Elevated Serum Troponin

Etiology

Myocardial Ischemia

  • Acute Coronary Syndrome (ACS) (see Coronary Artery Disease, [[Coronary Artery Disease]])
    • Non-ST-Elevation Acute MI (NSTEMI)
    • ST-Elevation Acute MI (STEMI)
  • Aortic Dissection (see Aortic Dissection, [[Aortic Dissection]])
    • Physiology: xxxx
  • Arrhythmia/Tachycardia
    • Bradyarrhythmia
      • Heart Block
      • Sinus Bradycardia (see Sinus Bradycardia, [[Sinus Bradycardia]])
        • Physiology: due to supply-demand mismatch
    • Tachyarrhythmia
      • Atrial Fibrillation (AF) (see Atrial Fibrillation, [[Atrial Fibrillation]])
        • Physiology: likely multifactorial, due to myocardial necrosis/apoptosis, myocardial stress due to the tachycardia, an underlying inflammatory/fibrotic process, myocardial dysfunction due to variations in atrial/ventricular volume and pressure load, and/or coronary microembolism
      • Supraventricular Tachycardia (SVT) (see Supraventricular Tachycardia, [[Supraventricular Tachycardia]])
        • Physiology: due to supply-demand mismatch
    • Tachycardia in the Setting of Coronary Artery Disease (see Sinus Tachycardia, [[Sinus Tachycardia]])
      • Physiology : increased oxygen demand
  • Coronary Artery Embolus
    • Physiology:
  • Coronary Artery Vasculitis
    • Kawasaki Disease (see xxxx)
      • Physiology: xxx
    • Systemic Lupus Erythematosus (SLE) (see Systemic Lupus Erythematosus, [[Systemic Lupus Erythematosus]])
      • Physiology: xxx
  • Coronary Vasospasm (Variant Angina, Prinzmetal Angina) (see Coronary Artery Disease, [[Coronary Artery Disease]])
    • Physiology: due to prolonged ischemia with myonecrosis
  • Coronary Intervention
  • Hypotension/Shock (see Hypotension, [[Hypotension]])
    • Etiology
      • Cardiogenic Shock (see Cardiogenic Shock, [[Cardiogenic Shock]])
      • Hypovolemic Shock (see Hypovolemic Shock, [[Hypovolemic Shock]])
      • Distributive Shock (Vasodilatory Shock)
      • Hemorrhagic Shock (see Hemorrhagic Shock, [[Hemorrhagic Shock]])
      • Obstructive Shock
      • Other Etiologies of Hypotension/Shock
    • Physiology: due to decreased cardiac output and/or decreased coronary artery perfusion pressure
  • Hypoxia (see Hypoxemia, [[Hypoxemia]])
    • Physiology: decreased myocardial oxygen supply
  • Left Ventricular Hypertrophy (LVH)
    • Epidemiology (Am J Cardiol, 2003) [MEDLINE]
      • Aortic Stenosis (AS) (see Aortic Stenosis, [[Aortic Stenosis]]): in patients with aortic valve disease, elevated troponin levels are associated with greater degrees of left ventricular wall thickness and higher pulmonary artery systolic pressures (Int J Cardiol, 2003) [MEDLINE]
      • Hypertensive Heart Disease (see Hypertension, [[Hypertension]])
      • Hypertrophic Cardiomyopathy (see Hypertrophic Cardiomyopathy, [[Hypertrophic Cardiomyopathy]])
    • Physiologic Mechanisms
      • Increased Myocardial Muscle Mass with an Increased Oxygen Demand, Leading to Subendocardial Ischemia
      • Decreased Flow Reserve Due to Remodeled Coronary Microcirculation
  • Pulmonary Hypertension
    • Acute Pulmonary Embolism (PE) (see Acute Pulmonary Embolism, [[Acute Pulmonary Embolism]])
      • Epidemiology
        • Elevated Troponin Occurs in 16-50% of Cases
        • Elevated Troponin Predicts Increased Pulmonary Embolism Mortality
      • Physiology: due to pulmonary hypertension with right heart overload
    • Pulmonary Hypertension of Any Etiology (see Pulmonary Hypertension, [[Pulmonary Hypertension]])
      • Epidemiology
        • Elevated Troponin Occurs in 14% of Cases
        • Elevated Troponin is Correlated with Elevated BNP and Worse 2 yr Survival
      • Physiology: due to pulmonary hypertension with right heart overload
    • Chronic Obstructive Pulmonary Disease (COPD) Exacerbation (see Chronic Obstructive Pulmonary Disease, [[Chronic Obstructive Pulmonary Disease]])
      • Epidemiology
        • Elevated Troponin Predicts Worse In-Hospital Mortality During Severe COPD Excaerbation (Intensive Care Med, 2003) [MEDLINE]
      • Physiology: due to pulmonary hypertension-associated RV stretch
  • Severe Hypertension (see Hypertension, [[Hypertension]])
    • Physiology: xxx
  • Sympathomimetics
    • Cocaine Intoxication (see Cocaine, [[Cocaine]])
      • Physiology: due to adrenergic effects
    • Methamphetamine Intoxication (see Methamphetamine, [[Methamphetamine]])
      • Physiology: due to adrenergic effects

