Akuter ischämischer Schlaganfall und Troponinerhöhung: Diagnostische Abklärung und therapeutische Konsequenzen

Zusammenfassung

Erhöhte Troponinwerte beim akuten ischämischen Schlaganfall sind ein häufiges klinisches Szenario, das vor dem Hintergrund der hohen kardialen Mortalität nach Schlaganfall eine angemessene diagnostische Aufarbeitung erfordert. Zur Vermeidung sekundärer intrazerebraler Hämorrhagien durch duale Thrombozytenaggregationshemmung sollte die Indikation zur Koronarintervention streng gestellt werden. Anhand dreier Fallbeispiele stellt diese Arbeit auf Grundlage der vorhandenen Evidenz einen diagnostischen Algorithmus vor.

Abstract

Elevated troponin values are frequently detected in patients with acute ischemic stroke, requiring adequate diagnostic work-up due to the high cardiac mortality after stroke. Since dual platelet inhibition can cause secondary intracerebral hemorrhage careful consideration of invasive coronary intervention is mandatory. Based on three case reports, this review article presents a diagnostic algorithm taking into account latest findings from the literature.

Schlüsselwörter

koronare Herzkrankheit - Myokardinfarkt - Koronarangiografie - zerebrale Infarktgröße - sekundäre intrazerebrale Hämorrhagie

Keywords

coronary heart disease - myocardial infarction - coronary angiography - cerebral infarction size - secondary intracerebral hemorrhage

