From protocol angiography to selective coronary evaluation in sepsis-associated myocardial injury

To the Editor,

Lörstad and colleagues [1] provide important invasive coronary physiology data in patients with sepsis-associated myocardial injury. High-sensitivity cardiac troponin T (hs-cTnT) was unrelated to microvascular resistance, limiting its use as a marker of a coronary microvascular mechanism. Obstructive coronary artery disease (CAD) was found in 12 of 55 patients; six underwent percutaneous coronary intervention (PCI) during the index hospitalisation. The authors appropriately reject routine angiography but suggest that selective evaluation may identify previously unrecognised and potentially treatable CAD. This is the statement most likely to influence practice.

The study appropriately used protocol angiography to address its mechanistic objectives; however, that design did not operationalise selective evaluation. Patients were screened by sepsis plus hs-cTnT ≥ 15 ng/L, irrespective of symptoms suggesting acute coronary syndrome or prior suspicion of CAD. Of 62 enrolled patients, 55 underwent angiography after clinical stabilisation. Eligibility, safety, feasibility, and capacity to receive downstream treatment determined who could enter this invasive pathway. Those conditions establish who could undergo research angiography; they do not establish whom an intensive care clinician should select for coronary investigation. The 12/55 yield is therefore conditional on a selected group of stabilised angiography recipients and, by itself, does not identify bedside features for selection.

The study offers candidate clinical signals: patients with CAD had a more conventional cardiovascular risk profile, but no pre-angiography rule was prespecified or evaluated, and no patient had suspected type 1 myocardial infarction. Nor did every obstructive finding lead to the same treatment. Six patients underwent index PCI, whereas six were managed conservatively because of chronic total occlusion, small-vessel disease, lesion complexity, or patient preference. One patient without obstructive CAD at the index procedure underwent repeat angiography and PCI two months later. Finding CAD, deciding whom to investigate, and finding a lesion that changes treatment are distinct steps.

Could the authors provide a compact descriptive comparison of patients who underwent index PCI (n = 6), those with obstructive CAD managed without index PCI (n = 6), and those without index obstructive CAD (n = 43)? Information available before angiography could include the conventional CAD risk profile, admission electrocardiography, regional wall-motion abnormality, and hs-cTnT. Documenting medical or interventional management changes explicitly linked in the records to angiographic findings would connect selection to treatment consequence. Given the small groups, this comparison should remain hypothesis-generating; no prediction model or formal inference is needed.

Such a comparison would show whether a recognisable bedside phenotype links selective coronary evaluation to actionable disease. Until that link is shown, the data support considering occult CAD in stabilised patients eligible for downstream treatment, but do not yet indicate which bedside features should guide selective evaluation. Defining that link would preserve the study’s principal findings while clarifying how the yield of protocol angiography should inform bedside evaluation.

Abbreviations

CAD

Coronary artery disease

hs-cTnT

High-sensitivity cardiac troponin T

PCI

Percutaneous coronary intervention

Author contributions

X.Z. conceived the letter, reviewed the target article and supplementary material, and drafted the manuscript. Z.H. supervised the work, revised the manuscript for important intellectual content, and approved the final version. Both authors read and approved the final manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Use of generative artificial intelligence

Generative artificial intelligence tools were used to assist source organisation, language editing, manuscript structuring, and drafting under full author oversight. Both authors reviewed the original article and Supplementary Material, verified all factual and scientific content, revised and approved the final argument, and take full responsibility for the submitted work.

Competing interests

The authors declare no competing interests.