Myocardial Injury without Ischemia

Chronic Kidney Disease (CKD)/ESRD (see Chronic Kidney Disease, [[Chronic Kidney Disease]]): unknown mechanism (possibly related to impaired renal troponin clearance)

  • Physiology
    • Potential Physiologic Mechanisms of Troponin Elevation in CKD
      • Cardiac Injury Associated with Chronic Structural Heart Disease, Such as Coronary Artery Disease or Heart Failure (Rather than Acute Myocardial Ischemia)
      • Decreased Renal Clearance of Troponin: however, there is controversy as to whether this is the primary mechanism of increased troponin in patients with CKD (J Am Coll Cardiol, 2012) [MEDLINE]
  • Clinical Data
    • Troponin Elevation in Patients without Suspected Acute Coronary Syndrome (ACS)
      • In Systematic Review and Meta-Analysis in Patients with CKD on Dialysis and without Suspected Acute Coronary Syndrome, Troponin Elevation was Associated with Increased All-Cause Mortality and Increased Cardiovascular Mortality (Ann Intern Med, 2014) [MEDLINE]
        • Hazard Ratio for All-Cause Mortality for Troponin T: 3.0 (95% CI, 2.4 to 4.3)
        • Hazard Ratio for All-Cause Mortality for Troponin I: 2.7 (CI, 1.9 to 4.6)
        • Hazard Ratio for Cardiovascular Mortality for Troponin T: 3.3 (CI, 1.8 to 5.4)
        • Hazard Ratio for Cardiovascular Mortality for Troponin I: 4.2 (CI, 2.0 to 9.2)
      • In Systematic Review and Meta-Analysis in Patients with CKD Not on Dialysis and without Suspected Acute Coronary Syndrome, Troponin Elevation was Associated with Increased All-Cause Mortality and Increased Cardiovascular Mortality (Ann Intern Med, 2014) [MEDLINE]
        • All-Cause Mortality and Cardiovascular Mortality Findings were Likewise Increased in CKD Patients Not on Dialysis (Similar to That Above for CKD Patients on Dialysis, But There Were Fewer Studies in This Analysis
    • Troponin Elevation in Patients with Suspected Acute Coronary Syndrome (ACS)
      • In Systematic Review and Meta-Analysis in Patients with CKD and Suspected Acute Coronary Syndrome, Troponin Levels Can Aid in the Identification of Patients with Poor Prognosis, But the Diagnostic Utility is Impaired by Varying Estimates of Sensitivity/Specificity (Ann Intern Med, 2014) [MEDLINE]
        • Sensitivity of Troponin T for Diagnosis of ACS: 71-100%
        • Specificity of Troponin T for Diagnosis of ACS: 31-86%
        • Sensitivity of Troponin I for Diagnosis of ACS: 43-94%
        • Specificity of Troponin I for Diagnosis of ACS: 48-100%
        • Elevated Troponin T or I was Associated with Higher Risk for Short-Term Mortality and Cardiac Events
        • A Similar Trend for Long-Term Mortality was Found for Troponin I, But There Was Less Evidence for Long-Term Cardiac Events for Troponin T and I
      • Patients with Advanced CKD Tended to Have Worse Prognosis with Elevated Troponin I Levels Than Those Without Elevated Troponin I Levels
  • Recommendations
    • A Change in Troponin Level >20% within 9 hrs (With 1 Value Exceeding the 99th Percentile) is Recommended for Acute MI Diagnosis in Patients with End-Stage Renal Disease and Suspected ACS (Clin Chem, 2007) [MEDLINE]

