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  • Review Article
  • Published:

Cardiac troponin level elevations not related to acute coronary syndromes

Nature Reviews Cardiology volume 10, pages 623–634 (2013)Cite this article

Subjects

Key Points

  • One-fifth of acutely symptomatic patients admitted to an emergency department have elevated levels of cardiac troponins (cTn), but the majority do not have an acute coronary syndrome (ACS)

  • Reasons for elevated cTn levels in acute or chronic non-ACS conditions are likely to be multifactorial, including myocardial ischaemia, ventricular strain, myocyte trauma, impaired renal clearance, and unknown mechanisms

  • High-sensitivity assays for cTn can rule out non-ST-segment elevation myocardial infarction at an early stage in the diagnostic process

  • The result of a test for cTn levels should not be interpreted in isolation, but in the context of clinical findings

  • Even low levels of cTn can be prognostically important and associated with adverse outcomes in the absence of an ACS, and require investigation of the underlying causes

Abstract

Over the past 2 decades, cardiac troponins (cTn) have emerged as the preferred biomarkers for the noninvasive detection of myocardial injury. In conjunction with typical clinical findings of ischaemia, elevated cTn levels in blood confirm a diagnosis of myocardial infarction. However, neither cTnT or cTnI are exclusively released as a result of ischaemic myocardial cell necrosis, but also with numerous nonischaemic acute and chronic cardiac conditions, such as myopericarditis, toxic injury, or severe cardiac overload. With the advent of high-sensitivity assays, causes of cTn elevation not related to an acute coronary syndrome (ACS) have become common findings in patients with chest pain and in those with acute or chronic systemic disorders. Elevated cTn levels in blood are associated with increased rates of cardiac events and mortality, independently of the underlying disease. However, the clinical conditions leading to cTn release in patients who do not have ACS, and the appropriate diagnostic and therapeutic strategies for these individuals, are largely unknown. Here, we provide an overview of the many causes and the prognostic importance of the release of cTn not related to ACS. We also recommend strategies to discriminate between ischaemic and nonischaemic cTn elevation, and describe the clinical evaluation of these patients.

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Figure 1: Algorithm for accelerated rule-out and rule-in of NSTEMI based on ESC recommendations.5,9
Figure 2: Release of cTnT after reperfused STEMI, after acute pulmonary embolism, and after a marathon run.
Figure 3: Proposed pathophysiological mechanisms and modifying factors for elevated levels of cardiac troponins (cTn) in blood.
Figure 4: Prevalence and reasons for elevated levels of cTnI among patients admitted to an emergency department over a 3-month period.

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  1. Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany

    Evangelos Giannitsis & Hugo A. Katus

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Both authors researched data for the article, contributed to the discussion of content, wrote the manuscript, and reviewed/edited the article before submission.

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Correspondence to Evangelos Giannitsis.

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Competing interests

H. A. Katus invented the cTnT assay and holds a patent jointly with Roche Diagnostics. He receives honoraria for lectures and research grants from Roche Diagnostics. E. Giannitsis receives honoraria for lecturers and research grants from Roche Diagnostics.

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Giannitsis, E., Katus, H. Cardiac troponin level elevations not related to acute coronary syndromes. Nat Rev Cardiol 10, 623–634 (2013). https://doi.org/10.1038/nrcardio.2013.129

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