What is the significance of increasing troponin (Trop) levels in the setting of an abscess with a negative electrocardiogram (EKG)?

From the Guidelines

In a patient with increasing troponin levels, a negative EKG, and an abscess, the priority is to address both the cardiac concern and the infection, with a high suspicion for Type 2 myocardial injury due to the infectious process rather than acute coronary syndrome. The significance of increasing troponin levels in this setting, as outlined in the universal definition of myocardial infarction 1, suggests that elevations of troponin can occur in the absence of overt ischemic heart disease, including conditions such as congestive heart failure, acute neurological disease, and critically ill patients, especially with respiratory failure or sepsis. Given the context of an abscess, which can lead to sepsis, a critical condition characterized by a systemic inflammatory response, it is plausible that the troponin elevation is related to the infectious process rather than a primary cardiac event.

Key Considerations

• The patient's clinical presentation, including the presence of an abscess, should guide the interpretation of troponin levels, with consideration of conditions that can cause troponin elevation without acute coronary syndrome, as detailed in the study by 1.
• The universal definition of myocardial infarction 1 emphasizes the importance of detecting a rise and/or fall in troponin measurements to diagnose acute myocardial infarction, but also acknowledges that troponin elevations can occur in various clinical contexts.
• The management of the patient should include prompt surgical drainage of the abscess and empiric antibiotic therapy, such as vancomycin and piperacillin-tazobactam, alongside supportive care measures like IV fluids, pain management, and close monitoring of vital signs.
• Serial troponin measurements and cardiac monitoring are crucial to assess the cardiac impact of the infection and to guide further management, considering the potential for myocardial injury due to increased oxygen demand and decreased oxygen supply.

Management Approach

• Consult cardiology for evaluation of the troponin elevation to determine the best course of action for managing the cardiac concern.
• Initiate broad-spectrum antibiotics and adjust based on culture results once available.
• Provide supportive care to manage the infection and monitor for any signs of cardiac compromise.
• Consider the potential for Type 2 myocardial injury and manage accordingly, focusing on optimizing oxygen supply and demand balance, as suggested by the context of the study 1.

From the Research

Significance of Increasing Troponin Levels

• Increasing troponin (Trop) levels in the setting of an abscess with a negative electrocardiogram (EKG) may indicate myocardial injury due to conditions other than occlusion myocardial infarction (OMI) 2.
• Troponin elevation can occur in various non-cardiac conditions, including sepsis, pulmonary embolism, and renal failure 3.
• In patients with sepsis, elevated troponin levels have been associated with increased risk of mortality, even in the absence of acute coronary syndrome (ACS) 4.

Clinical Context and Patient Symptoms

• Clinicians should consider the clinical context, patient symptoms, EKG, and ultrasound in their assessment of the patient with troponin elevation 2.
• The presence of chest pain, tobacco smoking, and wall motion abnormalities on echocardiogram have been associated with increased risk of true ACS in patients with elevated troponins 5.
• Elevated troponin levels during sepsis have been linked to increased risk of post-sepsis cardiovascular complications, including atherosclerotic cardiovascular disease, atrial fibrillation, and heart failure 6.

Diagnostic Considerations

• The diagnosis of ACS should not be solely based on elevated troponin levels, as it can lead to expensive workup and utilization of hospital resources 5.
• A negative EKG does not rule out myocardial injury, and clinicians should consider other diagnostic tests, such as echocardiogram and cardiac biomarkers, to evaluate the patient's condition 2, 3.
• Troponin elevation can be a marker for poor outcomes, including increased rates of mortality, and clinicians should carefully evaluate the patient's clinical context and symptoms to determine the underlying cause of the elevation 2, 4.