We present an interesting case of troponemia in a patient with acute stroke that was initially treated as Non-STEMI but eventually turned out to be a presentation of neurogenic myocardial stunning.
71-year-old male with no significant cardiac history presented to our hospital with complaints of acute onset of confusion. Evaluation with MRI of the brain showed multiple acute infarcts likely secondary to embolic phenomena. The patient did not receive thrombolytic therapy since he was out the therapeutic window. On initials labs he was also noted to have elevated troponin of 2.13 ng/ml with an EKG showing normal sinus rhythm without ischemic abnormality. His other labs including CBC and BMP were unremarkable. The patient remained chest pain free, however a repeat EKG showed new T wave inversion in lead V3-V6. Therefore, given the concern for Non-STEMI he was started on aspirin, atorvastatin and a heparin drip. Further evaluation with transthoracic echo revealed a preserved ejection fraction and absence of regional wall motion abnormality. This was followed by nuclear stress test that showed ischemia in anterior-lateral distribution hence was taken for emergent cardiac catheterization that failed to show any significant obstructive lesion. The patient did not have ST segment elevation on initial EKG hence diagnosis of coronary spasm was not entertained and patient was diagnoses as an interesting case of neurogenic myocardial stunning.
Discussion: Neurogenic myocardial stunning is described as transient myocardial dysfunction/damage seen in patients with acute brain pathology. It was first described in patients with sub-arachnoid hemorrhage; similar cases have also been reported in patients with seizure and raised intracranial tension. However our case is rare as the myocardial dysfunction occurred in the setting of an acute stroke. The proposed underlying mechanism in all these scenarios is dysfunction of autonomic regulation and is usually reversible requiring short-term supportive care only.
Conclusions: Troponemia is a commonly encountered problem in Hospitalist practice and the etiology varies ranging from acute coronary syndrome to demand ischemia. We present an interesting etiology of troponemia called neurogenic myocardial stunning, which is both under recognized and under diagnosed. This usually occurs in the setting of acute brain insult and in most cases it is reversible. Therefore, in patients with possible neurogenic myocardial stunning, ahressive invasive cardiac work up can be postponed, especially if the patient does not complain of chest pain and lacks cardiac risk factors.
To cite this abstract:Rattan R, Akhtar Z, Sidhu RS. Neurogenic Myocardial Stunning – an Interesting Case of Troponemia. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 757. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/neurogenic-myocardial-stunning-an-interesting-case-of-troponemia/. Accessed April 5, 2020.