What is the management approach for a patient with ischemic stroke and troponin elevation?

From the Guidelines

The management of a patient with ischemic stroke and troponin elevation should prioritize standard acute stroke management, including intravenous thrombolysis and mechanical thrombectomy when appropriate, alongside cardiac evaluation and management to address potential cardiac causes of troponin elevation. The approach to such patients requires a careful balance between stroke treatment and cardiac care. Initially, standard acute stroke management should proceed with intravenous thrombolysis using alteplase (0.9 mg/kg, maximum 90 mg, with 10% as bolus and remainder over 60 minutes) if the patient presents within the treatment window (typically 4.5 hours) and has no contraindications, as recommended by the 2018 guidelines for the early management of patients with acute ischemic stroke 1. Mechanical thrombectomy should be considered for large vessel occlusions.

For secondary prevention, antiplatelet therapy should be started, typically with aspirin 300 mg loading dose followed by 75-100 mg daily, or clopidogrel 300 mg loading dose followed by 75 mg daily. The troponin elevation necessitates a comprehensive cardiac evaluation, including ECG, echocardiogram, and cardiac monitoring for at least 24 hours. If acute coronary syndrome is suspected, cardiology consultation is essential. In such cases, dual antiplatelet therapy with aspirin and clopidogrel may be appropriate, along with high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily), as suggested by previous guidelines 1.

Key considerations in managing these patients include:

• Careful blood pressure management, aiming for <140/90 mmHg but avoiding excessive drops that could compromise cerebral perfusion.
• Distinguishing between neurogenic cardiac injury and concomitant coronary disease, as management approaches differ significantly.
• The importance of recent guidelines, such as those from 2018 1, in informing the management of acute ischemic stroke, including the role of intravenous thrombolysis and mechanical thrombectomy.
• The need for a multidisciplinary approach, involving neurologists, cardiologists, and other specialists, to optimize outcomes in patients with ischemic stroke and troponin elevation.

From the Research

Management Approach for Ischemic Stroke with Troponin Elevation

The management of patients with ischemic stroke and troponin elevation is complex and requires a comprehensive approach. Key considerations include:

• Cardiac evaluation: Patients with troponin elevation should undergo cardiac evaluation to rule out concomitant acute coronary syndrome or other cardiac conditions 2, 3.
• Neurological assessment: A thorough neurological assessment is essential to determine the severity of the stroke and identify potential neurological predictors of troponin elevation, such as higher National Institutes of Health Stroke Scale scores and insular cortical lesions 2.
• Risk stratification: Patients with troponin elevation are at higher risk of poor outcomes, including mortality and unfavorable functional outcomes 4, 5.
• Monitoring and treatment: Close monitoring of cardiac and neurological status is crucial, and treatment should be tailored to address both cardiac and neurological conditions 6.

Cardiac and Neurological Factors Associated with Troponin Elevation

Several cardiac and neurological factors have been associated with troponin elevation in patients with ischemic stroke, including:

• Cardiac factors:
  • Electrocardiography abnormalities, such as QTc-prolongation, left ventricular hypertrophy, Q-wave, and ST elevation 2.
  • Prior ischemic strokes 4.
• Neurological factors:
  • Higher National Institutes of Health Stroke Scale scores 2, 5.
  • Insular cortical lesions 2.
  • Clinical deterioration 5.

Prognostic Implications of Troponin Elevation

Troponin elevation is a strong independent predictor of poor outcome and in-hospital mortality in patients with ischemic stroke 4, 5. The prognostic implications of troponin elevation should be taken into account when managing these patients, and careful investigation of possible concomitant cardiac disorders is warranted 5.