From the Guidelines
Type 2 NSTEMI is the term used to describe elevated troponin levels in patients with sepsis, which occurs due to increased oxygen demand or decreased oxygen supply to the heart from systemic illness rather than a primary coronary event. This condition is characterized by the release of cytokines that directly damage cardiac myocytes, sepsis-induced hypotension that reduces coronary perfusion, tachycardia that increases myocardial oxygen demand, and hypoxemia from respiratory dysfunction that decreases oxygen delivery to the heart 1. The management of Type 2 NSTEMI in sepsis focuses primarily on treating the underlying sepsis with appropriate antibiotics, fluid resuscitation, and vasopressors if needed, rather than traditional acute coronary syndrome interventions 1.
Some key points to consider in the management of Type 2 NSTEMI in sepsis include:
- Cardiac monitoring is important as these patients may develop arrhythmias or heart failure 1
- Antiplatelet therapy and anticoagulation are typically not indicated unless there's evidence of concurrent coronary artery disease 1
- The prognosis depends largely on successful treatment of the sepsis, though elevated troponins in this setting are associated with higher mortality rates 1
- Troponin elevations can be due to various non-coronary causes, including sepsis, and should not be labeled as false positives 1
It is essential to note that the diagnosis of Type 2 NSTEMI in sepsis requires consideration of serial changes in troponin levels, and a troponin value above the 99th percentile of the upper reference level is required for diagnosis 1. Additionally, the use of high-sensitivity cardiac troponin T assays can provide more accurate diagnoses and prognostic information 1.
In terms of morbidity, mortality, and quality of life, the management of Type 2 NSTEMI in sepsis should prioritize the treatment of the underlying sepsis and the prevention of further cardiac injury 1. This can be achieved through the use of appropriate antibiotics, fluid resuscitation, and vasopressors, as well as close cardiac monitoring and the management of any arrhythmias or heart failure that may develop 1.
From the Research
Type of NSTEMI with High Troponins and Sepsis
- The type of NSTEMI that causes high troponins with sepsis is associated with septic cardiomyopathy, a condition characterized by reversible myocardial dysfunction in patients with sepsis 2, 3.
- Septic cardiomyopathy can lead to elevated troponin levels, indicating myocardial injury and poor outcome 4.
- The mechanism of septic cardiomyopathy involves mitochondrial dysfunction, direct myocardial depression, and weakened myocardial circulation, resulting in left ventricular dilatation and loss of contractility 3.
- High troponin levels in sepsis can be caused by various factors, including focal ischemia, microvascular failure, and regional wall motion abnormalities 4.
Diagnosis and Treatment
- Echocardiography can be used to diagnose septic cardiomyopathy, with systolic and diastolic dysfunction of the left ventricle present in 50-60% of patients with sepsis 3.
- Treatment of septic cardiomyopathy is aimed at optimizing hemodynamic parameters and using antibiotic therapies with targeted action 3.
- Anticoagulation may be an important part of the longer-term antithrombotic strategy in patients with NSTEMI, especially those with existing indications for anticoagulation 5.