Troponin testing: Clinical use
- Allan S Jaffe, MD
Allan S Jaffe, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Mayo Medical School
- David A Morrow, MD, MPH
David A Morrow, MD, MPH
- Professor of Medicine
- Harvard Medical School
- Section Editor
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
Cardiac troponin I and cardiac troponin T are relatively specific and sensitive biomarkers of cardiac injury. They are the preferred serologic tests for the evaluation of patients with suspected acute coronary syndrome (ACS). (See "Biomarkers of cardiac injury other than troponin", section on 'Why troponin is preferred'.)
Troponin assays with varying sensitivities are available. Some contemporary assays and rare point-of-care assays are "sensitive” assays." "Highly sensitive" troponin tests are available for clinical use throughout the world but not in the United States.
This topic will focus on the role of troponin testing in the evaluation of patients with suspected ACS but will also discuss troponin testing in other cardiovascular settings (See "Evaluation of patients with chest pain at low or intermediate risk for acute coronary syndrome", section on 'Initial evaluation'.).
Analytical and technical aspects of are discussed separately. (See "Troponin testing: Analytical aspects".)
Other biomarkers of cardiac injury and other (than an acute myocardial infarction) disease states in which elevation of biomarkers are seen are discussed separately. (See "Biomarkers of cardiac injury other than troponin" and "Elevated cardiac troponin concentration in the absence of an acute coronary syndrome".)
- Macrae AR, Kavsak PA, Lustig V, et al. Assessing the requirement for the 6-hour interval between specimens in the American Heart Association Classification of Myocardial Infarction in Epidemiology and Clinical Research Studies. Clin Chem 2006; 52:812.
- deFilippi CR, Tocchi M, Parmar RJ, et al. Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. J Am Coll Cardiol 2000; 35:1827.
- Ong P, Athanasiadis A, Hill S, et al. Coronary artery spasm as a frequent cause of acute coronary syndrome: The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) Study. J Am Coll Cardiol 2008; 52:523.
- Thygesen K, Alpert JS, White HD, Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007; 28:2525.
- Franz WM, Remppis A, Kandolf R, et al. Serum troponin T: diagnostic marker for acute myocarditis. Clin Chem 1996; 42:340.
- Villata G, Bollati M, Gambino A, et al. Comment on the 'pilot' GRACIA-2 randomized trial. Eur Heart J 2007; 28:2417.
- Reynolds HR, Srichai MB, Iqbal SN, et al. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation 2011; 124:1414.
- Müller-Bardorff M, Weidtmann B, Giannitsis E, et al. Release kinetics of cardiac troponin T in survivors of confirmed severe pulmonary embolism. Clin Chem 2002; 48:673.
- Allan JJ, Feld RD, Russell AA, et al. Cardiac troponin I levels are normal or minimally elevated after transthoracic cardioversion. J Am Coll Cardiol 1997; 30:1052.
- Carrier M, Pellerin M, Perrault LP, et al. Troponin levels in patients with myocardial infarction after coronary artery bypass grafting. Ann Thorac Surg 2000; 69:435.
- Januzzi JL, Lewandrowski K, MacGillivray TE, et al. A comparison of cardiac troponin T and creatine kinase-MB for patient evaluation after cardiac surgery. J Am Coll Cardiol 2002; 39:1518.
- Croal BL, Hillis GS, Gibson PH, et al. Relationship between postoperative cardiac troponin I levels and outcome of cardiac surgery. Circulation 2006; 114:1468.
- Steuer J, Bjerner T, Duvernoy O, et al. Visualisation and quantification of peri-operative myocardial infarction after coronary artery bypass surgery with contrast-enhanced magnetic resonance imaging. Eur Heart J 2004; 25:1293.
- Thielmann M, Massoudy P, Jaeger BR, et al. Emergency re-revascularization with percutaneous coronary intervention, reoperation, or conservative treatment in patients with acute perioperative graft failure following coronary artery bypass surgery. Eur J Cardiothorac Surg 2006; 30:117.
- Khan J, Alonso-Coello P, Devereaux PJ. Myocardial injury after noncardiac surgery. Curr Opin Cardiol 2014; 29:307.
- Daniels LB, Laughlin GA, Clopton P, et al. Minimally elevated cardiac troponin T and elevated N-terminal pro-B-type natriuretic peptide predict mortality in older adults: results from the Rancho Bernardo Study. J Am Coll Cardiol 2008; 52:450.
- Korley FK, Schulman SP, Sokoll LJ, et al. Troponin elevations only detected with a high-sensitivity assay: clinical correlations and prognostic significance. Acad Emerg Med 2014; 21:727.
- Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation 2012; 126:2020.
- Neumann JT, Sörensen NA, Schwemer T, et al. Diagnosis of Myocardial Infarction Using a High-Sensitivity Troponin I 1-Hour Algorithm. JAMA Cardiol 2016; 1:397.
- Carlton E, Greenslade J, Cullen L, et al. Evaluation of High-Sensitivity Cardiac Troponin I Levels in Patients With Suspected Acute Coronary Syndrome. JAMA Cardiol 2016; 1:405.
- Shah AS, Anand A, Sandoval Y, et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet 2015; 386:2481.
- Mueller C, Giannitsis E, Christ M, et al. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T. Ann Emerg Med 2016; 68:76.
