Can an infection cause elevated troponin levels?

Infection-Related Troponin Elevation

Yes, infections can cause elevated troponin levels through multiple mechanisms including oxygen supply-demand imbalance, inflammatory mediators, and direct myocardial injury.

Mechanisms of Troponin Elevation in Infections

• Infections can cause type 2 myocardial infarction through severe respiratory distress and hypoxemia, leading to an oxygen supply-demand imbalance in the myocardium 1
• Systemic inflammatory response during infections can trigger cytokine release syndrome potentially leading to microinfarction 1
• Direct viral and cytopathic effects may cause myocardial injury, particularly observed in COVID-19 infections 1
• Tachycardia and increased cardiac demand during infections can cause myocardial stress and subsequent troponin release 2
• Sepsis can cause inflammatory mediators and demand ischemia, leading to troponin elevation 2

Clinical Significance and Prevalence

• In patients with bacteremia, troponin elevation has been reported in up to 43% of cases 3
• In COVID-19 infections, 5-25% of hospitalized patients had troponin elevations, with higher prevalence in those admitted to intensive care units 1
• Influenza infection has been associated with troponin elevations in approximately 2.9% of patients 4
• Infective endocarditis can lead to elevated troponin levels, particularly with staphylococcal infections 5
• Troponin elevation in infectious conditions correlates with disease severity and has prognostic value 1

Interpretation of Troponin Elevation in Infectious Contexts

• Mild troponin elevations (<2-3 times upper limit of normal) in patients with infections generally do not require workup for type 1 MI unless strongly suggested by clinical symptoms or ECG changes 1
• Marked elevations (>5 times upper limit of normal) may indicate severe respiratory failure, tachycardia, systemic hypoxemia, shock, myocarditis, or type 1 MI triggered by infection 1
• Serial measurements are essential, as a single elevated value is insufficient for diagnosis 2
• Troponin elevation in infections may be related to demand ischemia rather than acute coronary syndrome 6

Clinical Approach to Troponin Elevation in Infections

• Interpret troponin in clinical context, considering chest pain, ECG changes, and other clinical parameters 2
• For patients with elevated troponin and infections but without symptoms/ECG changes suggestive of ACS, focus on treating the underlying infection 1
• Echocardiography should be considered if marked troponin elevation occurs without clear symptoms or ECG changes suggestive of type 1 MI 1
• The use of coronary angiography for infection-positive patients with troponin elevation should be restricted to those in whom type 1 MI is suspected 1

Risk Stratification and Prognosis

• Troponin elevation in infections is associated with increased mortality in univariate analysis, though this may not be independently predictive after adjusting for other factors 6, 3
• Elevated troponin in infections is associated with severity of the underlying infection, renal function, and underlying cardiac disease 3
• In COVID-19, troponin levels correlate with disease severity and have prognostic value 1
• Troponin elevation serves as a surrogate marker for disease severity and may help identify patients at higher risk 3