How to manage Covid-19 patients with elevated troponin (cardiac biomarker) indicating cardiac involvement?

Management of COVID-19 Patients with Elevated Troponin

Troponin elevation in COVID-19 patients should be stratified by level of elevation, with mild elevations (<2-3 times ULN) managed conservatively while marked elevations (>5 times ULN) require further cardiac evaluation with ECG and echocardiography to determine the underlying cause and guide treatment. 1

Understanding Troponin Elevation in COVID-19

Troponin elevation is common in COVID-19 patients, occurring in 5-25% of hospitalized patients with higher prevalence in those admitted to ICU and those who died 1. This elevation is associated with:

• Increased mortality risk (OR 4.75,95% CI 4.07-5.53) 2
• Higher risk of mechanical ventilation 3
• Longer hospital stays (median 14-16 days vs. 8 days for patients without elevation) 4
• Greater likelihood of requiring renal replacement therapy 4

Diagnostic Algorithm for Troponin Elevation

1. Measure troponin level and classify elevation:

   • Mild elevation: <2-3 times upper limit of normal (ULN)
   • Marked elevation: >5 times ULN 1

2. For all patients with elevated troponin:

   • Obtain ECG to assess for ischemic changes
   • Check BNP/NT-proBNP levels (often elevated concurrently) 1
   • Monitor vital signs with frequent blood pressure measurements 5

3. For patients with marked elevation (>5 times ULN):

   • Perform echocardiography to help diagnose underlying cause 1
   • Consider continuous ECG monitoring for arrhythmia detection 5

Management Based on Clinical Scenario

Mild Troponin Elevation (<2-3 times ULN)

• Without angina or ECG changes:

  • Conservative management focused on treating underlying COVID-19
  • No specific cardiac workup required 1
  • Continue monitoring troponin levels to track trends

• With angina or ECG changes:

  • Evaluate for type 1 MI despite mild elevation 1
  • Consider echocardiography

Marked Troponin Elevation (>5 times ULN)

• With typical angina and/or ECG changes:

  • Evaluate for type 1 MI
  • Consider coronary angiography if type 1 MI is suspected 1

• Without typical angina or ECG changes:

  • Perform echocardiography to differentiate between:
    • Myocarditis
    • Takotsubo syndrome
    • Type 2 MI due to hypoxemia/respiratory failure
    • Right ventricular strain 1

STEMI Presentation

• Treat according to standard STEMI protocols regardless of COVID-19 status
• Do not delay appropriate treatment even if COVID-19 is confirmed 1
• Implement protective measures for healthcare workers during procedures

NSTEMI Presentation

• Most patients respond well to medical treatment
• Allow time for COVID-19 testing before invasive procedures
• Manage very high-risk NSTEMI patients according to STEMI pathways 1

Important Clinical Considerations

• Prognostic value: Patients with elevated troponin have 45% probability of mortality versus 14% in those without elevation 2
• Sensitivity and specificity: Elevated troponin has 55% sensitivity and 80% specificity for predicting mortality 2
• Associated complications: Elevated troponin is independently associated with:
  • Acute kidney injury (OR: 6.76)
  • Venous thromboembolism (OR: 11.99)
  • Atrial fibrillation (OR: 10.66) 4

Common Pitfalls to Avoid

1. Overdiagnosis of MI: Not all troponin elevations in COVID-19 represent type 1 MI; multiple mechanisms can cause myocardial injury 1

2. Delayed diagnosis: Maintain high suspicion for cardiac complications as classical symptoms may be absent or masked by respiratory symptoms 1

3. Unnecessary invasive procedures: Restrict coronary angiography to patients with suspected type 1 MI rather than all COVID-19 patients with troponin elevation 1

4. Overlooking other causes: Consider multiple potential mechanisms including:

   • Direct viral myocardial injury
   • Cytokine release syndrome
   • Type 2 MI due to hypoxemia
   • Right ventricular strain from pulmonary involvement 1

By following this structured approach to evaluating and managing troponin elevation in COVID-19 patients, clinicians can appropriately identify those requiring cardiac interventions while avoiding unnecessary procedures in patients whose troponin elevation reflects the systemic effects of COVID-19 infection.