Effects of implantable cardioverter defibrillator implantation and shock application on biochemical markers of myocardial damage.The Implantation of an implantable cardioverter defibrillator defibrillator, device that delivers an electrical shock to the heart in order to stop certain forms of rapid heart rhythm disturbances (arrhythmias). The shock changes a fibrillation to an organized rhythm or changes a very rapid and ineffective cardiac rhythm to a (ICD ICD International Classification of Diseases (of the World Health Organization); intrauterine contraceptive device.
abbr. ) is a common approach in patients with ventricular tachycardia or who have survived cryptogenic cryptogenic /cryp·to·gen·ic/ (krip?to-jen´ik) of obscure or doubtful origin.
Of obscure or unknown origin. Used of diseases. sudden cardiac death Sudden Cardiac Death Definition
Sudden cardiac death (SCD) is an unexpected death due to heart problems, which occurs within one hour from the start of any cardiac-related symptoms. SCD is sometimes called cardiac arrest. (1). To check for normal ICD function, it is necessary to test the system and to determine the defibrillation Defibrillation Definition
Defibrillation is a process in which an electronic device sends an electric shock to the heart to stop an extremely rapid, irregular heartbeat, and restore the normal heart rhythm. threshold. The defibrillation threshold is defined as the lowest energy, in joules (J), for defibrillation of induced ventricular fibrillation (VF). However, repeated episodes of electrical therapy can have disadvantageous dis·ad·van·ta·geous
dis·advan·ta effects on myocardial myocardial /myo·car·di·al/ (-kahr´de-al) pertaining to the muscular tissue of the heart.
pertaining to the muscular tissue of the heart (the myocardium). performance (2, 3).
The cardiac isoforms of troponin T (cTnT) and troponin I (cTnI) are highly specific markers for the detection of myocardial damage. After myocardial ischemia but also as a result of other myocardial stress, such as myocarditis Myocarditis Definition
Myocarditis is an inflammatory disease of the heart muscle (myocardium) that can result from a variety of causes. While most cases are produced by a viral infection, an inflammation of the heart muscle may also be instigated by , cTnI and cTnT are released into the circulation (4, 5) where they can be detected with sensitive immunoassays (6, 7).
This study assesses the extent of myocardial injury after ICD implantation and testing by the release of the cardiospecific markers cTnT and cTnI in relation to other, not fully cardiospecific, markers of cardiac ischemia: creatine kinase (CK), CK-MB mass concentration, and myoglobin myoglobin (mī'əglō`bĭn), protein molecule isolated from the cells of vertebrate skeletal muscle that is both a structural and functional relative of hemoglobin, the oxygen-transport protein of the blood of higher animals. .
Materials and Methods
PATIENTS AND SAMPLES
Between February and November 1998, 14 patients (12 men, 2 women; median age, 63.5 years; range, 44-78 years) with high risk of ventricular tachyarrhythmia tachyarrhythmia /tachy·ar·rhyth·mia/ (tak?e-ah-rith´me-ah) any disturbance of the heart rhythm in which the heart rate is abnormally increased.
n. and scheduled for implantation of an ICD were included in this study (Table 1). Revascularization steps (angioplasty and stenting, or bypass grafting) had been completed in all patients suffering from coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. (CAD) before starting the implantation procedure. One patient was rejected because of signs of myocardial ischemia. None of the other 13 patients had stable or unstable angina. Eight patients suffered from CAD, two from cardiomyopathy Cardiomyopathy Definition
Cardiomyopathy is a chronic disease of the heart muscle (myocardium), in which the muscle is abnormally enlarged, thickened, and/or stiffened. (CMP CMP (cytidine monophosphate): see cytosine.
(1) (CMP Media LLC, Manhasset, NY, www.cmp.com) Part of United Business Media, CMP is a leading integrated media company that offers a wide variety of publications and services in the information ), and two from valvular heart disease Valvular Heart Disease Definition
Valvular heart disease refers to several disorders and diseases of the heart valves, which are the tissue flaps that regulate the flow of blood through the chambers of the heart. (VHD (Very High Density) A term applied to storage devices from time to time to indicate a higher capacity. ). One patient had both CAD and CMP, and another had CMP and VHD. All patients gave their informed consent to participate in this study. Blood samples were collected at four time points: before and 1, 4, and 24 h after intraoperative shock application. The samples before and 1 h after testing were drawn from a radialis catheter (for invasive blood pressure Invasive blood pressure is a method of measuring blood pressure internally by using a sensitive IV catheter inserted into an artery. This provides a more accurate reading of the patent's current blood pressure. This is usually used where rapid variations of blood pressure are anticipated. measurements); the samples 4 and 24 h after testing were drawn from peripheral veins.