Publikationsverlauf

Artikel online veröffentlicht:
26. Februar 2021

• Literatur

• 1 Scheitz JF, Mochmann H-C, Erdur H. et al. Prognostic relevance of cardiac troponin T levels and their dynamic changes measured with a high-sensitivity assay in acute ischaemic stroke: analyses from the TRELAS cohort. Int J Cardiol 2014; 177: 886-893
• 2 Sun Y, Miller MM, Yaghi S. et al. Association of Baseline Cardiac Troponin With Acute Myocardial Infarction in Stroke Patients Presenting Within 4.5 Hours. Stroke 2020; 51: 108-114
• 3 Kishore A, Vail A, Majid A. et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke 2014; 45: 520-526
• 4 Amarenco P, Lavallée PC, Labreuche J. et al. Prevalence of coronary atherosclerosis in patients with cerebral infarction. Stroke 2011; 42: 22-29
• 5 Prosser J, MacGregor L, Lees KR. et al. Predictors of early cardiac morbidity and mortality after ischemic stroke. Stroke 2007; 38: 2295-2302
• 6 Kerr G, Ray G, Wu O. et al. Elevated troponin after stroke: a systematic review. Cerebrovasc Dis Basel Switz 2009; 28: 220-226
• 7 Powers WJ, Rabinstein AA, Ackerson T. et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50: e344-e418
• 8 Thygesen K, Alpert JS, Jaffe AS. et al. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018; 72: 2231-2264
• 9 de Lemos JA, Drazner MH, Omland T. et al. Association of troponin T detected with a highly sensitive assay and cardiac structure and mortality risk in the general population. JAMA 2010; 304: 2503-2512
• 10 Wu AHB, Christenson RH, Greene DN. et al. Clinical Laboratory Practice Recommendations for the Use of Cardiac Troponin in Acute Coronary Syndrome: Expert Opinion from the Academy of the American Association for Clinical Chemistry and the Task Force on Clinical Applications of Cardiac Bio-Markers of the International Federation of Clinical Chemistry and Laboratory Medicine. Clin Chem 2018; 64: 645-655
• 11 Diener H-C, Bogousslavsky J, Brass LM. et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet Lond Engl 2004; 364: 331-337
• 12 Adams JE, Abendschein DR, Jaffe AS. Biochemical markers of myocardial injury. Is MB creatine kinase the choice for the 1990s?. Circulation 1993; 88: 750-763
• 13 Katus HA, Remppis A, Looser S. et al. Enzyme linked immuno assay of cardiac troponin T for the detection of acute myocardial infarction in patients. J Mol Cell Cardiol 1989; 21: 1349-1353
• 14 Fridén V, Starnberg K, Muslimovic A. et al. Clearance of cardiac troponin T with and without kidney function. Clin Biochem 2017; 50: 468-474
• 15 Anders B, Alonso A, Artemis D. et al. What does elevated high-sensitive troponin I in stroke patients mean: concomitant acute myocardial infarction or a marker for high-risk patients?. Cerebrovasc Dis Basel Switz 2013; 36: 211-217
• 16 Mochmann H-C, Scheitz JF, Petzold GC. et al. Coronary Angiographic Findings in Acute Ischemic Stroke Patients With Elevated Cardiac Troponin: The Troponin Elevation in Acute Ischemic Stroke (TRELAS) Study. Circulation 2016; 133: 1264-1271
• 17 Neumann JT, Sörensen NA, Rübsamen N. et al. Discrimination of patients with type 2 myocardial infarction. Eur Heart J 2017; 38: 3514-3520
• 18 Scheitz JF, Nolte CH, Doehner W. et al. Stroke-heart syndrome: clinical presentation and underlying mechanisms. Lancet Neurol 2018; 17: 1109-1120
• 19 Dütsch M, Burger M, Dörfler C. et al. Cardiovascular autonomic function in poststroke patients. Neurology 2007; 69: 2249-2255
• 20 Chen Z, Venkat P, Seyfried D. et al. Brain-Heart Interaction: Cardiac Complications After Stroke. Circ Res 2017; 121: 451-468
• 21 Wybraniec M, Mizia-Stec K, Krzych L. Stress cardiomyopathy: yet another type of neurocardiogenic injury: “stress cardiomyopathy”. Cardiovasc Pathol Off J Soc Cardiovasc Pathol 2014; 23: 113-120
• 22 Krause T, Werner K, Fiebach JB. et al. Stroke in right dorsal anterior insular cortex Is related to myocardial injury. Ann Neurol 2017; 81: 502-511
• 23 Kumar S, Selim MH, Caplan LR. Medical complications after stroke. Lancet Neurol 2010; 9: 105-118
• 24 Ibanez B, James S, Agewall S. et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39: 119-177
• 25 Albers GW, Marks MP, Kemp S. et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med 2018; 378: 708-718
• 26 Nogueira RG, Jadhav AP, Haussen DC. et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med 2018; 378: 11-21
• 27 Gibson CM, Mehran R, Bode C. et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med 2016; 375: 2423-2434
• 28 Scheitz JF, Nolte CH, Laufs U. et al. Application and interpretation of high-sensitivity cardiac troponin assays in patients with acute ischemic stroke. Stroke 2015; 46: 1132-1140
• 29 Collet J-P, Thiele H, Barbato E. et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2020;
• 30 Hochman JS, Lamas GA, Buller CE. et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006; 355: 2395-2407
• 31 Kontos MC, Diercks DB, Kirk JD. Emergency department and office-based evaluation of patients with chest pain. Mayo Clin Proc 2010; 85: 284-299
• 32 Engelter ST, Gostynski M, Papa S. et al. Epidemiology of aphasia attributable to first ischemic stroke: incidence, severity, fluency, etiology, and thrombolysis. Stroke 2006; 37: 1379-1384
• 33 Hofmann Bowman MA, Liao JK. Relative Lack of Culprit and Obstructive Coronary Lesions in Patients With Acute Ischemic Stroke and Elevated Cardiac Troponin. Circulation 2016; 133: 1228-1229
• 34 Knuuti J, Wijns W, Saraste A. et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41: 407-477
• 35 Maron DJ, Hochman JS, Reynolds HR. et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020; 382: 1395-1407
• 36 Neumann F-J, Sousa-Uva M, Ahlsson A. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40: 87-165
• 37 Haeusler KG, Wollboldt C, Bentheim LZ. et al. Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin. Stroke 2017; 48: 1241-1247
• 38 Achenbach S, Barkhausen J, Beer M. et al. Konsensusempfehlungen der DRG/DGK/DGPK zum Einsatz der Herzbildgebung mit Computertomographie und Magnetresonanztomographie. Kardiologe 2012; 6: 105-125