Neurologic Disease

  • Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]]
    • Epidemiology
      • In One Study, 27% of Patients with Acute Stroke Had Elevated Troponin I Levels (Tidsskr Nor Laegeforen, 2001) [MEDLINE]
    • Physiology: likely due to an imbalance in the autonomic nervous system, with excessive sympathetic activity and an increased catecholamine effect on myocardial cells
  • Intracerebral Hemorrhage (Hemorrhagic Cerebrovascular Accident) (see Intracerebral Hemorrhage, [[Intracerebral Hemorrhage]])
    • Physiology: likely due to an imbalance in the autonomic nervous system, with excessive sympathetic activity and an increased catecholamine effect on myocardial cells
  • Subarachnoid Hemorrhage (SAH) (see Subarachnoid Hemorrhage, [[Subarachnoid Hemorrhage]])
    • Epidemiology
      • Hunt-Hess Grade of SAH is Correlated with the Degree of Myocardial Necrosis After SAH (Stroke, 2004) [MEDLINE]
      • Troponin I Elevation After SAH is Associated with an Increased Risk of Cardiopulmonary Complications, Delayed Cerebral Ischemia, and Death or Poor Outcome at Discharge (Circulation, 2005) [MEDLINE]
    • Physiology: likely due to an imbalance in the autonomic nervous system, with excessive sympathetic activity and an increased catecholamine effect on myocardial cells

Strenuous Exercise

  • Epidemiology
    • Marathon Runners
  • Physiology: due to ventricular stretch
  • Clinical Data
    • Troponin T and I Elevations are Common in Maraton Runners Immediately After the Race, Occurring in >80% of Runners (Am J Cardiol., 2012) [MEDLINE]
      • Immediately After the Race, Approximately 8% of the Runners Had a Troponin Elevation in the Reference Range for Myocardial Infarction
      • By 24 hrs After the Race, All Runners Had Normal Troponin Levels

Other

  • Acute Pericarditis (see Acute Pericarditis, [[Acute Pericarditis]])
    • Epidemiology: troponin elevation may occur in acute pericarditis (Am J Cardiol, 2001) [MEDLINE]
    • Physiology: due to inflammation
  • Acute Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])
    • Physiology:
  • Burns (>25% Body Surface Area) (see Burns, [[Burns]])
    • Epidemiology
      • Increase in Troponin in Burn Patients is Related to the Extent of Burns Rather than Age, Underlying Medical Conditions, or the Administration of Resuscitation Fluid ( J Trauma, 1998) [MEDLINE]
    • Physiology: unclear mechanism
  • Carboxyhemoglobinemia (see Carboxyhemoglobinemia, [[Carboxyhemoglobinemia]])
    • Physiology: xxxx
  • Cardiac Ablation (see xxxx, [[xxxx]])
  • Cardiac Contusion (see Cardiac Contusion, [[Cardiac Contusion]])
    • Physiology: due to myocardial trauma
  • Cardiac Infiltrative Disease
    • Epidemiolgy
    • Physiology: due to myocyte compression
  • Cardiotoxic Chemotherapy/Toxins
    • Epidemiology
    • Physiology: due to cardiac toxicity
  • Cardioversion (Direct Current) (see Cardioversion, [[Cardioversion]])
  • Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])
    • Epidemiology: troponin elevation tends to be associated with advanced heart failure and worse prognosis
    • Physiology: due to myocardial strain and/or myocyte death
  • Diabetes Mellitus with Stable Coronary Artery Disease
    • Physiology: xxxx
    • Clinical Data
      • Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI 2D) Trial of High-Sensitivity Troponin Assay (NEJM, 2015) [MEDLINE]: n= 85 patients who had both type 2 diabetes and stable ischemic heart disease
        • Approximately 99.6% of Patients with Both NIDDM and Stable Ischemic Heart Disease Had Detectable (≥3 ng/L) Troponin T Levels
        • Approximately 39.3% of Patients with Both NIDDM and Stable Ischemic Heart Disease Had Abnormal Baseline Troponin T Levels (Above the Upper Reference Limit Which Defined Myocardial Injury)
        • In Patients with Both NIDDM and Stable Ischemic Heart Disease, Elevated Baseline Troponin T Level Correlated with Increased Risk of Death from Cardiovascular Disease, Myocardial Infarction, and Stroke at 5 Years: risk was 27% (double that of the group with normal baseline troponin T levels)
        • An Abnormal Troponin T of ≥14 ng/L Did Not Identify a Subgroup of Patients Who Benefited from Random Assignment to Prompt Coronary Revascularization
  • Duchenne Muscular Dystrophy (see Duchenne Muscular Dystrophy, [[Duchenne Muscular Dystrophy]])
    • Epidemiology: usually mild elevation (<1.5)
    • Physiology: xxx
  • Electrical Shock (see Electrical Shock, [[Electrical Shock]])
    • Physiology: xxxx
  • Endomyocardial Biopsy (see Endomyocardial Biopsy, [[Endomyocardial Biopsy]])
    • Physiology: xxx
  • Heart Transplant (see Heart Transplant, [[Heart Transplant]])
    • Physiology: due to inflammation and immune-mediated mechanisms
  • Myocarditis (see Myocarditis, [[Myocarditis]])
    • Epidemiology: troponin elevation may occur in myocarditis (Circulation, 1997) [MEDLINE]
    • Physiology: due to myocardial inflammation
  • Peripartum Cardiomyopathy
    • Physiology: xxx
  • Rhabdomyolysis (see Rhabdomyolysis, [[Rhabdomyolysis]])
    • Physiology: involving the cardiac muscle
  • Sepsis (see Sepsis, [[Sepsis]])
    • Physiology:
  • Takotsubo Cardiomyopathy (see Takotsubo Cardiomyopathy, [[Takotsubo Cardiomyopathy]])
    • Physiology: xxxx

