Serum cardiac troponins as prognostic markers in patients with traumatic and non-traumatic brain injuries: A meta-analysis

Published:October 03, 2018DOI:



      The association between brain injury and elevated serum cardiac troponin (cTn) remains poorly understood. We conducted a systematic review and meta-analysis to evaluate whether elevated cTn increases the risk of mortality in patients with traumatic (TBI) or non-traumatic brain injury (NT-BI).


      Cochrane Library, MEDLINE, PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, and Google scholar databases, and were searched for a retrospective, prospective and randomized clinical trials (RCT) or quasi-RCT studies that assessed the effect of elevated cTn (conventional or high sensitive assay) on the outcomes of brain injury patients. The main outcome of interest was mortality. Two authors independently abstracted the data using a data collection form. Results from different studies were pooled for analysis, whenever appropriate. The total number of patients pooled was 2435, of which 916 had elevated cTn and 1519 were in control group.


      Out of 691 references identified through the search, 8 analytical studies met inclusion criteria. Among both types of brain injuries, an elevated cTn was associated with a higher mortality with an overall pooled odd ratio (OR) of 3.37 (95% CI 2.13–5.36). The pooled OR for mortality was 3.31 (95% CI 1.99–5.53) among patients with TBI and 3.36 (95% CI 1.32–8.6) among patients with NT-BI.


      Pooled analysis indicates that elevated cTn is significantly associated with a high mortality in patients with TBI and NT-BI. Prospective clinical trials are needed to support these findings and to inform a biomarker risk stratification regardless of the mechanism of injury.


