Do you trend troponin (troponin) levels in pericarditis?

Troponin Monitoring in Pericarditis

Routine trending of troponin levels in pericarditis is not necessary as elevated troponin in pericarditis does not appear to confer a worse prognosis and may actually be associated with a lower risk of recurrences. 1, 2

Troponin Elevation in Pericarditis

Troponin elevation is common in pericarditis, occurring in:

• Up to 49% of patients with idiopathic acute pericarditis 3
• Levels exceeding myocardial infarction thresholds in approximately 22% of cases 3

When troponin is elevated in pericarditis, it indicates some degree of myocardial involvement (myopericarditis), reflecting inflammation extending from the epicardium to the myocardium.

Prognostic Implications

The 2021 AHA/ACC guideline and 2015 ESC guideline both emphasize that:

• Minimally elevated troponin in pericarditis does not confer a worse prognosis 1
• Recent evidence suggests elevated troponin levels may actually be associated with a lower incidence of recurrences (4% vs 17%) 2
• Elevated troponin identifies a group with reduced risk of composite adverse outcomes (13% vs 36%) 2

Diagnostic Approach

When troponin is elevated in suspected pericarditis:

1. Initial assessment:

   • Confirm pericarditis diagnosis (≥2 of: typical chest pain, pericardial friction rub, ECG changes, pericardial effusion)
   • Measure inflammatory markers (CRP, ESR)
   • Perform echocardiography to assess for effusion and rule out tamponade 4

2. If troponin is elevated:

   • Consider the diagnosis of myopericarditis
   • Coronary angiography may be warranted based on clinical presentation and risk factors to rule out acute coronary syndrome 1
   • CMR with gadolinium contrast is recommended to distinguish myopericarditis from other causes including MINOCA 1

Management Implications

The presence of troponin elevation:

• Does not significantly alter the management approach for pericarditis
• Does not require serial monitoring in most cases
• Should prompt consideration of CMR for confirmation of myocardial involvement 1

Special Considerations

• Younger patients and those with recent infections are more likely to have troponin elevation 3
• ST-segment elevation is more common in patients with troponin elevation (93% vs 57%) 3
• Patients with postcardiac injury pericarditis have a lower incidence of treatment failure and recurrence compared to idiopathic pericarditis 2

Clinical Pitfalls to Avoid

1. Don't mistake myopericarditis for acute coronary syndrome based solely on troponin elevation
2. Don't assume worse outcomes based on troponin elevation alone
3. Don't subject patients to unnecessary serial troponin measurements when the initial diagnosis is clear
4. Don't withhold appropriate anti-inflammatory treatment due to troponin elevation

In summary, while a single troponin measurement may be useful for diagnostic classification (pericarditis vs. myopericarditis), routine trending of troponin in established pericarditis cases does not provide additional prognostic value and is not recommended by current guidelines.