Article Text

Download PDFPDF
BET 2: Is there value in testing troponin levels after ICD discharge?

Abstract

A short cut review was carried out to establish whether testing for troponin levels is useful after discharge of an Implanted Cardioverter-Defibrillator (ICD). Many papers were found using the reported searches, none of which directly addressed the problem but some 13 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of those best papers are tabulated. It is concluded that the number of ICD discharges must be taken into account when evaluating any troponin level rise. Overall a positive troponin assay post ICD discharge is independently associated with an increased mortality.

  • emergency care systems

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Report by: Chris Targett, Specialty Doctor in Emergency Medicine

Search checked by: Tim Harris, Professor of Emergency Medicine

Institution: Hinchingbrooke Hospital NHS Trust, Huntingdon, UK

Clinical scenario

A 50-year-old man presents to the emergency department having been woken from sleep by his implanted cardioverter-defibrillator (ICD) firing; it has fired twice more since that time. He is in sinus rhythm and has no acute signs or symptoms. A recent angiogram showed no significant coronary artery disease (CAD). You speak to the Cardiology Registrar who advises that troponin levels should be checked. You wonder if there is any evidence for this and, further, how you might interpret the result.

Three-part question

In (an adult patient whose ICD has discharged) is (a rise in troponin) suggestive of (an ischaemic cardiac event precipitating ICD discharge or defibrillation induced myocyte damage)?

Search strategy

Ovid MEDLINE(R) 1946 to November Week 3 2013: ((defibrillators.af. AND implantable.af.) OR exp Defibrillators, Implantable/ OR implantable defibrillator$.af.) AND troponin.af. OR exp Troponin/ Results limited to English language and studies in humans.

The Cochrane Library Issue 12 of 12 December 2013: MeSH descriptor: [Troponin] explode all trees AND ICD:ti,ab,kw (Word variations have been searched) OR MeSH descriptor: [Pacemaker, Artificial] explode all trees

Google Scholar December 2013: >8000 search results.

Outcome

Ovid search retrieved 38 papers of which 11 were relevant. PubMed clinical queries: No additional papers identified. Cochrane search retrieved three papers, none of which were relevant. Two additional papers of note identified from first 100 best matches in Google Scholar. No paper directly answered the question posed. The relevant papers are summarised in the following table:

Table 2

Relevant papers

Comments

The majority of papers deal with defibrillator threshold testing (DFT) rather than spontaneous discharge, and use a variety of troponin assays. From the above research it can be seen that myocyte damage from an ICD discharge alone can raise troponin levels, and the more shocks, the higher the rise. There is no proven difference in level of troponin rise due to whether the discharge was appropriate, inappropriate or from DFT, but a positive troponin level is more common in spontaneous discharges. A small but significant proportion of patients whose ICD discharges on a background of CAD will have acute coronary syndrome (ACS). There is limited data in these studies to suggest that likely non-ACS related rises tend to peak earlier than those from ACS which confirms expert clinical experience that myocardial ischaemia causes a more prolonged troponin release compared to the discrete insult of an ICD discharge for arrhythmia.

Interrogation of any recently discharged ICD should be requested on all patients. Whether to employ a troponin level test depends on the patient's history of CAD and the clinical evaluation of ACS. Any patient with a confirmed absence of CAD (all patients with ICD will have had imaging of their coronary arteries) and who presents without symptoms of ACS does not require troponin level evaluation. So in the clinical scenario, the patient could be considered for discharge once ICD interrogation has been arranged. Any patient symptomatic of ACS should be managed as per local ACS protocol with a troponin assay. Any patient with known CAD but without symptoms of ACS should be discussed promptly with an electrophysiologist or, if this is not possible, have a 6–12 h troponin assay (depending on local policy). If the troponin assay is negative, the patient can be considered for discharge once ICD interrogation has been arranged. If the troponin assay is positive, the patient should be managed as per local ACS protocol.

Clinical bottom line

The number of implanted cardioverter defibrillator (ICD) discharges must be taken into account when evaluating any troponin level rise. Overall, a positive troponin assay post-ICD discharge is independently associated with an increased mortality.

  • Hurst TM, Hinrichs M, Breidenbach C, et al. Detection of myocardial injury during transvenous implantation of automatic cardioverter-defibrillators. J Am Coll Cardiol 1999;34:402–8.

  • Joglar JA, Kessler DJ, Welch PJ, et al. Effects of repeated electrical defibrillations on cardiac troponin I levels. Am J Cardiol 1999;83:270–2.

  • Rao SP, Miller S, Rosenbaum R, et al. Cardiac troponin I and cardiac enzymes after electrophysiologic studies, ablations, and defibrillator implantations. Am J Cardiol 1999;84:470, A9.

  • Schlüter T, Baum H, Plewan A, et al. Effects of implantable cardioverter defibrillator implantation and shock application on biochemical markers of myocardial damage. Clin Chem 2001;47:459–63.

  • Hasdemir C, Shah N, Rao AP, et al. Analysis of troponin I levels after spontaneous implantable cardioverter defibrillator shocks. J Cardiovasc Electrophysiol 2002;13:144–50.

  • Daubert JP, Zareba W, Cannom DS, et al. MADIT II Investigators. Inappropriate implantable cardioverter-defibrillator shocks in MADIT II: frequency, mechanisms, predictors, and survival impact. J Am Coll Cardiol 2008;51:1357–65.

  • Poole JE, Johnson GW, Hellkamp AS, et al. Prognostic importance of defibrillator shocks in patients with heart failure. N Engl J Med 2008;359:1009–17.

  • Alaiti MA, Maroo A, Edel TB. Troponin levels after cardiac electrophysiology procedures: review of the literature. Pacing Clin Electrophysiol 2009;32:800–10.

  • Blendea D, Blendea M, Banker J, et al. Troponin T elevation after implanted defibrillator discharge predicts survival. Heart 2009;95:1153–8.

  • Bhavnani SP, Kluger J, Coleman CI, et al. The prognostic impact of shocks for clinical and induced arrhythmias on morbidity and mortality among patients with implantable cardioverter-defibrillators. Heart Rhythm 2010;7:755–60.

  • Francis CK, Kuo YH, Azzam I, et al. Brain natriuretic peptide and biomarkers of myocardial ischemia increase after defibrillation threshold testing. Pacing Clin Electrophysiol 2012;35:314–19.

  • Toh N, Nishii N, Nakamura K, et al. Cardiac dysfunction and prolonged hemodynamic deterioration after implantable cardioverter-defibrillator shock in patients with systolic heart failure. Circ Arrhythm Electrophysiol 2012;5:898–905.

  • Davoodi G, Mohammadi V, Shafiee A, et al. Detection of myocardial injury due to defibrillation threshold checking after insertion of implantable cardioverter/defibrillators. Acta Cardiologica 2013;68:167–72.