After clotting and centrifugation Centrifugation
A mechanical method of separating immiscible liquids or solids from liquids by the application of centrifugal force. This force can be very great, and separations which proceed slowly by gravity can be speeded up enormously in centrifugal , the serum samples were stored at ~70[degrees]C until analysis
Implantation and ICD used. ICD systems from Guidant Corporation, Cardiac Pacemakers (Models 1749, 1782, 1783, and 1849) and from Medtronic, Inc. (Models 7250 and 7227) were used. Tined, steroid-eluting electrodes were used in 10 patients (Medtronic "Sprint" 6942/6932 and Cardiac Pacemakers Endotak Endurance: 145), and tined, non-steroid-eluting electrodes were used in 4 patients (Cardiac Pacemakers Endotak Endurance: 135). In five patients, additional steroid-eluting "screw-in" leads (Medtronic 6940) for atrial sensing were implanted.
Each patient received a 1-J test shock before every testing episode. VF was induced with a shock-on-T induction with 1.2 J. For determining the defibrillation threshold, the verification technique was used. Intermediate energies that successfully defibrillate de·fib·ril·late
tr.v. de·fib·ril·lat·ed, de·fib·ril·lat·ing, de·fib·ril·lates
To stop the fibrillation of (a heart) and restore normal contractions through the use of drugs or an electric shock. the patient and provide an adequate energy margin are determined in the verification procedure. This technique is widely accepted because it does not require the subject to be tested with energies that do not defibrillate as the threshold method does (8). If the first shock was effective, the physician could repeat the testing with the same energy or stop further testing. In case of failure, the system automatically applied a second shock with maximum energy. Implantation criteria were met if induced VF could be terminated one time with a shock of ~10-15 J to maximum output or if two subsequently induced VF episodes could be defibrillated successfully with 10-15 J to maximum output.
In case of missing implantation criteria, repositioning of the ventricular lead was performed before retesting. In one patient (patient 5), the physician decided not to reposition the electrode although the second shock after the first repositioning (shock 4) was ineffective and VF had to be terminated with an effective 31-J shock. Instead of repositioning, the physician tested again and defibrillated successfully with 23 J. In another patient (patient 18), the electrode had to be repositioned twice, and the patient received two external 360-J shocks. Three patients received atrial shocks through a additional lead for terminating atrial fibrillation.
To guarantee myocardium myocardium /myo·car·di·um/ (-kahr´de-um) the middle and thickest layer of the heart wall, composed of cardiac muscle.
hibernating myocardium see myocardial hibernation, under recovery between the ischemic Ischemic
An inadequate supply of blood to a part of the body, caused by partial or total blockage of an artery.
Mentioned in: Antiangiogenic Therapy, Subarachnoid Hemorrhage, Ventricular Fibrillation
ischemic episodes produced by VF, care was taken not to induce VF within 5 min after the previous testing episode.
Analytical procedures. cTnT and CK-MB were measured with an electrochemiluminescence immunoassay on an Elecsys[R] 2010 analyzer (Roche Diagnostics). The cTnT assay uses two monoclonal antibodies specific for the cardiac isoform of TnT and has <0.01% cross-reactivity with skeletal muscle troponin T. The CV is 5.1% at the cutoff of 0.1 [micro]g/L for cTnT, and for CK-MB, the CV is 3.9% at 5.98 [micro]g/L; the cutoff is 5 [micro]g/L (9). cTnI was measured on a Dimension[R] [micro]L analyzer (Dade Behring) using the TROP TROP Tropical
TROP Tax Refund Offset Program (IRS)
TROP Transmit Operate Flex[TM] reagent cassette. This assay uses two monoclonal antibodies specific for two different epitopes on the cTnI molecule. The cross-reactivity with skeletal troponin I is <0.1%. The CV is 9.4% at 0.5 [micro]g/L, and the cutoff is 0.4 [micro]g/L. Myoglobin was measured on a BN 2 analyzer (Dade Behring) using a immunonephelometric assay (N-Latex Myoglobin). The CV is 4.8% at 85 [micro]g/L, and the cutoff is 70 [micro]g/L. Total CK activity was measured on a Vitros[R] 950 IRC (Internet Relay Chat) Computer conferencing on the Internet. There are hundreds of IRC channels on numerous subjects that are hosted on IRC servers around the world. After joining a channel, your messages are broadcast to everyone listening to that channel. (Ortho Clinical Diagnostics) at 25[degrees]C. The CV is 3% at 70 U/L, and the cutoff is 80 U/L for men and 70 U/L for women. All assays were performed according the recommendations of the manufacturers.
