What is the best approach to management for a hospital patient with elevated troponin levels, but no evidence of myocardial infarction (MI) or acute coronary syndrome (ACS), admitted for treatment of cellulitis?

Management of Elevated Troponin Without Evidence of Myocardial Infarction or Acute Coronary Syndrome

For patients with elevated troponin values (such as 27-33.5) but no evidence of myocardial infarction or acute coronary syndrome, the best approach is to identify and treat the underlying non-coronary cause of troponin elevation while monitoring for cardiac complications.

Understanding Troponin Elevation in Non-ACS Settings

Troponin elevations can occur in numerous clinical scenarios beyond acute coronary syndromes. In a patient admitted for cellulitis, several mechanisms could explain troponin elevation:

• Common non-ACS causes of troponin elevation:
  • Sepsis (including from severe cellulitis)
  • Renal insufficiency
  • Heart failure
  • Tachyarrhythmias
  • Respiratory failure
  • Hypertensive emergencies
  • Critical illness
  • Myocarditis
  • Pulmonary embolism 1

Diagnostic Approach

1. Confirm absence of ACS:

   • Review ECG for ischemic changes
   • Assess for typical anginal symptoms
   • Evaluate troponin pattern (rising/falling pattern suggests acute injury) 1

2. Serial troponin measurements:

   • Obtain troponin levels at presentation and 3-6 hours later to identify pattern
   • Stable mild elevations without a rising pattern are less concerning for ACS 1

3. Additional cardiac assessment:

   • Echocardiography if there are hemodynamic disturbances or new murmurs 1
   • Consider cardiac monitoring in a telemetry unit 1

4. Evaluate for alternative diagnoses:

   • Complete blood count, inflammatory markers (for infection/sepsis)
   • Renal function tests
   • Chest X-ray
   • Blood gas determination if respiratory symptoms present 1

Management Strategy

For Patients with Confirmed Non-ACS Troponin Elevation:

1. Target the underlying cause:

   • For cellulitis: appropriate antibiotics and infection source control
   • Avoid unnecessary antithrombotic and antiplatelet agents that would be used for ACS 2

2. Risk stratification:

   • Despite absence of ACS, troponin elevation still carries prognostic value 1
   • Elevated troponin portends worse outcomes regardless of etiology 3

3. Cardiac monitoring:

   • It is reasonable to observe patients with elevated troponin in a telemetry unit with serial ECGs even without objective evidence of myocardial ischemia 1
   • Monitor for hemodynamic instability and arrhythmias

4. Consider additional cardiac testing before discharge:

   • For patients with normal serial ECGs and stabilizing troponin values, consider:
     • Stress testing (treadmill ECG, stress myocardial perfusion imaging, or stress echocardiography) before discharge or within 72 hours 1

Special Considerations for Cellulitis Patients

In a patient admitted for cellulitis with troponin elevation in the 27-33.5 range:

• Troponin elevation may result from:

  • Systemic inflammatory response causing myocardial strain
  • Demand ischemia from tachycardia and fever
  • Pre-existing coronary disease exacerbated by acute illness
  • Direct myocardial injury from cytokine release 4

• Management priorities:

  • Aggressive treatment of the infection
  • Hemodynamic support if needed
  • Correction of precipitating factors (fever, tachycardia, hypoxemia)
  • Cardiac monitoring during acute phase

Common Pitfalls to Avoid

1. Overdiagnosis of ACS: Avoid labeling all troponin elevations as ACS, which can lead to unnecessary invasive procedures and antithrombotic therapy 5

2. Underestimating risk: Despite absence of ACS, troponin elevation still indicates myocardial injury and carries prognostic significance 3

3. Incomplete evaluation: Failure to identify the underlying cause of troponin elevation may lead to missed diagnoses of conditions requiring specific treatment

4. Relying solely on troponin values: Troponin elevation should be interpreted in clinical context with ECG findings and symptoms 5

5. Premature discharge: Patients with unexplained troponin elevation should undergo appropriate risk stratification before discharge 1

By following this approach, clinicians can appropriately manage patients with elevated troponin in the absence of ACS while avoiding unnecessary interventions and ensuring proper treatment of the underlying condition.