Can aortic dissection have a troponin I positive result?

Can Aortic Dissection Cause Troponin I Elevation?

Yes, aortic dissection can definitely cause troponin I elevation, and this occurs in approximately 23-27% of patients with acute aortic dissection. 1, 2, 3, 4, 5

Mechanism and Prevalence

• Troponin elevation in aortic dissection reflects true myocardial injury, not a false positive result, and should always prompt consideration of this life-threatening diagnosis when evaluating chest pain. 1, 2

• The prevalence of elevated cardiac troponin I ranges from 23% to 33% in patients with acute aortic dissection, with approximately 10% exceeding the myocardial infarction threshold. 4, 5

• Multiple mechanisms can cause myocardial injury in aortic dissection: 1, 2, 3

  • Direct extension of the dissection into coronary ostia (particularly the right coronary artery)
  • Hemodynamic stress from acute aortic regurgitation
  • Cardiac tamponade from hemopericardium
  • Hypotension or shock reducing coronary perfusion

Clinical Significance and Prognosis

• Troponin elevation in aortic dissection carries significant prognostic implications, with elevated levels associated with a 2.57-fold increased risk of in-hospital mortality (OR 2.57; 95% CI 1.66-3.96). 4

• Patients with positive troponin are more likely to present with: 3, 5

  • Hypotension or cardiogenic shock (52% vs 3%, p<0.01)
  • Pericardial effusion or tamponade (61% vs 8%, p<0.01)
  • Need for catecholamine support (17.9% vs 4.4%, p=0.03)
  • Preoperative cardiac arrest (24% vs 7%, p=0.051)

• In-hospital mortality is significantly higher in troponin-positive patients (47% vs 14%, p<0.01). 3

Critical Diagnostic Considerations

• Aortic dissection must always be considered as a differential diagnosis when evaluating troponin elevation with chest pain, as misdiagnosis can be fatal. 1, 2

• The European Society of Cardiology explicitly lists aortic dissection among the most important differential diagnoses for troponin elevation (marked as "bold: important differential diagnoses" in their guidelines). 1

• Troponin has poor discriminatory value for aortic dissection versus other causes of chest pain (area under ROC curve only 0.50), making it unreliable for ruling in or out this diagnosis. 6

Practical Approach When Troponin is Elevated

• Do not assume acute coronary syndrome when troponin is elevated—always assess for clinical features suggesting aortic dissection: 1, 2

  • Tearing or ripping chest pain radiating to the back
  • Blood pressure differential between arms (>20 mmHg)
  • New aortic regurgitation murmur
  • Pulse deficits or neurological deficits

• Immediate echocardiography should be performed in patients with hemodynamic instability or when aortic dissection is suspected, as it can rapidly identify dissection flaps, pericardial effusion, and aortic regurgitation. 1

• If aortic dissection is suspected, obtain CT angiography or transesophageal echocardiography rather than proceeding to cardiac catheterization, as the latter could be catastrophic in undiagnosed dissection. 1

Key Pitfall to Avoid

• The most dangerous error is attributing troponin elevation solely to acute coronary syndrome and proceeding with anticoagulation or fibrinolysis, which would be catastrophic in aortic dissection. 1, 2

• Serial troponin measurements showing rising and falling patterns help distinguish acute MI from other causes, but in aortic dissection with ongoing ischemia, troponins may also show dynamic changes. 1, 2