Statistics. Analyses were performed using a commercially distributed software package (Astute, Statistics Add-in for Microsoft Excel; DDU See Delivered Duty Unpaid. Software). To test for the differences in serum markers at baseline and after ICD implantation, the Wilcoxon matched-pairs signed-ranks test was used. Significance was estimated as P <0.05.
The P values for all markers and all patients are shown in Table 2, which compares the serum samples drawn at 1, 4, and 24 h with the serum samples drawn before implantation and testing. Four hours after ICD implantation and testing, all markers showed significant increases compared with the baseline values before testing. In contrast, for cTnT and myoglobin, this was at all three time points after ICD testing.
The individual markers and the biochemical findings of all patients are shown in Table 3. In nine patients, cTnT was detectable. cTnI was detectable in eight patients, all of whom also had detectable cTnT values. cTnI peak concentrations above the cutoff were seen in three patients, two of whom also exceeded the cTnT cutoff. In both patients, we also found CK-MB mass increases over the cutoff. All of the patients with cTnT/cTnI peak concentration above the cutoff received two ventricular shocks; two patients had additional atrial screw-in electrodes, and one of them received three additional atrial shocks with lower energy. No repositioning had to be performed in all of these patients. There was a weak correlation between troponin troponin /tro·po·nin/ (tro´po-nin) a complex of muscle proteins which, when combined with Ca2+, influence tropomyosin to initiate contraction.
n. increase and cumulative energy in all of the patients who received two effective ventricular shocks (r = 0.647 for cTnI and r = 0.636 for cTnT).
CK-MB mass concentrations above the cutoff were seen in four patients. One of these patients received three atrial and seven ventricular shocks (cumulative energy, 194 J). Additionally, the physician applied two external 360-J shocks, and the electrode had to be repositioned twice.
The CK activity increased to >80 U/L in five patients. Patient 18 showed the largest increase (164 U/L); this patient received the largest cumulative energy (194 J) and two external 360-J shocks. In two of the five patients showing CK activity >80 U/L, additional atrial leads were implanted (patients 7 and 18). In all of these five patients, CK showed no peak within 24 h.
Myoglobin concentrations peaked at >70 [micro]g/L in nine patients. In three patients, additional atrial leads were implanted. The very high myoglobin peak concentration for patient 18 (291 [micro]g/L) correlated with the high CK in this patient.
No patient who received only one shock showed detectable cTnT or cTnI values. When we compared the number of shocks and the increases in cTnT and cTnI, only patients receiving two effective shocks showed concentrations above the cutoff. Median peak values postoperatively were 0.08 [micro]g/L (range, 0-2.16 [micro]g/L) for cTnI, 0.023 [micro]g/L (range, 0-0.26 [micro]g/L) for cTnT, and 2.5 [micro]g/L (range, 0-14.93 [micro]g/L) for CK-MB.
Animal experiments have suggested that repeated high-energy direct current shocks produce myocardial damage (3, 4). The way the energy is delivered to the heart is an important factor that influences the release of cardiac markers into circulation. Intracardial applied shocks with rather low energy are probably more damaging than transthoracic transthoracic /trans·tho·rac·ic/ (-thah-ras´ik) through the thoracic cavity or across the chest wall.
Across or through the thoracic cavity or chest wall. shocks with high energy (10). Increasing CK and CK-MB concentrations after transthoracic shocks have been described (11), but it has been found that most of the CK released after transthoracic cardioversion Cardioversion Definition
Cardioversion refers to the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. derives from chest wall skeletal muscles, because cardiospecific markers such as cTnT and cTnI show no or minimal increases after transthoracic shock (12-14).
