From the Guidelines
Elevated troponin levels can occur in many conditions besides ST-elevation myocardial infarction (STEMI), including non-ST elevation myocardial infarction (NSTEMI), unstable angina, myocarditis, pericarditis, heart failure, pulmonary embolism, sepsis, and kidney failure, as well as other causes such as tachyarrhythmias, strenuous exercise, and cardiac procedures 1.
Causes of Elevated Troponin
The causes of elevated troponin levels can be broadly categorized into:
- Myocardial ischemia-related injury, such as plaque rupture, intraluminal coronary artery thrombus formation, and supply/demand imbalance of myocardial ischemia 1
- Myocardial injury not related to ischemia, such as cardiac contusion, surgery, ablation, pacing, or defibrillator shocks, rhabdomyolysis with cardiac involvement, and myocarditis 1
- Multifactorial or indeterminate myocardial injury, including heart failure, stress (Takotsubo) cardiomyopathy, severe pulmonary embolism or pulmonary hypertension, sepsis, and critically ill patients 1
Clinical Context
When evaluating elevated troponin, it's essential to consider the patient's complete clinical picture, including their medical history, physical examination, and other diagnostic findings, rather than viewing the biomarker in isolation 1. The pattern of elevation, clinical context, and other diagnostic findings help differentiate between the various causes of elevated troponin.
Diagnostic Approach
The diagnosis of myocardial infarction (MI) requires a rise and/or fall in troponin values with at least one value above the decision level, coupled with a strong pre-test likelihood 1. A rising or falling pattern is not absolutely necessary to make the diagnosis of MI if a patient with a high pre-test risk of MI presents late after symptom onset 1.
Key Considerations
- Elevated troponin levels can occur in many conditions besides STEMI, and a thorough clinical evaluation is necessary to determine the underlying cause 1
- The pattern of elevation, clinical context, and other diagnostic findings help differentiate between the various causes of elevated troponin 1
- A rising or falling pattern of troponin values is not always necessary to diagnose MI, especially in patients with a high pre-test risk of MI who present late after symptom onset 1