Serum Troponin Predicts Severe Sepsis
June 1, 1998
Serum Troponin Predicts Severe Sepsis
ABSTRACT & COMMENTARY
Synopsis: The presence of an elevated level of serum troponin T predicted higher mortality in patients with early sepsis, while abnormalities in serial ECGs (primarily ischemia) and MB-CK levels did not correlate with TT or predict mortality.
Source: Spies C, et al. Chest 1998;113(4):1055-1063.
Hemodynamic profile, serum troponin t (tt), 12-lead ECG, total CK, and MB fractions were obtained every four hours for the first day and daily afterward after development of the signs and symptoms of the systemic inflammatory response syndrome (sepsis) in 26 post-surgical patients. Patients were divided into two groups: those with normal TT (< 0.2 mcg/L) and those with elevated TT. Fifteen of 18 patients (83%) with high TT died, while only three of eight (38%) with a normal TT expired. Other markers of cardiac dysfunction were equally distributed between the groups and consisted of ischemic electrocardiographic changes (present in 19% of the patients in the high TT group vs 38% in the normal TT group), peak MB-CK (7% in the high TT group vs 4% in the normal TT group), use and type of vasoactive drugs, and cardiac index. Other variables were identical between the low and high group including age (61 vs 59 years), body size (BSA 1.7 vs 1.8 m2), and, remarkably, also average APACHE III Score (47 vs 48). The prevalence of congestive heart failure was also similar in the two groups (12.5% vs 11%). None of the studied patients experienced a myocardial infarction, although many demonstrated abnormal cardiac function characteristic of the sepsis syndrome.
Patients were treated to "hyperdynamic" end-points during this study. They all had thermodilution, continuous oximetric pulmonary artery catheters placed in order to facilitate a management strategy that sought to achieve an oxygen delivery of greater than 600 mL O2 per minute. Dopamine and dobutamine infusions were used in order to reach this goal. Mean arterial blood pressure was maintained at 70 mmHg or higher, using infusions of norepinephrine if necessary. Success in achieving these "hyperdynamic" goals was not different between the low and high TT groups, and there was no difference in drug use, although there was a trend to use higher doses in the high TT group.
COMMENT BY CHARLES G. DURBIN, Jr., MD, FCCM
This is a preliminary and provocative observation. TT is a sensitive marker of myocardial damage, and is useful in confirming the presence of myocardial infarction in patients with chest pain. Its contribution in other clinical conditions is under investigation. Cardiac contusion and ischemia, as opposed to myocardial infarction, have been suggested as areas in which TT may provide both diagnostic and prognostic information. This is the first report of TT as a predictor of mortality in the septic syndrome.
This is a small study and the results must be repeated in a larger and more diverse group of patients. All of the patients included in this study were previously operated on. Patients died of multiple organ system failure, not from a cardiac event. The pathophysiologic significance of the elevation in TT may provide insight into the cardiac lesions of sepsis. In addition, the effects that cardiac drug use had on the findings and the hyperdynamic treatment approach need to be sorted out. Failure of the APACHE III score to predict outcome in these groups is particularly concerning, casting doubt on the validity of the reported data.
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