A 64-year-old female patient has been ventilated in your ICU for 36 hours with septic shock and is receiving significant doses of noradrenaline and vasopressin. On the morning review you note her troponin level is elevated to over 10 times the normal range for your institution.
How do you interpret the raised troponin level in this setting? (40% marks)
Outline your assessment and management plan specific to the raised troponin level. (60% marks)
a) Interpretation of raised troponin- should not be used in isolation in this patient. The measured
value of troponin is high and should not be ignored or dismissed. If unexpected, repeat the
test. Symptoms of chest pain are not easy to elicit in the ventilated patient. Troponin leak in
this setting may be due to myocarditis associated with sepsis, acute cardiomyopathy.
Takotsubo disease given high dose vasopressor or a STEMI or NSTEMI or right ventricular
disease. Elevated troponin in renal failure should also be considered if relevant. Elevated
troponins are associated with poor outcomes in septic patients.
b) Management plan- Comprehensive clinical assessment especially cardiovascular and
haemodynamic assessment. Look for recent, rapid increase in vasopressor requirement,
signs of cardiogenic shock. Review ECG for any evidence of STEMI or other new changes,
Review CXR for new pulmonary oedema/heart failure. Echo- transthoracic or if available TOE
is mandatory to look for any regional wall motion abnormalities that may be new. Evidence of
global changes on echocardiography may indicate acute cardiomyopathy e.g. Myocarditis.
Look for classic changes of Takatsubo’s.
Further management will be determined by ECG and echo findings. Cardiology review,
anticoagulation, careful consideration of thrombolysis or angioplasty if STEMI or regional
changes on echo with consideration given to haemodynamic instability and challenges of
transfer and management in cardiac catheter lab. Role of IABP in global hypokinesis related
to acute cardiomyopathies.
Troponin increases in septic patients is thought to be associated with poor prognosis
Additional Examiners’ Comments:
Candidates were not expected to reproduce the template, but to demonstrate a reasonable and
structured approach to the issue.
Interpretation of a raised troponin in septic shock:
Assessment and management plan:
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