From the Guidelines
Elevated troponin levels with a negative cardiac catheterization (cath) are often caused by non-coronary related myocardial injury, such as myocarditis, pulmonary embolism, or severe noncardiac conditions like sepsis or respiratory failure 1.
Possible Causes of Elevated Troponin Levels
- Myocardial injury not related to ischemia: cardiac contusion, surgery, ablation, pacing, or defibrillator shocks, rhabdomyolysis with cardiac involvement, myocarditis, cardiotoxic agents 1
- Supply/demand imbalance of myocardial ischemia: tachy-/brady-arrhythmias, aortic dissection or severe aortic valve disease, hypertrophic cardiomyopathy, cardiogenic, hypovolemic, or septic shock, severe respiratory failure, severe anemia, hypertension with or without LVH 1
- Chronic or acute renal dysfunction, severe congestive heart failure, hypertensive crisis, inflammatory diseases, acute neurological disease, including stroke, or subarachnoid haemorrhage 1
- Other life-threatening conditions: aortic dissection, pulmonary embolism, acute pulmonary thromboembolic disease, and severe noncardiac conditions such as sepsis, burns, respiratory failure, acute neurological diseases, and drug toxicity 1 It is essential to consider these possible causes when evaluating a patient with elevated troponin levels and a negative cardiac catheterization, as they may require different management and treatment strategies 1.
Diagnostic Approach
- Measure cardiac troponin levels at presentation and repeat 3-6 hours later 1
- Consider serial changes in troponin values to distinguish acute from chronic elevations 1
- Evaluate the patient's clinical presentation, ECG, and other diagnostic tests to determine the underlying cause of elevated troponin levels 1
From the Research
Causes of Elevated Troponin Levels
Elevated troponin levels can be caused by various factors, including:
- Myopericarditis, perimyocarditis, and myocarditis 2, 3, 4
- Drug intoxications, carbon monoxide poisoning, and severe aortic stenosis 2, 3
- Gastrointestinal bleeding, sepsis, left ventricular hypertrophy, and severe congestive heart failure 3
- Cerebrovascular accident, electrical trauma, myocardial contusion, and hypertensive emergency 3
- Myocardial bridging, pulmonary embolism, diabetic ketoacidosis, and chronic obstructive pulmonary disease exacerbation 3
- Renal failure and other non-cardiovascular diseases 5, 4
Non-Ischemic Cardiac Conditions and Non-Cardiac Diseases
Elevated troponin levels can also occur in non-ischemic cardiac conditions and non-cardiac diseases, such as:
- Heart failure and pulmonary embolism 5
- Atrial fibrillation, congestive heart failure, and myocardial contusion 4
- Sepsis, hypovolemia, and renal failure 4
Prognostic Value of Troponin Elevation
Troponin elevation in the absence of thrombotic acute coronary syndromes still retains prognostic value 4
- Patients with non-thrombotic troponin elevation should not be treated with antithrombotic and antiplatelet agents, but rather the underlying cause of the troponin elevation should be targeted 4
- Elevated levels of cardiac troponin provide a very sensitive measure for clinicians diagnosing patients with myocardial necrosis, but such measures are also useful in defining a broad spectrum of disease 6