We found increased serum concentrations of all markers, cTnT, cTnI, CK-MB, CK, and myoglobin, after ICD implantation. Patients who received only one shock showed no increases in cTnT, cTnI, and CK-MB mass above the cutoff values. All patients with cTnT and cTnI peak concentrations above the cutoff had received two ventricular shocks.
It is remarkable that patients who received more than two shocks, very high cumulative energy, and repositioning of the electrode (patients 5 and 18) had no (patient 5) or only marginal (patient 18) increases in cTnT and cTnI. Wrong positioning of the electrode leads to a higher number of ineffective shocks; these ineffective shocks therefore do not lead to a release of cTnT and cTnI from the myocardium. One patient received two additional external 360-J shocks. This patient showed only marginal increases in the specific markers cTnT, cTnI, and CK-MB mass, and large increases in the nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.
2. not directed against a particular agent, but rather having a general effect.
1. markers CK and myoglobin. External shocks may lead only to a release from the thoracic skeletal muscles (11-14), which explains the large increases in CK activity and myoglobin in this patient.
Our results correlate well with those of Hurst et al. (15) and Runsio (10), who also found increased serum concentrations of cTnT and cTnI or cTnT and CK-MB after ICD implantation (Table 4). In contrast to these studies, we found a clearly visible lower postoperative peak value for cTnT, but also lower peak values for cTnI and CK-MB. This discrepancies are attributable to the lower cumulative energy used in our patients, but the assays used for determining the cardiac-specific markers, especially for cTnT, are also important influencing factors. For measuring cTnT, we used a highly specific second-generation assay (9) with negligible cross-reactivity with skeletal muscle troponin T (6). The cTnT assay used by Hurst et al. (15) and Runsio et al. (10) shows 2% cross-reactivity with skeletal muscle troponin T (16), leading to possible false-positive results.
Troponins T and I are structurally bound regulator proteins of the contractile contractile /con·trac·tile/ (kon-trak´til) able to contract in response to a suitable stimulus.
Capable of contracting or causing contraction, as a tissue. apparatus of the skeletal muscle and myocardium. Only a small portion of both can be found as a soluble portion in the cytoplasm. For cTnT, this is ~6-8%; for cTnI, it is 2.5% (17). The release into the circulation is therefore characterized by two steps. In the first step, the cytoplasmic pool is released simultaneously with other cytoplasmic proteins, such as CK, CK-MB, and myoglobin. After loss of integrity of the contractile apparatus, cTnT and cTnI are released continuously until the infarcted area is healed. The first release can be measured in the blood -4 h after damage, whereas the second release will occur into the serum after 24 h (18). Additionally, the half-time of both cTnT and cTnI is ~2 h (10). As shown in the Results, cTnT, cTnI, and CK-MB show a peak value after 4 h. Therefore, we suggest that the release of cTnT and cTnI is only from the small amount located in the cytoplasm. Cell necrosis would cause a second, additional release of disintegrated structurally bound proteins into circulation, which did not occur in our patients. CK showed additional increases even after 24 h. Each testing episode caused a short skeletal muscle spasm that could explain the further increase of CK after 24 h.
In conclusion, ICD implantation and testing often leads to a short release of cardiac markers into the circulation. The effectiveness of the individual shock, depending on the positioning of the electrode and the position of the heart in the electrical field, seems to influence the release of the cardiac-specific markers. Because the cardiac-specific markers cTnT and cTnI peak after 4 h, theoretically no cell necrosis can occur. It seems to be rather from cytoplasmic origin as a result of a reversible change of permeability of the cellular membrane.
Received September 27, 2000; accepted January 4, 2001.
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Used to express disdain for something deemed stupid or obvious, especially a self-evident remark.
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 Nonstandard non·stan·dard
1. Varying from or not adhering to the standard: nonstandard lengths of board.
2. abbreviations: ICD, implantable cardioverter defibrillator; VF, ventricular fibrillation; cTnT and cTnI, cardiac troponin T and 1; CK-MB, creatine kinase MB; CAD, coronary artery disease; CMP, cardiomyopathy; and VHD, valvular heart disease.
