolionco on |hoso mo|oriols. This documon| doos no| roploco individuol physicion clinicol |udgmon|.
Suppor|od in por| by on unros|ric|od oduco|ionol gron| lrom Rocho Diognos|ics.
benelll ln uslng glycoproleln llblllo lnhlbllors
43
ond low
moleculorwelghl heporln
44
lor pollenls wllh CKD lhough
lhese pollenls hove nol been speclllcolly sludled. lhese
sludles hove lyplcolly excluded pollenls wllh moderole
lo severe CKD so lhe volue ol lroponln meosuremenl ln
such pollenls musl be exlropololed. lhe benellls ol such
lheroples ln lhe presence ol elevoled cordloc lroponln l
ond l lor pollenls wllh severe CKD lhus requlres lurlher
evoluollon.
#ONCLUSIONS
lnlerprelollon ol cordloc lroponln l ond l ln pollenls
wllh CKD remolns o dllllcull losk ln lhe emergency
selllng. Pollenls wllh CKD olreody hove o hlgher prelesl
llkellhood ol ACS lhon lhe generol populollon. ln
osymplomollc pollenls wllh CKD, elevollons ln cordloc
lroponln l ond l hove been ossocloled wllh worsenlng
ollcouse ond cordlovosculor morlollly. lhough ll moy
be dllllcull lo exlropolole lhese resulls lo o symplomollc
ED populollon wllh CKD, lhose pollenls hovlng elevoled
cordloc lroponln l ond l ore llkely ol hlgher rlsk lor poor
oulcomes ond should be evoluoled corelully. Cbservlng
o lyplcol rlse ln serum cordloc lroponln l ond l levels
should lurlher lncreose lhe cllnlclons susplclon lor ACS
wllh myocordlol necrosls. slng cordloc lroponln l ond l
levels lo gulde lheropy ln lhls pollenl populollon requlres
lurlher sludy.
kecommendolions lor Cordioc Iroponin lnlerprelolion in Polienls
wilh CKD in lhe ED
* Elevollons ln clnl or clnl llkely represenl myocordlol ln|ury, ond should nol be consldered
nonspeclllc lncreoses due lo CKD.
* Pollenls wllh elevoled clnl or clnl levels, no moller how mlnor, ore ol hlgher rlsk lor
ollcouse ond cordlovosculor morlollly.
* lhough oll myocordlol domoge ond elevoled lroponln levels moy nol be secondory lo
coronory orlery dlseose, pollenls wllh CKD ore ol hlgher rlsk lor ACS. Any elevollon ln
cordloc lroponln levels should worronl lurlher cordloc evoluollon.
* Meosurlng o lyplcol rlse ln clnl ond clnl over o perlod ol severol hours lmproves
dlognosllc occurocy lor ocule myocordlol ln|ury ln pollenls wllh CKD hovlng chronlc low
level elevollons ln clnl ln lhe blood.
EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI VAY 2005 VOLUVE 3
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge 9
kEFEkENCE5
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2002,2:1ZZ83.
3. Foley RM, Porlrey PS, Sornok M). Cllnlcol epldemlology ol
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4. Herzog CA, Mo )Z, Colllns A). Poor longlerm survlvol oller
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. McCullough PA, Mowok RM, Forebock C, lokorskl G,
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Z. Apple FS, Murokoml MM, Peorce LA, Herzog CA. Predlcllve
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CA, Moghrobl A, Somson Y, Schorln MA, Gelber RD,
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VAY 2005 VOLUVE 3 EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge J0
3. Apple FS, Murokoml MM, Peorce LA, Herzog CA. Mulll
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l elevollons ln renol dlseose pollenls wllhoul ocule coronory
syndromes: o Pmonlh oulcome onolysls. Mephrol Dlol
lronsplonl. 1PPP,14:148PP.
3Z. Venge P, Logerqvlsl B, Dlderholm E, Llndohl B, Vollenlln
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38. Morlln GS, Becker BM, Schulmon G. Cordloc lroponlnl
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40. Chrlslenson RH, Duh SH, Apple FS, Bodor GS, Bunk DM,
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41.
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[Abslrocl|.
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ond creollne klnoseMB lsoenzyme ln osymplomollc longlerm
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mlnor elevollons ol lroponlns l ond l lo predlcl benelll lrom
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1PPP,32:ZP.
33. Khon lA, Vollonosuwon M, Mehlo M), lun A, Slngh M,
Slngh HK, Vosovodo BC, Socchl l). Prognosllc volue ol
serum cordloc lroponln l ln ombulolory pollenls wllh chronlc
renol lollure undergolng longlerm hemodlolysls: o lwoyeor
oulcome onolysls. ) Am Coll Cordlol. 2001,38:PP18.
34. Bouller A, )oussenl l, lerrler M, Mourlce F, Rlvory )P, Cholobl
L, Bouloron AM, Delcourl C, Dupuy AM, Conoud B, Crlslol
)P. Meosuremenl ol clrculollng lroponln lc enhonces lhe
prognosllc volue ol Creocllve proleln ln hoemodlolysls
pollenls. Mephrol Dlol lronsplonl. 2004,1P:23138.
EVERGENCY VEDICINE CARDIAC RESEARCH AND EDUCATION GROUI VAY 2005 VOLUVE 3
lnlerprelolion ol Cordioc Iroponins in Polienls wilh Chronic Kidney Diseose
ond 5uspecled Acule Coronory 5yndrome in lhe Emergency 5elling
Poge JJ
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e. Greoler lhon Z0
2| Ccrdcc Irepenn | e|evcIens cbeve Ihe AM| cuIe|| cre
seen n whcI percenIcge e| csympIemcIc dc|yss pcIenIs:
o. Less lhon 1
b.
c. 20
d. 0
e. Greoler lhon Z0
3| |n csympIemcIc dc|yss pcIenIs, e|evcIed ccrdcc
Irepenn | cnd mesI |ke|y re||ecI:
o. cross reocllon skelelol muscle cordloc lroponln
b. myocordlol domoge
c. lnoblllly ol lhe kldney lo remove whole cordloc
lroponln molecules
d. dlolysls
e. none ol lhe obove
4| |n Ihe emergency seIIng, e|evcIed ccrdcc Irepenn hcs
been csseccIed wIh _______ n pcIenIs wIh chrenc
kdney dsecse cnd suspecIed AC5:
o. 30doy deolh
b. 30doy AMl
c. Bolh A ond B
d. Mellher A or B
5| |s Ihe |e||ewng sIcIemenI Irue er |c|se? |n Ihe emergency
seIIng, mpreved spec|cIy |er cn e|evcIed ccrdcc
Irepenn cnd ccrdcc Irepenn | |er Ihe dcgness e| AC5
mcy be mpreved by ebservng c Iypcc| rse cnd grcduc|
|c|| n pcIenIs wIh CKD.
oJ Truo
bJ Folso
EMCREGln|orno|ionol
ML 0Z
231 Albor| Sobin Woy
Cincinno|i, hio 452Z0Z
I nt er nat i onal
Prosor| STD
U.S. Pos|ogo
PAlD
Cincinno|i, hio
Pormi| Mo. 4452
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Interpretation of Cardiac Troponins in
Patients with Chronic Kidney Disease and
Suspected Acute Coronary Syndrome
in the Emergency Setting
May 2005, Volume 3
Interpretation of Cardiac Troponins in
Patients with Chronic Kidney Disease and
Suspected Acute Coronary Syndrome
in the Emergency Setting
May 2005, Volume 3