Kosin Med J.  2023 Dec;38(4):252-258. 10.7180/kmj.23.133.

Troponin I and D-dimer levels as triaging biomarkers to distinguish acute pulmonary thromboembolism from myocardial infarction

• Kim SJ
• Kim MH
• Lee KM
• Lee JW
• Cha YS
• Koh DE
• Hwang JY
• Park JS

• KMID: 2549497
• DOI: http://doi.org/10.7180/kmj.23.133

Abstract

Background
Acute pulmonary thromboembolism (APTE) is often confused with myocardial infarction. Previous studies have shown that patients with APTE exhibit lower initial and peak cardiac troponin I (CTI) levels, but higher D-dimer (DD) levels, than patients with myocardial infarction. The present study aimed to reaffirm the tree model algorithm using an entirely new set of data.
Methods
We reviewed retrospective clinical and laboratory data from patients who were diagnosed with APTE or non-ST-elevation myocardial infarction (NSTEMI) between 2015 and 2016. Subjects who were not classified with a diagnosis or did not have their CTI or DD levels assessed were excluded. We categorized patients according to the previous algorithm and compared the outcomes with the previous test dataset.
Results
The analysis involved data from 156 patients with APTE and 363 patients with NSTEMI. In the validation data set, the APTE group showed higher initial DD levels (9.80±10.84 μg/mL) and lower initial CTI levels (0.17±0.54 μg/mL) than the NSTEMI group. The accuracy rate for the test dataset and the validation set were similar. The test set accuracy rate was 91.0%, while the accuracy rate in the validation set improved to 88.6%.
Conclusions
Patients with APTE exhibited lower initial and peak CTI levels, but higher DD levels than NSTEMI patients. The accuracy rate estimates were similar between the test set obtained from the tree model algorithm and the validation set. The study findings demonstrate that the assessment of cardiac biomarkers can be useful for differentiating between APTE and NSTEMI.

Keyword

Acute pulmonary thromboembolism; Cardiac troponin I; D-dimer; Myocardial infarction

Figure

• 

  Fig. 1. Validation and diagnostic performance of the previous algorithm. The tree model created five groups. When the validation set was matched to the corresponding group and compared with the previous test set, similarities were noted. NSTEMI, non-ST-elevation myocardial infarction; APTE, acute pulmonary thromboembolism; CTI, cardiac troponin I; T, test set; V, validation set.

• 

  Fig. 2. Initial troponin I and D-dimer level in validation data. APTE, acute pulmonary thromboembolism; NSTEMI, non-ST-elevation myocardial infarction.

• 

  Fig. 3. Decision-making tree for rapid diagnosis of APTE or NSTEMI. APTE, acute pulmo­nary thromboembolism; NSTEMI, non-ST-elevation myocardial infarction; CT, computed tomography.

Reference

References

1. Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation. 2007; 116:427–33.

2. Becattini C, Agnelli G. Acute pulmonary embolism: risk stratification in the emergency department. Intern Emerg Med. 2007; 2:119–29.

3. Gul EE, Nikus KC, Erdogan HI, Ozdemir K. Differential diagnostic dilemma between pulmonary embolism and acute coronary syndrome. J Arrhythm. 2016; 32:160–1.

4. Stein PD, Sostman HD, Hull RD, Goodman LR, Leeper KV, Gottschalk A, et al. Diagnosis of pulmonary embolism in the coronary care unit. Am J Cardiol. 2009; 103:881–6.

5. Kim SJ, Kim MH, Lee KM, Kim TH, Choi SY, Son MK, et al. Troponin I and D-dimer for discriminating acute pulmonary thromboembolism from myocardial infarction. Cardiology. 2017; 136:222–7.

6. Abdalla A, Kelly F. 'STEMI-like' acute pulmonary embolism, an unusual presentation. BMJ Case Rep. 2014; 2014:bcr2014206517.

7. Kang G, Kim SE. How to write an original article in medicine and medical science. Kosin Med J. 2022; 37:96–101.

8. Saar JA, Maack C; European Society of Cardiology. Diagnosis and management of acute pulmonary embolism. ESC guidelines 2014. Herz. 2015; 40:1048–54.

9. Lempereur M, Moonen M, Gach O, Lancellotti P; European Society for Cardiology. 2011 ESC guidelines for the management of acute coronary syndromes without ST segment elevation. Rev Med Liege. 2012; 67:8–10.

10. Bayes-Genis A, Mateo J, Santalo M, Oliver A, Guindo J, Badimon L, et al. D-Dimer is an early diagnostic marker of coronary ischemia in patients with chest pain. Am Heart J. 2000; 140:379–84.

11. van Belle A, Buller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006; 295:172–9.

12. Correia LC, Noya-Rabelo M. The D-dimer approach for troponin in the diagnosis of myocardial infarction: is it really useful? J Am Coll Cardiol. 2012; 59:1570–2.

13. Lippi G, Filippozzi L, Montagnana M, Salvagno GL, Guidi GC. Diagnostic value of D-dimer measurement in patients referred to the emergency department with suspected myocardial ischemia. J Thromb Thrombolysis. 2008; 25:247–50.

14. Derhaschnig U, Laggner AN, Roggla M, Hirschl MM, Kapiotis S, Marsik C, et al. Evaluation of coagulation markers for early diagnosis of acute coronary syndromes in the emergency room. Clin Chem. 2002; 48:1924–30.

15. Gong P, Yang SH, Li S, Luo SH, Zeng RX, Zhang Y, et al. Plasma D-dimer as a useful marker predicts severity of atherosclerotic lesion and short-term outcome in patients with coronary artery disease. Clin Appl Thromb Hemost. 2016; 22:633–40.

16. Hansen CH, Ritschel V, Andersen GO, Halvorsen S, Eritsland J, Arnesen H, et al. Markers of thrombin generation are associated with long-term clinical outcome in patients with ST-segment elevation myocardial infarction. Clin Appl Thromb Hemost. 2018; 24:1088–94.

17. Reihani H, Sepehri Shamloo A, Keshmiri A. Diagnostic value of D-dimer in acute myocardial infarction among patients with suspected acute coronary syndrome. Cardiol Res. 2018; 9:17–21.

18. Sedaghat-Hamedani F, Kayvanpour E, Frankenstein L, Mereles D, Amr A, Buss S, et al. Biomarker changes after strenuous exercise can mimic pulmonary embolism and cardiac injury: a metaanalysis of 45 studies. Clin Chem. 2015; 61:1246–55.

19. Yang J, Li CS. The predictive values of D-dimer for the early prognosis of the acute myocardial infarction (AMI): a review of 3134 AMI patients. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. 2012; 24:725–9.

20. Kim JY, Kim KH, Cho JY, Sim DS, Yoon HJ, Yoon NS, et al. D-dimer/troponin ratio in the differential diagnosis of acute pulmonary embolism from non-ST elevation myocardial infarction. Korean J Intern Med. 2019; 34:1263–71.

21. Meignan M, Rosso J, Gauthier H, Brunengo F, Claudel S, Sagnard L, et al. Systematic lung scans reveal a high frequency of silent pulmonary embolism in patients with proximal deep venous thrombosis. Arch Intern Med. 2000; 160:159–64.