THOMAS SCHLUTER,  HANNSJORG BAUM,  * ANDREAS PLEWAN  and DIETER NEUMEIER 
 Institut fur Klinische Chemie and Pathobiochemie, and
 I. Medizinische Klinik, Klinikum rechts der Isar, Technische Universitat Munchen, D-81675 Munich, Germany.
* Address correspondence to this author at: Institut fur Klinische Chemie and Pathobiochemie, Klinikum rechts der Isar, Ismaningerstrasse 22, D-81675 Munchen, Germany. Fax 49-89-4140-4875; e-mail firstname.lastname@example.org.
Table 1. Patient characteristics. All patients (a) (n = 14) Age, years 63.5 (44-78) Sex, M/F 12/2 LV-EF, (b) % 45(18-70) Cardiovascular disease CAD 9 Dilated CMP 4 VHD 3 Cumulative energy, J 38(17-194) Number of shocks 2(1-10) Additional leads 5 (a) Data are presented as median and range. (b) LV-EF, left ventricular ejection fraction. Table 2. Comparison of significance of deviations. After 1 h vs After 4 h vs After 24 h vs before before before cTnT 0.0093 0.0077 0.0094 cTnl NS (a) 0.0186 NS CK-MB 0.006 0.0043 NS Myoglobin 0.0029 0.001 0.0012 CK NS 0.02 0.0076 (a) NS, not significant. Table 3. ICD shocks and resulting biochemical changes. Patient Atrial Total Atrial Ventr. (a) shocks, J electrode energy, J shocks, J 1 Yes 44 4/4 18/18 2 No 23 23 3 Yes 44 2/2/4 18/18 5 No 143 17/31/21/20/31/23 6 No 23 23 7 Yes 36 18/18 8 No 50 25/25 9 No 42 21/21 10 Yes 36 18/18 11 No 40 25/15 16 No 21 21 17 No 17 17 18 Yes 194 2/3/4 21/31/21/31/31/21/29 Patient No. of No. of Peak Time, Peak shocks repositionings cTnl, h cTnT, [micro]g/L [micro]g/L 1 4 0 0.22 1 0.04 2 1 0 0 0.023 3 5 0 0.53 4 0.076 5 6 1 0 0 6 1 0 0.14 4 0.019 7 2 0 0.27 4 0.034 8 2 0 2.16 4 0.26 9 2 0 0.08 4 0.014 10 2 0 1.11 4 0.131 11 2 0 0 0 16 1 0 0 0 17 1 0 0 0 18 10 2 0.07 4 0.026 Patient Time, Peak CK-MB Time, Peak h mass, h myoglobin, [micro]g/L [micro]g/L 1 24 2.02 4 40.8 2 1 1.63 1 71.7 3 4 6.3 4 43.3 5 1.9 24 56.8 6 4 2.06 4 209 7 4 2.5 4 315 8 4 14.93 4 144 9 1 4.76 1 171 10 4 9.14 4 104 11 0.73 4 44.5 16 2.79 0 102 17 1.89 4 211 18 4 5.25 4 291 Patient Time, Peak Time, Cardiac h CK, U/L h disease 1 4 39 0 CAD 2 24 20 0 CMP 3 4 38 24 VHD 5 4 22 1 CMP 6 4 79 24 CAD 7 4 100 24 CAD 8 4 132 24 CAD 9 1 112 24 VHD 10 4 64 24 VHD/CMP 11 24 39 24 CAD 16 24 56 0 CAD 17 4 92 24 CAD 18 24 164 24 CAD/CMP (a) Ventr., ventricular. Table 4. Comparison of our results (a) with the studies of Hurst et al. (15) and Runsio et al. (10). This study Hurst et al. Peak cTnT, [micro]g/L 0.023 (0-0.26) 0.26 (b) (0.02-6.46) Peak cTnl, [micro]g/L 0.08 (0-2.16) 0.8 (b) (0.3-5.5) Peak CK-MB, [micro]g/L 2.5 (0.73-14.93) Not done Number of shocks 2(1-10) 7.0 [+ or -] 2.5 (d) Mean cumulative energy, J 38(17-194) 111.2 [+ or -] 62.7 (d) Runsio et al. Peak cTnT, [micro]g/L 0.16 (0.008-0.350) (c) Peak cTnl, [micro]g/L Not done Peak CK-MB, [micro]g/L 5.8 (1.0-11.7) (c) Number of shocks 5(4-8) Mean cumulative energy, J 114(94-174) (a) Data are presented as median and range except where otherwise indicated. (b) Mean. (c) 95% confidence interval. (d) Mean [+ or -] SD.