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CardioNerds\xa0(Amit Goyal\xa0&\xa0Daniel Ambinder) join University of Washington cardiology fellows (Shannon McConnaughey, Betty Ashinne and Andrew Perry - host of the AP Cardiology podcast) for some tacos and beer at the water and discuss a puzzling case of recurrent troponin elevation. Dr. Kelly Branch provides the E-CPR and program director, Dr. Rosario Freeman, provides a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Eunice Dugan with mentorship from University of Maryland cardiology fellow\xa0Karan Desai.\xa0\xa0\xa0\n\n\n\n\n\nJump to: Patient summary - Case media - Case teaching - References \n\n\n\nEpisode graphic by Dr. Carine Hamo\n\n\n\nCardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademySubscribe to our newsletter- The HeartbeatSupport our educational mission by becoming a Patron!Cardiology Programs Twitter Group created by Dr. Nosheen Reza\n\n\n\n\n\n\n\nPatient Summary\n\n\n\nA female is her late 50s with past medical history of alcohol use disorder and intravenous drug use\xa0complicated by hepatitis C\xa0presented with generalized weakness and was found to have lower extremity fractures. Cardiology was consulted for pre-operative management.\xa0When obtaining a cardiac history, she reported\xa0rare, intermittent, and non-anginal chest pain. She had no current chest pain or dyspnea. On chart review, she had multiple presentations over the past 3 years for various complaints - some were chest pain - during which she was found to have elevated troponin\xa0I\xa0values. Most of the elevations were in the 0.5 to 1\xa0ng/mL\xa0range, but one time, her peak troponin was 32\xa0ng/mL.\xa0At one of those presentations, she had a TTE that showed septal wall motion abnormalities.\xa0She underwent\xa0coronary angiography\xa0on two occasions, which both showed\xa0proximal and mid-LAD calcifications, but no\xa0significant\xa0stenosis and\xa0she was managed medically.\xa0\xa0\n\n\n\nAt the current presentation, her vitals were within normal limits and her exam did not show any cardiopulmonary abnormalities.\xa0Labs were notable for troponin\xa0I of 10 ng/mL\xa0but CK-MB was normal.\xa0Interestingly, alkaline\xa0phosphatase was 3 times the upper limit of normal, and rheumatoid factor was 1156\xa0IU/mL\xa0compared to 70 previously (normal range 0-20 IU/mL).\xa0EKG was without ischemic changes.\xa0TTE showed no wall motion abnormalities, normal LVEF,\xa0and no significant valvular disease.\xa0Cardiac catherization was deferred, and the patient was not interested in cardiac MRI. Due to an incongruent troponin elevation with the clinical presentation, there was concern for interference with the troponin assay due to the elevated\xa0rheumatoid factor and alkaline phosphatase levels.\xa0Upon further investigation,\xa0dilution of the troponin yielded results lower than factor of dilution or undetectable results. Mayo testing of the sample showed troponin-T of 0.024\xa0ng/mL (normal < 0.01 ng/mL), and troponin I of 0.02\xa0ng/mL\xa0(normal < 0.04 ng/mL).\xa0Although there were still some aspects of her previous presentations including rising\xa0troponin pattern and previous wall motion abnormalities that are unexplained at this time, her troponin elevation at this presentation was attributed to assay interference.\u202f\xa0\n\n\n\n\n\n\n\nCase Media\n\n\n\n\nABCClick to Enlarge\n\n\n\nA. ECG from MayB. Coronary angiography form MayC. ECG August (same year) \n\n\n\n\n\nTTE 1 (May)\n\n\n\n\n\n\n\n\n\nTTE 2 (May)\n\n\n\n\n\nTEE 3 (May)\n\n\n\n\n\n\n\nTTE 4 (May)\n\n\n\n\n\nTTE 1 (August)\n\n\n\n\n\n\n\n\n\nTTE 2 (August)\n\n\n\n\n\n\n\n\nTTE 3 (August)\n\n\n\n\n\nTTE 4 (August)\n\n\n\n\n\n\n\n\n\n\n\n\n\nEpisode Schematics & Teaching\n\n\n\nComing soon!\n\n\n\n\n\n\n\nThe CardioNerds 5! \u2013 5 major takeaways from the #CNCR case\n\n\n\nWhat is the universal definition of myocardial infarction?\xa0\xa0\n\n\n\n\xb7\xa0\xa0\xa0\xa0\xa0\xa0\xa0As per the current 4th\xa0universal\xa0definition, myocardial infarction is defined as an elevation in cardiac troponin (cTn) above the 99th\xa0percentile in high sensitivity assays in the setting of acute myocardial ischemia. It is considered acute if there is a characteristic rise/fall pattern in\xa0cTn.