Rising Cardiac Troponin: A Prognostic Biomarker for Mortality After Acute Ischemic Stroke.

BACKGROUND: Elevated cardiac troponin (cTn) is detected in 10% to 30% of patients with acute ischemic stroke (AIS) and correlates with poor functional outcomes. Serial cTn measurements differentiate a dynamic cTn pattern (rise/fall >20%), specific for acute myocardial injury, from elevated but stable cTn levels (nondynamic), typically attributed to chronic cardiac/noncardiac conditions. We investigated if the direction of the cTn change (rising versus falling) affects mortality and outcome. METHODS AND RESULTS: We retrospectively screened consecutive patients with AIS admitted to 5 stroke centers for elevated cTn at admission and at least 1 additional cTn measurement within 48 hours. The pattern of cTn was defined as rising if >20% increase from baseline, falling if >20% decrease, or nondynamic if ≤20% change in either direction. Logistic regression analyses were performed to assess the association of cTn patterns and 7-day mortality and unfavorable discharge disposition. Of 3789 patients with AIS screened, 300 were included. Seventy-two had a rising pattern, 66 falling, and 162 nondynamic. In patients with AIS with rising cTn, acute ischemic myocardial infarction was present in 54%, compared with 33% in those with falling cTn (P<0.01). Twenty-two percent of patients with a rising pattern had an isolated dynamic cTn in the absence of any ECG or echocardiogram changes, compared with 53% with falling cTn. A rising pattern was associated with higher risk of 7-day mortality (adjusted odds ratio [OR]=32 [95% CI, 2.5-415.0] rising versus aOR=1.3 [95% CI, 0.1-38.0] falling versus nondynamic as reference) and unfavorable discharge disposition (aOR=2.5 [95% CI, 1.2-5.2] rising versus aOR=0.6 [95% CI, 0.2-1.5] versus falling). CONCLUSIONS: Rising cTn is independently associated with increased mortality and unfavorable discharge disposition in patients with AIS.

Spontaneous Intracranial Hemorrhages in a Community of Asian Americans: Case Series and Literature Review.

Background and objectives Several Asian populations abroad are reported to have a higher prevalence of spontaneous intracranial hemorrhages (sICH) and a greater proportion of all stroke types attributed to ICH compared to non-Asians. However, the causes are unknown, and few studies have examined the issue among Asian Americans. This report aims to highlight some less common, but not rare, clinical features that could bear on several pathophysiological factors, by presenting a selected case series of 13 Asian American patients admitted to a Boston-based healthcare system and hospital. Methods The selected cases were classified into six categories based on presumed sICH mechanisms including vasculopathy, hypertensive crises, moyamoya disease/syndrome, venous sinus thrombosis, brainstem hemorrhages, and arterial malformation/aneurysm. We also examined 5 years of medical records at our institution, a single healthcare system among several in a large urban area having its main hospital embedded in an Asian community, to arrive at stroke-type proportions, comparing our Asian to non-Asian population. ICH cases excluded trauma, coagulopathy, and hemorrhagic transformation. ICH patient counts were compared to acute ischemic stroke and subarachnoid hemorrhage across various ethnicities. Results Pathophysiology-biomarker correlations within each ICH stroke category were reviewed, some possibly having specificity for Asian populations. We found some evidence to support an increased proportion of sICH among all stroke types in our Asian American patients, relative to other ethnic groups. A higher apparent estimate of sICH incidence in Asian Americans vs. Caucasians was also uncovered. However, these did not reach statistical significance and so no conclusion on risk could be made from this preliminary study. Conclusions We review the extensive literature on epidemiology and genetic markers and affirm that an awareness of the potential increased risk of sICH in this expanding population is clinically prudent. An expanded epidemiologic study to refine ICH risk estimates in Asian Americans is planned.