From the Guidelines
Chronic troponin elevation with reduced ejection fraction (35%) without myocardial infarction, heart failure, chronic kidney disease, or arrhythmias can be caused by several conditions, with the most likely causes including myocarditis, infiltrative cardiomyopathies, stress cardiomyopathy, coronary microvascular dysfunction, or cardiotoxicity from medications or treatments like chemotherapy, as supported by the most recent evidence from 1. The causes of chronic troponin elevation in this context can be multifactorial, including:
- Myocarditis
- Infiltrative cardiomyopathies (such as amyloidosis, sarcoidosis, or hemochromatosis)
- Stress cardiomyopathy (Takotsubo)
- Coronary microvascular dysfunction
- Cardiotoxicity from medications or treatments like chemotherapy Other possibilities include severe hypertension, pulmonary hypertension, or systemic inflammatory conditions affecting the heart. Evaluation should include:
- Cardiac MRI with gadolinium enhancement to assess for inflammation or infiltration
- Coronary CT angiography to rule out coronary disease
- Possibly endomyocardial biopsy in select cases Treatment depends on the underlying cause but often includes:
- ACE inhibitors (like ramipril 2.5-10mg daily)
- Beta-blockers (such as metoprolol 25-200mg daily)
- Potentially aldosterone antagonists (spironolactone 25-50mg daily) to improve cardiac function, as recommended by 1. These medications help reduce cardiac workload, prevent adverse remodeling, and improve long-term outcomes by blocking neurohormonal pathways that contribute to progressive cardiac dysfunction. Regular monitoring of troponin levels, echocardiography to track ejection fraction, and addressing the specific underlying cause are essential components of management, as emphasized by 1 and 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Causes of Chronic Troponin Elevation
- Chronic troponin elevation can be caused by various factors, including cardiac and non-cardiac conditions 2
- In patients with reduced left ventricular ejection fraction (LVEF), troponin elevation can be associated with adverse clinical outcomes, even in the absence of myocardial infarction (MI), heart failure (HF), chronic kidney disease (CKD), or arrhythmias 3, 4
- A study found that patients with severe left ventricular systolic dysfunction (LVEF <35%) had the highest level of Troponin-I with worse in-hospital outcomes 5
Association with Left Ventricular Ejection Fraction (LVEF)
- Troponin-I level has been found to have a negative correlation with LVEF levels, with medium strength of association (r= -0.5394, p=0.001) 5
- Patients with high Troponin-I levels tend to have low ejection fraction (LVEF), while those with low Troponin-I levels tend to have preserved ejection fraction (LVEF) 5
Clinical Significance
- Elevated troponin levels are associated with increased risk of mortality, even in the absence of MI, HF, CKD, or arrhythmias 4
- Clinicians should consider the clinical context, patient symptoms, electrocardiogram, and ultrasound in their assessment of the patient with troponin elevation 2
- Identifying and treating the underlying precipitant of troponin elevation is crucial, as it can have a significant impact on patient outcomes 4