Brief Report
Serum troponin testing in patients with paroxysmal supraventricular tachycardia: outcome after ED care

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Abstract

Paroxysmal supraventricular tachycardia (PSVT), a common dysrhythmia seen in the emergency department (ED), is usually managed without difficulty and with a favorable prognosis. Serum cardiac troponin I (cTnI) testing provides important risk stratification information in certain patients; its use in PSVT patients, however, has not been explored. A retrospective review of consecutive adult ED PSVT patients seen for 21 months was performed. Fifty-four PSVT patients were identified on the basis of International Classification of Disease, Ninth Edition codes and the ED patient log at a university hospital. Three patients were excluded for incorrect rhythm, leaving 51 who were included in data analysis. Thirty-eight patients had at least one serum cTnI value measured. Of those, 11 had a positive result, defined as serum cTnI of more than 0.02 ng/dL. Thirty-day outcomes for these patients were evaluated and showed one ED return, no PSVT recurrences, and no deaths at our regional hospital. In this sample, serum cTnI testing did not identify PSVT patients at risk for poor outcome. Further consideration of the use of this testing modality in the PSVT patient population is recommended.

Introduction

Paroxysmal supraventricular tachycardia (PSVT), a common dysrhythmia seen in the emergency department (ED), is usually managed without difficulty and often with a favorable prognosis [1]. Poor outcomes rarely occur in ED PSVT patients. Most patients with PSVT are discharged from the ED after conversion to normal sinus rhythm. A retrospective study of 111 PSVT patients reported no patient deaths secondary to PSVT or its complications [2]. The medical literature regarding the ED evaluation and disposition of these patients, however, is scarce; practice guidelines lack outcome data to guide emergency clinicians in safe patient discharge. Emergency medicine textbooks state that PSVT can occur in the setting of a normal heart as well as in rheumatic heart disease, pericarditis, myocardial infarction (MI), mitral valve prolapse, preexcitation syndromes, and electrolyte imbalance. They also recommend admission for patients with underlying complicating disease and for patients with PSVT recurrence in the ED [3], [4]. There are no recommendations for or against using serum cardiac markers such as troponin I (cTnI).

The use of cTnI has greatly impacted the ED disposition of patients experiencing acute chest pain [5]. In patients with acute coronary syndrome (ACS), elevated cTnI levels provide prognostic information and help identify patients at risk for adverse outcomes [6], [7]. Although this relationship is well defined, the significance of cTnI levels in some non-ACS conditions remains unclear.

Several studies have reported increased risk for future cardiovascular events in patients with elevated cTnI levels without evidence of myocardial ischemia [8], [9]. In addition, cTnI elevations are associated with worsened prognoses in conditions such as pulmonary embolism, renal failure, sepsis, pneumonia, and congestive heart failure [10], [11], [12]. Several investigators, however, have described elevated cTnI levels in patients with supraventricular tachycardia subsequently found to have normal coronary arteries [13], [14], [15], [16], [17]. These findings raise the question of whether patients with PSVT and elevated cTnI levels require the same evaluation and risk stratification as patients with ACS. This question remains difficult to answer without a better understanding of the prognostic implications of elevated cTnI levels in patients with PSVT.

To determine whether cTnI levels in patients presenting to the ED with PSVT can help predict those at risk for an unfavorable 30-day outcomes, we retrospectively evaluated 51 consecutive patients with PSVT, 38 of whom had at least one troponin sent. Eleven cases were subsequently found to have elevated cTnI levels. We present the largest case series of PSVT patients with elevated cTnI levels, none of whom had adverse 30-day cardiovascular outcomes.

Section snippets

Methods

A retrospective chart review of patients presenting to the ED with PSVT during the period from January 1, 2004, to September 30, 2005, was performed. Two chart reviewers identified patients using both International Classification of Disease, Ninth Edition codes for PSVT and the ED patient log book at a university hospital with an annual volume of 60 000 patients. The first chart reviewer was a fourth year medical student with paramedic experience. The second chart reviewer was a board-certified

Result

During the study period, 54 patients were diagnosed with supraventricular tachycardia. Three patients were excluded for incorrect rhythm analysis, leaving 51 patients identified with PSVT. Thirty-eight patients (74.5%) had at least one serum cTnI value measured. Eleven (28.9%) of the 38 patients who underwent serum cTnI testing had a positive result. In this group of 11 patients, there were no PSVT recurrences and no deaths. One patient returned to the ED for a noncardiac concern. Otherwise,

Discussion

Cardiac troponin I is a sensitive and specific marker for myocardial injury with a well-defined prognostic value in patients with ACS [6], [7], [18]. There are many non-ACS causes of elevated cTnI, however, including congestive heart failure, pericarditis, myocarditis, cardiac contusion, renal insufficiency, sympathomimetic drug ingestion, pulmonary embolism, sepsis, cerebrovascular accident, multitrauma, and strenuous exercise [13], [19]. The use of cTnI in non-ACS patients has not been well

Conclusion

We have presented the largest case series of patients with PSVT and elevated cTnI levels. In this small sample, cardiac marker testing did not identify PSVT patients who experienced adverse outcomes. This series underscores the importance of continuing to evaluate the prognostic value of cardiac serum markers in patients with PSVT and other non-ACS presentations. It also emphasizes the importance of monitoring outcome data for PSVT patients treated in the ED. Both prospective observational

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Cited by (24)

  • Assessment of the Utility of Ordering a Troponin in Low- and Intermediate-Risk Patients Presenting to the Emergency Department with Supraventricular Tachycardia: A Retrospective Chart Review

    2018, Journal of Emergency Medicine
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    Compared with patients with a negative troponin, patients with a positive troponin had an average total length of stay approximately 47 h longer (69 h vs. 22 h; p = 0.04), higher rates of cardiology consults in the ED of 86% versus 21% (p < 0.001), and higher admission rates of 86% versus 21% (p = 0.006). Our results are consistent with a growing body of studies demonstrating that elevated troponin level in the setting of SVT can occur in the absence of relevant structural heart disease or CAD, and is not predictive of poor outcomes (2–11). Additional studies have shown that elevated troponin levels in SVT patients lead to more hospital admissions; again, without being associated with worse outcomes or CAD (12,13).

  • Prognostic value of cardiac troponin levels in patients presenting with supraventricular tachycardias

    2020, Journal of Electrocardiology
    Citation Excerpt :

    The mean follow-up period was 2.2 ± 1.7 years. On the other hand, a retrospective study by Calberg et al. [32] of 38 patients with PSVT, of whom 11 patients had elevated cTnI, found that none of the patients had adverse cardiovascular outcomes. Both studies were similar to our study in terms of study conception and design, but included less patients and evaluated different clinical endpoints.

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