From the Guidelines
Elevated high sensitivity troponin (hs-troponin) levels in children should be approached with careful clinical correlation, considering the patient's presentation, medical history, and other diagnostic findings, rather than relying solely on absolute values. When encountering elevated hs-troponin in pediatric patients, clinicians should first determine if the elevation is clinically significant. Unlike in adults, there are no well-established reference ranges or cutoff values specifically for children 1. Serial measurements are recommended to assess trends, with rising levels suggesting acute cardiac injury. Common non-cardiac causes of troponin elevation in children include sepsis, respiratory failure, seizures, renal dysfunction, and strenuous exercise, which should be ruled out before attributing elevation to primary cardiac pathology.
Key Considerations
- Cardiac causes to consider include myocarditis, pericarditis, cardiomyopathy, congenital heart disease, and cardiac contusion
- Management depends on the underlying cause rather than treating the biomarker itself
- Additional cardiac evaluation with echocardiography, electrocardiogram, and cardiology consultation is warranted in cases of significant or persistent elevation, especially when accompanied by cardiac symptoms The physiological basis for this approach is that troponin is released during cardiomyocyte injury, but children may have different baseline levels and release patterns compared to adults due to developmental differences in cardiac physiology. It is essential to note that the utility of routine assessment of serum troponin levels in patients with acute or chronic heart failure, as well as the appropriate diagnostic and therapeutic approaches to elevated serum troponin levels in non-ACS setting remains to be determined, as highlighted in the guidelines for clinical utilization of cardiac biomarker testing in heart failure 1.
From the Research
Approach to Elevated High Sensitivity Troponin (hs-troponin) Levels in Children
Elevated high sensitivity troponin (hs-troponin) levels in children can be caused by various cardiac and non-cardiac pathologies. The approach to these elevated levels involves a thorough diagnostic evaluation to determine the underlying cause.
Common Causes of Elevated hs-troponin Levels in Children
- Myopericarditis 2
- Drug intoxications 2
- Carbon monoxide poisoning 2
- Perimyocarditis 2
- Intensive inhalation β agonist use in acute asthma and lower respiratory tract infections 2
- Sepsis 3
- Cardiac pathologies such as tachyarrhythmias and cardiomyopathies 3
- Myocarditis 3, 4, 5
- Trauma and other causes of multiorgan dysfunction 3
Diagnostic Tests for Elevated hs-troponin Levels in Children
- ECG 2, 4
- Echocardiography 2, 4
- Right heart catheterization 4
- MRI 4
- High sensitivity troponin T (hs-cTnT) levels 5
Interpretation of hs-troponin Levels in Children
- A high sensitivity troponin cut-off value of 90 ng/dL was established for diagnosis of myocarditis, providing high sensitivity (100%) and specificity (95%) 5
- The extent of raised troponin I levels may potentially be useful in differentiating between cardiac and non-cardiac pathologies 3
- The interpretation of biomarkers is often challenging, especially when institutions transition from conventional cTn assays to high-sensitivity (hs-cTn) methods 6
Management of Elevated hs-troponin Levels in Children
- Unlike adults, troponin I elevation may not require emergency cardiac catheterization in children 2
- Cardiac catheterization is not necessary except for rare cardiac pathologies and does not alter the prognosis 2
- Left heart catheterization and coronary angiography should be reserved for a highly selective group, and adult "door-to-balloon time" protocols should not be applied routinely 4