From the Guidelines
Chronically elevated troponin levels are most commonly caused by chronic kidney disease, chronic heart failure, and coronary artery disease, as well as other conditions such as hypertrophic cardiomyopathy, pulmonary hypertension, and cardiac infiltrative disorders, as evidenced by the most recent study in 2021 1.
Causes of Chronically Elevated Troponin Levels
The causes of chronically elevated troponin levels can be diverse and multifactorial. Some of the key causes include:
- Chronic kidney disease, where reduced renal clearance leads to troponin accumulation
- Chronic heart failure, which causes ongoing myocardial stress and cell damage
- Coronary artery disease with recurrent ischemia
- Structural heart diseases like hypertrophic cardiomyopathy or amyloidosis, which create persistent cardiac strain
- Pulmonary hypertension
- Cardiac infiltrative disorders
- Severe hypertension causing ventricular hypertrophy
- Chronic inflammatory conditions such as myocarditis, systemic inflammatory diseases, and sepsis, which can elevate troponins through inflammatory damage to cardiac tissue ### Clinical Context and Evaluation When evaluating chronically elevated troponins, it is crucial to consider the patient's clinical context, as the pattern and degree of elevation often reflect the underlying pathology 1. For instance, renal dysfunction typically causes modest but persistent elevations, while acute cardiac events produce more dramatic spikes. The most recent guidelines from 2021 emphasize that elevations in cardiac troponin should not be primarily attributed to impaired clearance and considered harmless, especially in elderly patients with renal dysfunction, as cardiac conditions such as chronic coronary syndromes or hypertensive heart disease seem to be the most important contributor to cardiac troponin elevation in this setting 1.
Importance of Recent Evidence
The study from 2021 1 provides the most up-to-date and highest quality evidence on the causes of chronically elevated troponin levels, superseding earlier studies from 2011 2 and 2019 3. This recent study highlights the importance of considering the clinical context and the underlying pathology when evaluating chronically elevated troponins.
From the Research
Causes of Chronically Elevated Troponin Levels
- Chronically elevated troponin levels can be caused by various medical conditions in the absence of acute coronary syndrome (ACS) 4
- Chronic stable heart failure is one of the conditions that can lead to elevated troponin levels, which is associated with a high risk of mortality and combined adverse cardiovascular outcomes 5
- Other clinical scenarios beyond obstructive coronary artery disease can also cause elevations of cardiac troponin, including myocardial injury without overt ischemia 6, 7
- Myocardial injury is a broad differential diagnosis that can be divided into acute and chronic precipitants, and its incidence is likely to increase with an aging population and greater sensitivity of troponin assays 7
- In critically ill patients, elevated cardiac troponin in the absence of ACS is associated with increased mortality, and certain medications such as statins, β-blockers, and aspirin may be associated with reduced mortality in a troponin-dependent manner 8
Conditions Associated with Chronically Elevated Troponin Levels
- Chronic stable heart failure 5
- Myocardial injury without overt ischemia 6, 7
- Other clinical scenarios beyond obstructive coronary artery disease 6
- Critical illness in the absence of ACS 8
Mechanisms and Prognosis
- Elevated troponin levels are associated with a high risk of mortality and combined adverse cardiovascular outcomes in patients with chronic stable heart failure 5
- Myocardial injury is associated with a concerning prognosis, with a 5-year mortality rate of approximately 70% and a major adverse cardiovascular event rate of 30% in the same period 7
- The prognosis of chronically elevated troponin levels depends on the underlying condition and the presence of other cardiovascular risk factors 5, 7