References

  • Elevations of cardiac troponin I associated with myocarditis. Experimental and clinical correlates. Circulation. 1997;95(1):163 [MEDLINE]
  • Evaluation of troponin-I as an indicator of cardiac dysfunction after thermal injury. J Trauma. 1998;45(4):700 [MEDLINE]
  • Elevation of serum cardiac troponin I in noncardiac and cardiac disease other than acute coronary syndromes.  Am J Emerg Med.  1999;17:225–229 [MEDLINE]
  • [Myocardial injury in acute stroke assessed by troponin I]. Tidsskr Nor Laegeforen. 2001;121(4):421 [MEDLINE]
  • Circulating cardiac troponin I in acute pericarditis. Am J Cardiol. 2001;87(11):132 [MEDLINE]
  • Cardiac troponin I in patients with severe exacerbation of chronic obstructive pulmonary disease. Intensive Care Med. 2003;29(4):584 [MEDLINE]
  • Troponin-I elevation in patients with increased left ventricular mass. Am J Cardiol. 2003;92(1):88 [MEDLINE]
  • Cardiac troponin I in aortic valve disease. Int J Cardiol. 2003;89(2-3):281 [MEDLINE]
  • Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke. 2004;35(2):548. Epub 2004 Jan 22 [MEDLINE]
  • Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage. Circulation. 2005;112(18):2851 [MEDLINE]
  • National Academy of Clinical Biochemistry laboratory medicine practice guidelines: use of cardiac troponin and B-type natriuretic peptide or N-terminal proB-type natriuretic peptide for etiologies other than acute coronary syndromes and heart failure. Clin Chem. 2007;53:2086-96 [MEDLINE]
  • Diseased skeletal muscle: a noncardiac source of increased circulating concentrations of cardiac troponin T. J Am Coll Cardiol. 2011;58(17):1819 [MEDLINE]
  • CCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2012;60:2427-63 [MEDLINE]
  • Cardiac troponins in young marathon runners.  Am J Cardiol.  2012;110:594–598 [MEDLINE]
  • Role of troponin in patients with chronic kidney disease and suspected acute coronary syndrome: a systematic review. Ann Intern Med. 2014 Oct 7;161(7):502-12. doi: 10.7326/M14-0746 [MEDLINE]
  • Prognostic value of cardiac troponin in patients with chronic kidney disease without suspected acute coronary syndrome: a systematic review and meta-analysis. Ann Intern Med. 2014 Oct 7;161(7):491-501. doi: 10.7326/M14-0743 [MEDLINE]
  • Troponin and cardiac events in stable ischemic heart disease and diabetes.  N Engl J Med.  2015;373:610–620 [MEDLINE]