What is the management for a patient with elevated troponin (cardiac enzyme) and inverted ST segment (electrocardiogram abnormality)?

From the Guidelines

Management of a patient with elevated troponin and inverted ST segments requires immediate hospitalization and treatment for acute coronary syndrome (ACS), specifically non-ST elevation myocardial infarction (NSTEMI). Initial therapy includes dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as ticagrelor or clopidogrel, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. The use of aspirin and a P2Y12 inhibitor has been shown to reduce the risk of recurrent ischemia and myocardial infarction in patients with NSTEMI. Anticoagulation with unfractionated heparin or enoxaparin should be started, as well as high-intensity statin therapy, such as atorvastatin or rosuvastatin, to reduce the risk of further cardiac events. Beta-blockers, such as metoprolol, are recommended if there are no contraindications, and nitroglycerin can be used for symptomatic relief of chest pain. Oxygen should be administered if saturation is below 90%, and early cardiology consultation for possible cardiac catheterization within 24-72 hours is essential. This comprehensive approach targets platelet aggregation, thrombus formation, and myocardial oxygen demand to limit infarct size and prevent further cardiac damage, as supported by the European Society of Cardiology's recommendations for the management of acute coronary syndromes without persistent ST segment elevation 1. The identification of patients with elevated troponin levels is also useful for selecting appropriate treatment, as these patients have been shown to benefit from treatment with low-molecular weight heparin or GP IIb/IIIa blockers 1. Overall, the management of a patient with elevated troponin and inverted ST segments requires a multifaceted approach that includes antiplatelet therapy, anticoagulation, statin therapy, beta-blockers, and early cardiology consultation.

From the FDA Drug Label

The CURE study included 12,562 patients with ACS without ST-elevation (UA or NSTEMI) and presenting within 24 hours of onset of the most recent episode of chest pain or symptoms consistent with ischemia Patients were required to have either ECG changes compatible with new ischemia (without ST-elevation) or elevated cardiac enzymes or troponin I or T to at least twice the upper limit of normal.

The management for a patient with elevated troponin and inverted ST segment is to receive antiplatelet therapy, such as clopidogrel (2), in addition to aspirin and other standard therapies, as the CURE study showed a 20% relative risk reduction in the primary outcome of CV death, MI, or stroke.

• Key points:
  • Elevated troponin indicates myocardial infarction
  • Inverted ST segment on ECG is consistent with ischemia
  • Antiplatelet therapy, such as clopidogrel, is recommended
  • Aspirin and other standard therapies should also be used
• Important consideration: The use of tirofiban (3) may also be considered in patients with ACS, as it has been shown to reduce the risk of refractory ischemia, new MI, and death.

From the Research

Management of Elevated Troponin and Inverted ST Segment

The management of a patient with elevated troponin and inverted ST segment involves several key considerations:

• Diagnosis: Elevated troponin levels without ST-segment elevation on electrocardiography suggest non-ST-segment elevation acute coronary syndrome (ACS) 4.
• Initial Management: Aspirin is recommended for all patients with suspected ACS unless contraindicated. Addition of a second antiplatelet (e.g., clopidogrel, ticagrelor, or prasugrel) is also recommended for most patients 5.
• Anticoagulation: Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux 5, 6.
• Medical Therapies: Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain), and oxygen 5.
• Revascularization: Patients with ACS should receive coronary angiography with percutaneous or surgical revascularization 4.
• Dual Antiplatelet Therapy: Initiation of dual antiplatelet therapy is an important management consideration 4.

Specific Considerations for Inverted ST Segment

• ST-Segment Elevation Myocardial Infarction (STEMI): If the patient has STEMI, primary percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible. However, fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes 5, 7.
• Non-ST-Segment Elevation ACS: For non-ST-segment elevation ACS, PCI is recommended; fibrinolytic therapy typically is not recommended 5.

Additional Interventions

• Smoking Cessation: Smoking cessation is an important intervention to reduce mortality in patients who have had a recent myocardial infarction 4.
• Annual Influenza Vaccination: Annual influenza vaccination is also recommended to reduce mortality in patients who have had a recent myocardial infarction 4.
• Cardiac Rehabilitation: Cardiac rehabilitation is an additional intervention shown to reduce mortality in patients who have had a recent myocardial infarction 4.