Positive Troponin in Diabetic Ketoacidosis without Evident Acute Coronary Syndrome Predicts Adverse Cardiac Events

Abstract

SummaryBackground: Elevated troponin I has been associated with increased mortality in critically ill patients without acute coronary syndrome (ACS). However, the prognostic significance of troponin elevation in patients with diabetic ketoacidosis (DKA) without evident ACS has not been studied.Methods: Retrospective study of all patients admitted to a U.S. tertiary center between 01/98 and 12/00 with DKA and had troponin I level measured. Patients with evidence of ACS or who met the American College of Cardiology/European Society of Cardiology (ACC/ESC) definition for myocardial infarction were excluded. Baseline characteristics, cardiac evaluation and 2 year major adverse coronary event (MACE) rate were compared between patients with positive and negative troponin.Results: Ninety-six patients fulfilled the inclusion criteria of this study, 26 had positive troponin. There were no differences in baseline characteristics between the two groups. After a 2 year follow-up, there was significantly increased mortality in patients with elevated troponin (50.0% versus 27.1%, hazard-ratio (HR) 2.3, 95% confidence intraval (CI) 1.2-4.8, p = 0.02). Patients with elevated troponin also had significantly increased MACE rate at 2 years (50.0% versus 28.6%, HR 2.6, 95% CI 1.3-5.3, p = 0.007) driven primarily by mortality. Using

History of diabetes mellitus is associated with elevated cardiac troponin I levels in patients with chest pain but no coronary heart disease

“…Of these, 65.96% of patients with a history of DM had elevated cTnI levels. This was a higher rate than previously reported, possibly because the patients in this analysis had more risk factors than those included in the study by Al-Mallah et al [11]. Moreover, history of DM was able to predict elevated cTnI levels (OR 3.34, p < 0.01) in logistic regression analysis, and the risk of elevated cTnI levels in patients with a history of DM was 3-times that of normal patients.…”

“…However, no studies have included information from CAG or CTGA examinations. Al-Mallah et al [11] reported that 26 of 96 patients with elevated cTnI levels and diabetic ketoacidosis but no evidence of acute coronary syndrome had higher risks of mortality than patients with normal cTnI levels during a 2-year follow-up (50.0% vs. 27.1%, HR 2.3, 95% CI 1.2-4.8, p = 0.02). Mehta et al [12] found that 16 (43%) of 37 patients with septic shock had elevated cTnI levels (≥ 0.01 ng/mL).…”

ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations

“…In an important retrospective study of 96 adults without evidence of ACS and who had troponin I drawn when presenting with diabetic ketoacidosis, 2-year mortality was significantly higher among the 26 patients with elevated troponin levels (50% vs. 27%), as were all major cardiac events. Kaplan-Meier analysis and Cox proportional hazard models identified troponin I elevation as a predictor of mortality independent of ketoacidosis severity or underlying cardiovascular disease (327). Should this predictive association be confirmed in prospective observational studies, troponin I could become an important prognostic tool among the growing diabetic population.…”

A Review of Causes and Systemic Approach to Cardiac Troponin Elevation

“…Acidosis also contributes in Tn release. 44 With sepsis, TNF-α and mediators produced by neutrophilic granulocytes may lead to anincreased permeability of the cardiomyocyte membrane formacromolecules and therefore leakage of Tn withoutmyocyte necrosis. 45 Elevated cTnI has been associated with increased mortality in patients with 46 -48 and without 17,49 ACS.…”