Pitfalls in the diagnosis of the acute coronary syndrome in hemodialysis patients

    Authors

    Keywords

    acute coronary syndrome, end-stage renal disease, high-sensitivity troponins

    DOI

    https://doi.org/10.15836/ccar2022.164

    Full Text

    **Introduction**: Cardiac death is the most common cause of death among hemodialysis patients, predominantly acute myocardial infarction. High-sensitivity troponins (hs-cTnT, hs-cTnI) have become the gold standard for the diagnosis of the acute coronary syndrome (ACS) in the general population. The aim of this presentation is to show the limitation of these biomarkers in patients with end-stage renal disease (ESRD) because the serum troponin levels are very often elevated in those patients (1-3). **Case report**: 68-year-old woman has been on a chronic hemodialysis program for the past 4 years. She also had a history of arterial hypertension, dyslipidemia, and diabetes. During the regular hemodialysis program, she mentioned intensive chest pain that she had two days ago. She had a high blood pressure (240/120 mmHg) then, but now she felt good. In the laboratory elevated values of hs-cTnI were found (1995 ng/L). 12-lead electrocardiogram showed the signs of septal ischemia with a discretely elevated ST segment in inferior leads (**Figure 1**). An emergency echocardiography was done. Concentric hypertrophy of the left ventricle with normal ejection fraction was found but with regional wall motion abnormality - hipocontractility of the basal part of anteroseptum and basal part of inferoseptum. The patient was referred to the University Hospital for coronary angiography. The stenosis of the proximal right coronary artery around 40% was found. Obstructive coronary disease has been ruled out as well as the diagnosis of ACS. It was concluded that echocardiographic and ECG changes are related to hypertensive heart disease. FIGURE 1. 12-lead electrocardiogram in the hemodialysis patient with a history of chest pain. **Conclusion**: When patients with ESRD present themselves with chest pain and the ECG findings are suggestive of myocardial ischemia, it is necessary to make a coronary angiography to confirm or to exclude the diagnosis of ACS. In any case, we must keep in mind that elevated troponin in patients undergoing dialysis, is directly correlated with cardiovascular and total mortality.

    Literature

    1. Lozić B, Delalić Đ, Marković D, Svaguša T, Prkačin I. Significance and Measurement of High-sensitivity Troponins I and T in Patients with Chronic Kidney Disease. Cardiol Croat. 2022;17(1-2):3–8. https://doi.org/10.15836/ccar2022.3
    2. Freda BJ, Tang WH, Van Lente F, Peacock WF, Francis GS. Cardiac troponins in renal insufficiency: review and clinical implications. J Am Coll Cardiol. 2002;40(12):2065–71. https://doi.org/10.1016/S0735-1097(02)02608-6
    3. Tarapan T, Musikatavorn K, Phairatwet P, Takkavatakarn K, Susantitaphong P, Eiam-Ong S, et al. High Sensitivity Troponin-I Levels in Asymptomatic Hemodialysis Patients. Ren Fail. 2019;41:393–400. https://doi.org/10.1080/0886022X.2019.1603110
    Cardiologia Croatica
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    Pitfalls in the diagnosis of the acute coronary syndrome in hemodialysis patients

    Extended Abstract
    Issue9-10
    Published
    Pages164
    PDF via DOIhttps://doi.org/10.15836/ccar2022.164
    acute coronary syndrome
    end-stage renal disease
    high-sensitivity troponins

    Authors

    Vlasta Soukup Podravec*ORCIDBjelovar General Hospital, Bjelovar, Croatia
    Ivana Petrović-JurenORCIDBjelovar General Hospital, Bjelovar, Croatia
    Renata Ivanac JankovićORCIDBjelovar General Hospital, Bjelovar, Croatia
    Andreja Čleković-KovačićORCIDBjelovar General Hospital, Bjelovar, Croatia
    Sandra PršaORCIDBjelovar General Hospital, Bjelovar, Croatia
    Kristina Milevoj KrižićORCIDBjelovar General Hospital, Bjelovar, Croatia

    *Correspondence email: vlasta.soukuppodravec@gmail.com

    Full Text

    Introduction: Cardiac death is the most common cause of death among hemodialysis patients, predominantly acute myocardial infarction. High-sensitivity troponins (hs-cTnT, hs-cTnI) have become the gold standard for the diagnosis of the acute coronary syndrome (ACS) in the general population. The aim of this presentation is to show the limitation of these biomarkers in patients with end-stage renal disease (ESRD) because the serum troponin levels are very often elevated in those patients (1–3).

    Case report: 68-year-old woman has been on a chronic hemodialysis program for the past 4 years. She also had a history of arterial hypertension, dyslipidemia, and diabetes. During the regular hemodialysis program, she mentioned intensive chest pain that she had two days ago. She had a high blood pressure (240/120 mmHg) then, but now she felt good. In the laboratory elevated values of hs-cTnI were found (1995 ng/L). 12-lead electrocardiogram showed the signs of septal ischemia with a discretely elevated ST segment in inferior leads (Figure 1). An emergency echocardiography was done. Concentric hypertrophy of the left ventricle with normal ejection fraction was found but with regional wall motion abnormality - hipocontractility of the basal part of anteroseptum and basal part of inferoseptum. The patient was referred to the University Hospital for coronary angiography. The stenosis of the proximal right coronary artery around 40% was found. Obstructive coronary disease has been ruled out as well as the diagnosis of ACS. It was concluded that echocardiographic and ECG changes are related to hypertensive heart disease.

    FIGURE 1. 12-lead electrocardiogram in the hemodialysis patient with a history of chest pain.

    Conclusion: When patients with ESRD present themselves with chest pain and the ECG findings are suggestive of myocardial ischemia, it is necessary to make a coronary angiography to confirm or to exclude the diagnosis of ACS. In any case, we must keep in mind that elevated troponin in patients undergoing dialysis, is directly correlated with cardiovascular and total mortality.

    Literature

    1. 1.
      Lozić B, Delalić Đ, Marković D, Svaguša T, Prkačin I. Significance and Measurement of High-sensitivity Troponins I and T in Patients with Chronic Kidney Disease. Cardiol Croat. 2022;17(1-2):3–8.DOI
    2. 2.
      Freda BJ, Tang WH, Van Lente F, Peacock WF, Francis GS. Cardiac troponins in renal insufficiency: review and clinical implications. J Am Coll Cardiol. 2002;40(12):2065–71.DOI
    3. 3.
      Tarapan T, Musikatavorn K, Phairatwet P, Takkavatakarn K, Susantitaphong P, Eiam-Ong S, et al. High Sensitivity Troponin-I Levels in Asymptomatic Hemodialysis Patients. Ren Fail. 2019;41:393–400.DOI