From the Guidelines
Troponin leak is caused by any condition that damages heart muscle cells, allowing troponin proteins to escape into the bloodstream, with the most common causes including acute myocardial infarction, myocarditis, severe heart failure, pulmonary embolism, sepsis, kidney failure, and after cardiac procedures or surgeries. The mechanism of troponin leak involves damage to cardiomyocyte membranes, allowing these normally intracellular proteins to leak into circulation 1. When evaluating troponin elevation, it's essential to consider the clinical context, as not all elevations indicate a heart attack. Serial measurements showing a rise and fall pattern, along with clinical symptoms and ECG changes, help distinguish between acute coronary syndrome and other causes of troponin leak 1.
Some of the possible non-acute coronary syndrome causes of troponin elevation include:
- Chronic or acute renal dysfunction
- Severe congestive heart failure – acute and chronic
- Hypertensive crisis
- Tachy- or bradyarrhythmias
- Pulmonary embolism, severe pulmonary hypertension
- Inflammatory diseases, e.g. myocarditis
- Acute neurological disease, including stroke, or subarachnoid haemorrhage
- Aortic dissection, aortic valve disease or hypertrophic cardiomyopathy
- Cardiac contusion, ablation, pacing, cardioversion, or endomyocardial biopsy
- Hypothyroidism
- Apical ballooning syndrome (Tako-Tsubo cardiomyopathy)
- Infiltrative diseases, e.g. amyloidosis, haemochromatosis, sarcoidosis, sclerodermia
- Drug toxicity, e.g. adriamycin, 5-fluorouracil, herceptin, snake venoms
- Burns, if affecting >30% of body surface area
- Rhabdomyolysis
- Critically ill patients, especially with respiratory failure, or sepsis 1.
It's also important to note that troponin elevation can occur in patients with heart failure, and serial testing of high-sensitivity troponin concentrations can help differentiate MI from chronic troponin elevations due to heart failure 1. In clinical practice, it's crucial to consider the clinical context and use serial troponin measurements to distinguish between different causes of troponin elevation, in order to provide appropriate management and improve patient outcomes.
From the Research
Troponin Leak Causes
Troponin leak can be caused by various conditions, including:
- Cardiac conditions such as heart failure, dysrhythmia, and dissection 2
- Non-cardiac conditions such as pulmonary embolism, sepsis, stroke, and others 2, 3
- Myopericarditis, renal failure, rhabdomyolysis, and other conditions that cause myocardial damage unrelated to coronary occlusion 3
- Physical exertion, inflammatory heart disease, pulmonary embolism, renal failure, and sepsis 4
Mechanisms of Troponin Elevation
The mechanisms of troponin elevation include:
- Myocyte injury and necrosis
- Myocyte apoptosis and cell turnover
- Oxygen supply demand mismatch 2
- Any type of reversible or irreversible cardiomyocyte injury 4
Clinical Considerations
When evaluating troponin elevation, clinicians should consider: