From the Guidelines
Elevated troponin levels are primarily caused by damage to heart muscle cells, with the most common cause being acute myocardial infarction, but can also be raised by other conditions such as severe heart failure, myocarditis, pericarditis, pulmonary embolism, sepsis, kidney failure, and certain cardiac procedures. The causes of elevated troponin levels can be diverse and include:
- Acute myocardial infarction (heart attack)
- Severe heart failure
- Myocarditis (heart inflammation)
- Pericarditis
- Pulmonary embolism
- Sepsis
- Kidney failure
- Certain cardiac procedures like cardioversion or cardiac surgery
- Strenuous exercise, particularly endurance activities like marathons
- Medications and treatments such as chemotherapy drugs (especially anthracyclines) and radiation therapy to the chest
- Cardiac contusion from trauma and certain systemic diseases like amyloidosis As noted in the most recent and highest quality study 1, many cardiac pathologies other than myocardial infarction can result in cardiomyocyte injury and therefore cardiac troponin elevations, emphasizing the importance of considering the clinical context when interpreting troponin levels. When elevated troponin is detected, it's essential to consider the clinical context, as the pattern and degree of elevation often help distinguish between acute coronary syndrome and other causes, with serial measurements showing a rise and fall pattern being particularly suggestive of acute heart damage 1. Given the potential for various conditions to elevate troponin levels, a thorough evaluation is necessary to determine the underlying cause, taking into account the patient's symptoms, medical history, and other diagnostic findings. In clinical practice, the detection of elevated troponin levels should prompt a comprehensive assessment to identify the cause and guide appropriate management, considering the patient's overall clinical presentation and risk factors 1.
From the Research
Causes of Elevated Troponin Levels
Elevated troponin levels can be caused by various conditions, including:
- Cardiac conditions such as heart failure, dysrhythmia, and dissection 2, 3
- Non-cardiac conditions such as pulmonary embolism, sepsis, stroke, and renal failure 2, 3, 4, 5
- Physical exertion, inflammatory heart diseases (myocarditis and endocarditis), and systemic inflammation (sepsis) 4, 5
- Any type of reversible or irreversible cardiomyocyte injury can result in elevated serum troponin levels 5
Mechanisms of Troponin Elevation
The mechanisms of troponin elevation are numerous and not limited to ischemic necrosis of cardiac myocytes, including:
- Myocyte injury and necrosis, myocyte apoptosis and cell turnover, and oxygen supply demand mismatch 2
- Cardiomyocyte damage, which is correlated with rising troponin levels 6
Diagnostic Considerations
When evaluating patients with elevated troponin levels, clinicians should consider:
- The clinical context, patient symptoms, electrocardiogram, and ultrasound 2
- The maximum troponin level, which is a more sensitive and specific predictor of mortality and the diagnosis of acute myocardial infarction (AMI) than the initial troponin level or change in troponin level 6
- The possibility of diagnostic errors and the need to choose the most correct tactics for further patient management 4, 5