Can sepsis cause elevated troponin levels?

Sepsis Can Cause Elevated Troponin Levels

Yes, sepsis can definitely cause elevated troponin levels, as it is specifically listed as a non-ischemic cause of troponin elevation in clinical guidelines. 1, 2

Mechanisms of Troponin Elevation in Sepsis

• Sepsis can cause troponin elevation through systemic inflammatory response triggering cytokine release syndrome, potentially leading to myocardial microinfarction 2
• Severe respiratory distress and hypoxemia during sepsis can create an oxygen supply-demand imbalance in the myocardium, resulting in type 2 myocardial infarction 2
• Left ventricular diastolic dysfunction and right ventricular dilatation are the echocardiographic variables that best correlate with elevated troponin levels in sepsis 3
• Sepsis-induced myocardial injury can occur without coronary artery occlusion, representing a form of demand ischemia 2

Clinical Significance of Troponin Elevation in Sepsis

• Elevated troponin in sepsis is associated with increased mortality, with a meta-analysis showing a risk ratio of 1.91 (95% CI: 1.65-2.22) 4
• Troponin elevation serves as a prognostic marker in septic shock, with cTnT-positive patients having significantly higher mortality rates 5
• Recent meta-analysis (2023) confirmed that elevated cardiac troponin levels in sepsis patients predict both hospital mortality (HR = 1.35) and long-term mortality (HR = 1.96) 6
• However, some studies suggest that troponin may not independently predict mortality when adjusted for other factors like APACHE-II score and serum lactate 7

Differentiating Sepsis-Related Troponin Elevation from ACS

• When evaluating elevated troponin, it's essential to determine if it's due to sepsis or acute coronary syndrome (ACS) 1
• For diagnosis of acute myocardial infarction, evidence of a rising and/or falling pattern with at least one value above the 99th percentile is required 1
• Serial measurements at 3-6 hour intervals are essential to identify a rising or falling pattern characteristic of acute myocardial injury 2
• Interpret troponin elevation in clinical context, considering chest pain, ECG changes, or new wall motion abnormalities, which suggest MI rather than sepsis-related elevation 2

Interpretation of Troponin Values in Sepsis

• The Universal Definition of Myocardial Infarction specifically lists sepsis as a non-ischemic cause of troponin elevation 1
• Mild troponin elevations (<2-3 times upper limit of normal) in patients with sepsis generally do not require workup for type 1 MI unless strongly suggested by clinical symptoms or ECG changes 2
• Marked elevations (>5 times upper limit of normal) may indicate severe respiratory failure, tachycardia, systemic hypoxemia, shock, or myocarditis 2
• When troponin is elevated in sepsis, clinicians should search for other etiologies of myocardial necrosis rather than assuming acute coronary syndrome 1

Clinical Approach to Troponin Elevation in Sepsis

• Focus on treating the underlying sepsis when troponin elevation occurs without symptoms/ECG changes suggestive of ACS 2
• Consider echocardiography if marked troponin elevation occurs without clear symptoms or ECG changes suggestive of type 1 MI 2
• Coronary angiography for sepsis patients with troponin elevation should be restricted to those in whom type 1 MI is strongly suspected 2
• Clinicians should treat septic patients with elevated troponin more cautiously given the association with higher mortality 6