What is the term for elevated troponins (troponin) with sepsis?

From the Guidelines

High troponin levels in patients with sepsis are often referred to as sepsis-induced myocardial dysfunction or septic cardiomyopathy, and management should focus on treating the underlying sepsis and providing hemodynamic support, rather than specific cardiac interventions like coronary angiography, unless there is strong suspicion of concurrent acute coronary syndrome 1.

Definition and Pathophysiology

High troponin levels in sepsis can occur due to multiple mechanisms, including direct cardiac injury from inflammatory mediators, increased oxygen demand, decreased coronary perfusion, and microvascular dysfunction. This condition is associated with increased mortality and morbidity, and its management is crucial to improve patient outcomes.

Management

Management of high troponin levels in sepsis includes:

• Treating the underlying sepsis with appropriate antibiotics, source control, and hemodynamic support
• Fluid resuscitation should be carefully monitored to avoid volume overload
• Vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) are often needed to maintain adequate perfusion
• Cardiac function should be assessed with echocardiography, and inotropic support with dobutamine (2.5-20 mcg/kg/min) may be considered if there is evidence of cardiac dysfunction with adequate filling pressures

Diagnosis and Monitoring

Diagnosis of myocardial infarction in sepsis can be challenging, and troponin assays are the preferred method for diagnosis, with a measurement exceeding the 99th percentile of a normal reference population considered elevated 1. Regular monitoring of cardiac biomarkers, hemodynamic parameters, and organ perfusion is essential for guiding therapy.

Key Considerations

• Specific cardiac interventions like coronary angiography are generally not indicated unless there is strong suspicion of concurrent acute coronary syndrome
• The use of assays that do not have independent validation of optimal precision (CV10%) is not recommended for troponin measurement 1
• The values for the 99th percentile can be found on the International Federation for Clinical Chemistry website, and gender-specific values should be employed for CKMB measurements 1

From the Research

High Troponin Levels with Sepsis

• High troponin levels in patients with sepsis are often referred to as myocardial injury or septic cardiomyopathy 2, 3, 4, 5.
• This condition is characterized by elevated levels of cardiac troponin, which can indicate myocardial dysfunction and poor outcome 3, 4.
• The etiology of myocardial injury in sepsis is complex and multifactorial, involving systemic activation of coagulation, inflammation, and endothelial dysfunction 2.

Clinical Significance of Elevated Troponin

• Elevated troponin levels are associated with increased mortality and morbidity in patients with sepsis, particularly in the early stages of the disease 4, 5.
• However, the role of troponin elevation in risk stratification remains controversial, and some studies have found no significant difference in hospital mortality between patients with elevated and normal troponin levels 5.
• Landmark analysis has revealed that patients with elevated troponin levels may have a lower survival probability after 1 week and higher kidney Sequential Organ Failure Assessment scores 5.

Management of Sepsis with High Troponin Levels

• The management of sepsis with high troponin levels requires careful consideration of the patient's underlying cardiac function and the potential risks and benefits of various interventions 6.
• Aggressive volume resuscitation and vasopressor therapy may be necessary to restore perfusion, but these interventions must be balanced against the risk of exacerbating cardiac dysfunction 6.
• The use of norepinephrine, dopamine, and dobutamine may be considered in patients with sepsis and high troponin levels, but these agents must be used cautiously and with careful monitoring of cardiac function 6.