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Dr. D. Love
Dr. D. Love, Doctor
Category: Medical
Satisfied Customers: 18671
Experience:  Family Physician for 10 years; Hospital Medical Director for 10 years.
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Elevated troponin value of 38.7. I know this is bad, but how

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Elevated troponin value of 38.7. I know this is bad, but how bad? 75 yr. husband in hospital after serious motorcycle accident. He has broken left humerus at shoulder, several broken ribs, right broken wrist, left shattered tibia and broken fibula. He was pronounced fit for surgery by trauma team after echo for ankle fixation. His hemologlobin dropped to 7.7 from 11 at admission. When they transfused blood he had a heart attack that started with tachycardia in normal sinus rhythm, went to A-Fib. He did not fully arrest. Heart rate went to 171 then with drugs came back down. Converted to normal sinus rhythm spontaneously. He has no memory of the heart attack. 12 hours later during a second transfusion ( first one was stopped because Docs initially though it was a transfusion reaction ) he had a second smaller run of tachycardia in sinus rhythm (141) which looked like another heart attack, profuse sweating followed by wracking chills and disorientation. He now has a nitroglycerin patch and a heparin drip. Doctors haven't said anything about prognosis or what caused the infarct. He's had numerous EKG's and two echocardiograms. What questions should I be asking. He is supposed to go to a SNF until he walk with a walker. Then come home for rehab. Believe it or not the insurance company for the woman who hit him has called me twice to ask if he's been released yet. Did the stress of the accident cause these heart attacks or was there some underlying heart disease we didn't know about? He was on blood pressure medication for mild hypetension. Just borderline.
I'm sorry that your husband is going through all this.
It will help if you could provide some further information:
How much time had passed between the accident and the heart attack?
How much time before the troponin level of 38.7?
Do you have the results of the echocardiograms?
Customer: replied 4 years ago.

The accident was Sunday at 12:35 in the afternoon. Surgery was Tuesday, mid day. Heart attack event began about 11:00 pm Wednesday night. Prior to that troponin level was 1. Following first attack it went to 34.5. Second attack was 11:00 am yesterday. Most recent troponin was 38.7. They do have the echo results but don't give me any of that information. What should I ask when they come in this morning? I just talked to his night nurse who said he was doing well overnight. No more tachycardia.

Thank you for the additional information.

This is a complex explanation, and I am not the fastest typist, but please be patient. I will post the explanation of why I asked and the answers to your questions once I get done typing it.

There is no need to reply to this message.
The question of timing is pertinent to your question about the cause of the heart attack, and with this amount of time between the accident and the heart attack, there less potential confusion regarding the cause of the elevation.

The troponin levels (and other markers of heart attacks) are actually measures of damage to the heart. The vast majority of the time that we see an elevation in troponin levels is from a heart attack (the medical term is a myocardial infarction), and particularly if there is a pattern of an initial normal level, then an increase, then a gradual return to normal. However, one of the possible conditions that can also raise the troponin levels is direct trauma to the heart, called a cardiac contusion. A contusion is the medical term for a deep bruise, and can be applied to almost any tissue, but in the case of a cardiac contusion, it refers to the heart muscle. However, if there had been a cardiac contusion from the accident on Sunday, there would have been elevation of the troponin level long before Wednesday. Therefore, it is unlikely that there is a cardiac contusion that could be confused with a myocardial infarction.

The other aspect of your question is whether the myocardial infarction was caused by the accident or whether there was some amount of underlying disease that was present, and the answer is that both are true. While a cardiac contusion can occur in any person regardless of age or current level of artery disease int he heart, the precipitation of a myocardial infarction typically occurs in a person with pre-existing narrowing in at least one of the arteries to the heart, that then becomes blocked with clot, completely blocking blood flow. Therefore, the usual scenario is that there was a pre-existing narrowing and the sudden blockage was precipitated by the acute condition.

It is impossible to know whether or when any of the underlying heart narrowing may have caused problems. When there are studies done to look for heart disease, such as in autopsy studies of people that die from other causes, we find that many people have narrowings that had not caused any problems, so there is a fair incidence of some degree of narrowings, but it cannot be said whether they would have caused problems without the precipitating event of the accident. Even though his hypertension has been mild, he also has risk factors of being male and older (and perhaps others), and if anyone lives long enough, they will likely develop narrowings in the heart.

I asked about the echocardiogram because the extent of damage of the heart is better measured by the echocardiogram than by the troponin level. Sometimes, the area of poor blood supply can get a return of blood supply relative quickly, which can flush out the troponin from the damaged muscle and cause a higher elevation, but the relatively rapid return of blood flow will limit the extent of damage. If the echocardiogram shows a relatively small area of damage, then the patient will generally do better than if a larger area of damage was seen. When talking to the doctors, you can ask how much damage was seen on the echocardiogram.

The other questions that you should ask are regarding recovery. The usual recovery process after a heart attack involves cardiac rehabilitation, but will obviously be complicated in his case because of the extent of the musculoskeletal injuries. The ability of the person to participate in cardiac rehab, including whether there is any evidence of continued problems with blood supply with increasing activity, are important indicators of long term prognosis. There will also usually be some assessment of whether there is any evidence of ongoing poor blood supply, such as though an exercise stress test, although there are some other tests that can be done in persons that cannot perform that level of exertion. This test is usually done after there has been time for healing of the myocardial infarction, and if there is any evidence of ongoing poor blood supply, there may need to be further evaluation or intervention, such as angioplasty. At this point, the doctor would not be able to anticipate every possible scenario, but the findings on the echocardiograms, the plan for performing the rehab and the assessment after recovery could be explained.

If you have any further questions or need clarification, please let me know.
I cannot see that you have received and reviewed my above answer.

Sometimes there is a problem with notification, so I am posting another reply, hopefully so that you can be notified of the answer.

If you have any further questions or clarification, please let me know.
Dr. D. Love and 3 other Medical Specialists are ready to help you
Customer: replied 4 years ago.

I did receive it. I have one more question. I read " herefore, the usual scenario is that there was a pre-existing condition narrowing and the sudden blockage was precipitated by the acute condition." The acute condition is the accident trauma? That's my only question. Your answer has been extremely good. Today I will be able to get the information I need to understand what his condition is and what his prognosis is. I didn't know what questions to ask. I'm disappointed they didn't tell me.

The acute condition is the accident and the clinical consequences of the accident the bleeding, the drop in blood level, and the transfusion. It is the entire clinical picture that can precipitate the acute blockage. There is some risk from the accident alone, but having all of the other issues also entail some risk.
Dr. D. Love and 3 other Medical Specialists are ready to help you