Is elevated troponin (cardiac biomarker) indicative of atypical chest pain?

From the Guidelines

Elevated troponin levels in the context of chest pain should be considered indicative of cardiac injury, suggesting that the chest pain is likely typical for cardiac pathology rather than atypical. When evaluating chest pain with elevated troponin, it's crucial to consider the differential diagnoses that could lead to troponin elevation, as outlined in the European Society of Cardiology guidelines 1. These include conditions such as acute coronary syndrome, but also other life-threatening conditions like pulmonary embolism or aortic dissection. The most recent guidelines from 2016 emphasize the importance of using high-sensitivity cardiac troponin assays for the diagnosis and risk stratification of patients with suspected non-ST-elevation acute coronary syndromes (NSTE-ACS) 1. Key points to consider in the management of such patients include:

• The use of high-sensitivity cardiac troponin assays to detect cardiomyocyte injury 1
• The interpretation of troponin elevation in the context of clinical presentation and other diagnostic findings, such as ECG changes and biomarker levels 1
• The consideration of alternative causes of cardiac injury, especially in patients with atypical presentations or those with conditions that could lead to non-ischemic troponin elevation 1 Given the potential for significant morbidity and mortality associated with cardiac conditions, it is essential to prioritize a thorough diagnostic evaluation and timely initiation of appropriate treatment based on the clinical context and biomarker results. This may include aspirin, anticoagulation, and consideration of cardiac catheterization, among other interventions, tailored to the individual patient's needs and diagnosis.

From the Research

Troponin Elevation and Atypical Chest Pain

• Troponin elevation is not exclusive to acute coronary syndrome (ACS) or occlusion myocardial infarction (OMI), as it can be caused by various cardiac and non-cardiac conditions 2.
• Elevated troponin levels can be seen in conditions such as heart failure, dysrhythmia, dissection, pulmonary embolism, sepsis, stroke, and others 2.
• A high troponin level, particularly in young patients, should raise suspicion of a myocardial or pericardial inflammatory process, such as myopericarditis 3.
• The clinical context, patient symptoms, electrocardiogram, and ultrasound should be considered in the assessment of a patient with troponin elevation to avoid misdiagnosis 2.

Diagnostic Considerations

• Elevated troponin levels do not necessarily require coronary angiography, as the clinical presentation and electrocardiogram must be taken into account 4.
• High-sensitivity cardiac troponins can produce false positives, and careful interpretation of elevated troponin levels is necessary, especially when clinical findings and further investigations do not support a cardiac origin for troponin elevation 5.
• Patients with mildly increased cardiac troponin concentrations and acute chest pain can be safely managed as outpatients, but may require further investigations and treatments to determine the underlying cause of troponin elevation 6.

Prognostic Implications

• Elevated high-sensitivity cardiac troponin T (hs-cTnT) is associated with increased mortality and acute myocardial infarction (AMI) at 90 days and 360 days in patients discharged from the emergency department after AMI has been ruled out 6.
• The presence of elevated troponin levels, even in the absence of ACS or OMI, can be a marker for poor outcomes, including increased rates of mortality 2.