- Bohula May EA, Bonaca MP, Jarolim P, et al. Prognostic performance of a high-sensitivity cardiac troponin I assay in patients with non-ST-elevation acute coronary syndrome. Clin Chem 2014; 60:158.
- Bonaca MP, O'Malley RG, Murphy SA, et al. Prognostic performance of a high-sensitivity assay for cardiac troponin I after non-ST elevation acute coronary syndrome: Analysis from MERLIN-TIMI 36. Eur Heart J Acute Cardiovasc Care 2015; 4:431.
- Reichlin T, Hochholzer W, Bassetti S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 2009; 361:858.
- Keller T, Zeller T, Peetz D, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 2009; 361:868.
- Jaffe AS, Apple FS. High-sensitivity cardiac troponin: hype, help, and reality. Clin Chem 2010; 56:342.
- Mills NL, Churchhouse AM, Lee KK, et al. Implementation of a sensitive troponin I assay and risk of recurrent myocardial infarction and death in patients with suspected acute coronary syndrome. JAMA 2011; 305:1210.
- Keller T, Zeller T, Ojeda F, et al. Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA 2011; 306:2684.
- Korley FK, Jaffe AS. Preparing the United States for high-sensitivity cardiac troponin assays. J Am Coll Cardiol 2013; 61:1753.
- Giannitsis E, Kurz K, Hallermayer K, et al. Analytical validation of a high-sensitivity cardiac troponin T assay. Clin Chem 2010; 56:254.
- Diamond GA, Kaul S. How would the Reverend Bayes interpret high-sensitivity troponin? Circulation 2010; 121:1172.
- Januzzi JL Jr, Bamberg F, Lee H, et al. High-sensitivity troponin T concentrations in acute chest pain patients evaluated with cardiac computed tomography. Circulation 2010; 121:1227.
- Wu AH, Jaffe AS. The clinical need for high-sensitivity cardiac troponin assays for acute coronary syndromes and the role for serial testing. Am Heart J 2008; 155:208.
- Katus HA, Giannitsis E, Jaffe AS, Thygesen K. Higher sensitivity troponin assays: Quo vadis? Eur Heart J 2009; 30:127.
- Giannitsis E, Becker M, Kurz K, et al. High-sensitivity cardiac troponin T for early prediction of evolving non-ST-segment elevation myocardial infarction in patients with suspected acute coronary syndrome and negative troponin results on admission. Clin Chem 2010; 56:642.
- Reiter M, Twerenbold R, Reichlin T, et al. Early diagnosis of acute myocardial infarction in the elderly using more sensitive cardiac troponin assays. Eur Heart J 2011; 32:1379.
- Saunders JT, Nambi V, de Lemos JA, et al. Cardiac troponin T measured by a highly sensitive assay predicts coronary heart disease, heart failure, and mortality in the Atherosclerosis Risk in Communities Study. Circulation 2011; 123:1367.
- Licka M, Zimmermann R, Zehelein J, et al. Troponin T concentrations 72 hours after myocardial infarction as a serological estimate of infarct size. Heart 2002; 87:520.
- Panteghini M, Cuccia C, Bonetti G, et al. Single-point cardiac troponin T at coronary care unit discharge after myocardial infarction correlates with infarct size and ejection fraction. Clin Chem 2002; 48:1432.
- Steen H, Giannitsis E, Futterer S, et al. Cardiac troponin T at 96 hours after acute myocardial infarction correlates with infarct size and cardiac function. J Am Coll Cardiol 2006; 48:2192.
- Giannitsis E, Steen H, Kurz K, et al. Cardiac magnetic resonance imaging study for quantification of infarct size comparing directly serial versus single time-point measurements of cardiac troponin T. J Am Coll Cardiol 2008; 51:307.
- Vasile VC, Babuin L, Giannitsis E, et al. Relationship of MRI-determined infarct size and cTnI measurements in patients with ST-elevation myocardial infarction. Clin Chem 2008; 54:617.
- Olatidoye AG, Wu AH, Feng YJ, Waters D. Prognostic role of troponin T versus troponin I in unstable angina pectoris for cardiac events with meta-analysis comparing published studies. Am J Cardiol 1998; 81:1405.
- Heidenreich PA, Alloggiamento T, Melsop K, et al. The prognostic value of troponin in patients with non-ST elevation acute coronary syndromes: a meta-analysis. J Am Coll Cardiol 2001; 38:478.
- Heeschen C, Hamm CW, Goldmann B, et al. Troponin concentrations for stratification of patients with acute coronary syndromes in relation to therapeutic efficacy of tirofiban. PRISM Study Investigators. Platelet Receptor Inhibition in Ischemic Syndrome Management. Lancet 1999; 354:1757.
- Vasile VC, Babuin L, Ting HH, et al. Aborted myocardial infarction: is it real in the troponin era? Am Heart J 2009; 157:636.
- Ottani F, Galvani M, Nicolini FA, et al. Elevated cardiac troponin levels predict the risk of adverse outcome in patients with acute coronary syndromes. Am Heart J 2000; 140:917.
- Morrow DA, Antman EM, Tanasijevic M, et al. Cardiac troponin I for stratification of early outcomes and the efficacy of enoxaparin in unstable angina: a TIMI-11B substudy. J Am Coll Cardiol 2000; 36:1812.
- Lindahl B, Venge P, Wallentin L. Relation between troponin T and the risk of subsequent cardiac events in unstable coronary artery disease. The FRISC study group. Circulation 1996; 93:1651.
- Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996; 335:1342.
- