Who to Cath? Troponemia in Seizure Presentations

Background
Patients admitted for neurological evaluation after experiencing a seizure are often found to have elevated troponin levels. Limited studies are available where patients had undergone diagnostic coronary angiography for further cardiac evaluation. The aim of this study is to determine which patient attributes confer higher risk of obstructive coronary disease in patients presenting with seizures as the initial trigger for myocardial infarction.

Methods
This retrospective single-center study analyzed a prospectively collected database of adult patients presenting with a seizure and elevated troponin levels on admission from 1/1/16-12/31/17. Analysis was conducted using a machine learning (neural network) guided forward and backward stepwise regression-augmented multivariable linear regression.

Results
Of the 52 subjects meeting study criteria, 17 (32.7%) underwent left heart catheterization (LHC), who compared to non-LHC patients were more likely to have increased cardiac risk factors (median 3.4 versus 2.3, p=0.023) and mean troponin I (11.4 versus 4.1, p=0.043) with no other significantly demographic, comorbidity, or laboratory differences. Of the LHC patients, 10 (58.8%) had >=70% stenosis and 5 (29.4%) had significant left main equivalent disease requiring CABG. In a multivariable regression adjusting for age, smoking and diabetes together were the only significant and independent predictors of troponemia among seizure patients (beta 12.04, 95%CI 1.98-22.11, p=0.020) but not smoking or diabetes separately.

Conclusions
Our analysis suggests there is wide variance as to which seizure patients with incidentally found troponemia undergo LHC. The high prevalence of significant occlusive stenosis and left main equivalent coronary artery disease in our cohort supports risk stratifying these patients for invasive assessment particularly if they smoke, have diabetes, and a troponin I elevation greater than 4.