What is the cause of chest pain and elevated troponin (cardiac biomarker) levels one week following percutaneous coronary intervention (PCI) with coronary angioplasty?

From the Guidelines

The patient with chest pain and elevated troponin 1 week after coronary angioplasty should be immediately evaluated for in-stent thrombosis or restenosis, which are potentially life-threatening complications. Urgent cardiac catheterization is recommended to assess stent patency, as suggested by the guidelines for management of acute coronary syndromes 1. While awaiting catheterization, the patient should receive dual antiplatelet therapy with aspirin 325 mg and either ticagrelor 180 mg loading dose followed by 90 mg twice daily or prasugrel 60 mg loading dose followed by 10 mg daily if not already on these medications, in line with the recommendations for percutaneous coronary intervention 1. Intravenous heparin or low molecular weight heparin should be initiated, along with high-dose statin therapy such as atorvastatin 80 mg daily. Other causes to consider include pericarditis, which may develop after angioplasty and present with positional chest pain and troponin elevation. Stent thrombosis typically occurs within the first 30 days after placement, with the highest risk in the first week, and is associated with premature discontinuation of antiplatelet therapy, inadequate antiplatelet response, or technical issues during stent deployment, as noted in the guidelines for perioperative beta blockade 1. Some key points to consider in the management of this patient include:

• The importance of urgent cardiac catheterization to assess stent patency
• The need for dual antiplatelet therapy to prevent further thrombotic events
• The consideration of other causes of chest pain and troponin elevation, such as pericarditis
• The potential risks and complications associated with stent thrombosis and restenosis. An ECG and echocardiogram should be performed to assess for new wall motion abnormalities or pericardial effusion, as part of a comprehensive evaluation of the patient's condition 1.

From the Research

Possible Causes of Chest Pain and Elevated Troponin after Coronary Angioplasty

• Chest pain and elevated troponin levels after coronary angioplasty can be caused by various factors, including late stent thrombosis 2, myocardial infarction, or other cardiac conditions.
• A study found that elevation of troponin levels after coronary angioplasty is significantly related to angiography findings in treated lesions, such as calcification of coronary arteries, intracoronary thrombus, and increased number of implanted stents 3.
• Another study suggested that chest pain after coronary artery stent implantation can occur in the absence of in-stent restenosis and may be associated with more intense coronary vasoreactivity 4.

Importance of Interpreting Elevated Troponin Levels

• Elevated troponin levels do not always indicate a cardiac origin, and false positives can occur 5.
• A case report highlighted the importance of carefully interpreting elevated troponin levels, especially when clinical findings and further investigations do not support a cardiac origin for troponin elevation 5.
• It is essential to consider alternative diagnoses, such as pulmonary embolism or aortic aneurysm, in patients presenting with chest pain and elevated troponin levels, even if coronary arteries are normal 6.

Clinical Implications

• Patients who undergo coronary angioplasty should be closely monitored for signs of chest pain and elevated troponin levels, and further investigations should be conducted to determine the cause of these symptoms.
• The use of high-sensitivity cardiac troponins should be interpreted with caution, and clinical findings and further investigations should be taken into account to avoid false positives 5.
• A comprehensive clinical history, physical examination, and timely investigations are crucial in diagnosing the cause of chest pain and elevated troponin levels after coronary angioplasty 6.