      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Taylor C.A.
        • Bell J.M.
        • Breiding M.J.
        • Xu L.
        Traumatic brain injury–related emergency department visits, hospitalizations, and deaths — United States, 2007 and 2013.
        MMWR Surveill Summ. 2017; 66: 1-16
        • Ma V.Y.
        • Chan L.
        • Carruthers K.J.
        Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain.
        Arch Phys Med Rehabil. 2014; 95: 986-995.e1
        • Mock C.
        • Lormand J.D.
        • Goosen J.
        • Joshipura M.
        • Peden M.
        Guidelines for essential trauma care.
        World Health Organization, Geneva2004 (Available from:)
        • Al-Otaiby M.A.
        • Al-Amri H.S.
        • Al-Moghairi A.M.
        The clinical significance of cardiac troponins in medical practice.
        J Saudi Heart Assoc. 2011; 23: 3-11
        • Mahmood I.
        • El-Menyar A.
        • Dabdoob W.
        • Abdulrahman Y.
        • Siddiqui T.
        • Atique S.
        • et al.
        Troponin T in patients with traumatic chest injuries with and without cardiac involvement: insights from an observational study.
        N Am J Med Sci. 2016; 8: 17-24
        • Edouard A.R.
        • Felten M.L.
        • Hebert J.L.
        • Cosson C.
        • Martin L.
        • Benhamou D.
        Incidence and significance of cardiac troponin I release in severe trauma patients.
        Anesthesiology. 2004; 101: 1262-1268
        • Hasanin A.
        • Kamal A.
        • Amin S.
        • Zakaria D.
        • El Sayed R.
        • Mahmoud K.
        • et al.
        Incidence and outcome of cardiac injury in patients with severe head trauma.
        Scand J Trauma Resusc Emerg Med. Apr 27 2016; 24: 58
        • Herrmann M.
        • Curio N.
        • Jost S.
        • Grubich C.
        • Ebert A.D.
        • Fork M.L.
        • et al.
        Release of biochemical markers of damage to neuronal and glial brain tissue is associated with short and long term neuropsychological outcome after traumatic brain injury.
        J Neurol Neurosurg Psychiatry. 2001; 70: 95-100
        • Smith A.
        • John M.
        • Trout R.
        • Davis E.
        • Moningi S.
        Elevated cardiac troponins in sepsis: what do they signify?.
        W V Med J. 2009; 105: 29-32
        • Lim W.
        • Cook D.J.
        • Griffith L.E.
        • Crowther M.A.
        • Devereaux P.J.
        Elevated cardiac troponin levels in critically ill patients: prevalence, incidence, and outcome.
        Am J Crit Care. 2006; 15: 280-288
        • Poe S.
        • Vandivier-Pletsch R.H.
        • Clay M.
        • Wong H.R.
        • Haynes E.
        • Rothenberg F.G.
        Cardiac troponin measurement in the critically ill: potential for guiding clinical management.
        J Invest Med. Dec 2015; 63: 905-915
        • Salim A.
        • Hadjizacharia P.
        • Brown C.
        • Inaba K.
        • Teixeira P.G.R.
        • Chan L.
        • et al.
        Significance of troponin elevation after severe traumatic brain injury.
        J Trauma. 2008; 64: 46-52
        • Bukur M.
        • Mohseni S.
        • Ley E.
        • Salim A.
        • Margulies D.
        • Talving P.
        • et al.
        Efficacy of beta-blockade after isolated blunt head injury: does race matter?.
        J Trauma Acute Care Surg. 2012; 72: 1013-1018
        • Hays A.
        • Diringer M.N.
        Elevated troponin levels are associated with higher mortality following intracerebral hemorrhage.
        Neurology. May 9 2006; 66: 1330-1334
        • Ramappa P.
        • Thatai D.
        • Coplin W.
        • Gellman S.
        • Carhuapoma J.R.
        • Quah R.
        • et al.
        Cardiac troponin-I: a predictor of prognosis in subarachnoid hemorrhage.
        Neurocrit Care. 2008; 8: 398-403
        • Sandhu R.
        • Aronow W.S.
        • Rajdev A.
        • Sukhija R.
        • Amin H.
        • D'Aquila K.
        • et al.
        Relation of cardiac troponin I levels with in-hospital mortality in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage.
        Am J Cardiol. Sep 1 2008; 102: 632-634
        • Gupte M.
        • John S.
        • Prabhakaran S.
        • Lee V.H.
        Troponin elevation in subarachnoid hemorrhage does not impact in-hospital mortality.
        Neurocrit Care. Jun 2013; 18: 368-373
        • Cai S.S.
        • Bonds B.W.
        • Hu P.F.
        • Stein D.M.
        The role of cardiac troponin I in prognostication of patients with isolated severe traumatic brain injury.
        J Trauma Acute Care Surg. Mar 2016; 80: 477-483
        • El-Menyar A.
        • Asim M.
        • Latifi R.
        • Bangdiwala S.I.
        • Al-Thani H.
        Predictive value of positive high-sensitivity troponin T in intubated traumatic brain injury patients.
        J Neurosurg. Jan 5 2018; : 1-9
        • Lippi G.
        • Dipalo M.
        • Carbucicchio A.
        • Aloe R.
        • Benatti M.
        • Cervellin G.
        The concentration of highly-sensitive troponin I is increased in patients with brain injury after mild head trauma.
        Int J Cardiol. Sep 30 2013; 168: 1617-1618
        • Ahmed A.N.
        • Blonde K.
        • Hackam D.
        • Iansavichene A.
        • Mrkobrada M.
        Prognostic significance of elevated troponin in non-cardiac hospitalized patients: a systematic review and meta-analysis.
        Ann Med. Dec 2014; 46: 653-663
        • El-Menyar A.
        • Goyal A.
        • Latifi R.
        • Al-Thani H.
        • Frishman W.
        Brain-heart interactions in traumatic brain injury.
        Cardiol Rev. 2017; 25: 279-288
        • El-Menyar A.
        Beta blockers therapy in traumatic brain injury: is it the time to disclose the brain-cardiac interactions?.
        J Trauma Acute Care Surg. Feb 23 2018;
        • Naidech A.M.
        • Kreiter K.T.
        • Janjua N.
        • et al.
        Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage.
        Circulation. 2005; 112: 2851-2856
        • Naredi S.
        • Lambert G.
        • Edén E.
        • et al.
        Increased sympathetic nervous activity in patients with nontraumatic subarachnoid hemorrhage.
        Stroke. 2000; 31: 901-906
        • Alali A.S.
        • Mukherjee K.
        • McCredie V.A.
        • Golan E.
        • Shah P.S.
        • Bardes J.M.
        • et al.
        Beta-blockers and traumatic brain injury: a systematic review, meta-analysis, and Eastern Association for the Surgery of Trauma guideline.
        Ann Surg. Dec 2017; 266: 952-961