From the Guidelines
Elevated troponin levels without chest pain can be caused by various conditions, including heart failure, pulmonary embolism, kidney disease, myocarditis, sepsis, and tachyarrhythmias, as highlighted in the 2011 European Society of Cardiology guidelines 1. These conditions can lead to myocardial injury, resulting in troponin elevation. Other potential causes include cardiac contusion, cardiac procedures, strenuous exercise, stroke, and certain medications like chemotherapy agents. Systemic conditions such as severe anemia, hypotension, respiratory failure, and critical illness can also lead to troponin elevation through demand ischemia. According to the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1, troponin elevations can be due to various non-coronary-related myocardial injuries, and solitary elevations of troponin cannot be assumed to be due to MI. Some key points to consider when evaluating elevated troponin levels without chest pain include:
- Serial troponin measurements to distinguish acute from chronic elevations
- Considering the patient's complete clinical picture, including vital signs, ECG findings, and other symptoms
- Identifying and treating the underlying cause rather than assuming acute coronary syndrome
- Cardiac evaluation may still be warranted to rule out silent myocardial ischemia, especially in patients with diabetes or other risk factors. It is essential to note that troponin elevation is frequently found when the serum creatinine level is >2.5 mg/dL (221 mmol/L) in the absence of proven ACS, and is also associated with an adverse prognosis, as mentioned in the 2011 European Society of Cardiology guidelines 1. Therefore, a thorough evaluation and management plan should be based on the most recent and highest-quality evidence, prioritizing the patient's morbidity, mortality, and quality of life.
From the Research
Causes of Elevated Troponin Without Chest Pains
Elevated troponin levels without chest pain can be caused by various factors, including:
- Non-cardiac conditions such as renal failure, pulmonary embolism, or sepsis 2, 3
- Cardiac conditions such as heart failure, cardiomyopathy, or myocarditis 4, 5
- Chronic conditions such as hypertension, diabetes, or chronic kidney disease 3, 6
- Alternative diagnoses such as acute coronary syndrome, unstable angina, or coronary revascularization 2, 4
Clinical Utility and Downstream Testing
The clinical utility of elevated troponin levels without chest pain is unclear, and downstream testing is often unnecessary 2. However, some studies suggest that elevated troponin levels can predict major adverse events, including mortality, myocardial infarction, and heart failure 3, 6.
Prognostic Significance
Elevated troponin levels without chest pain are associated with a higher mortality rate and worse prognosis compared to patients with chest pain and elevated troponin levels 4, 3. The absence of chest pain accompanying troponin elevation is an independent predictor of mortality 3.
Investigations and Findings
Patients with elevated troponin levels without chest pain are rarely investigated for detection of cardiac disease or followed up, and are less likely to receive cardiovascular medication compared to patients with myocardial infarction 5. However, some studies suggest that careful work-up is required in these patients to establish a definite diagnosis and predict major adverse events 6.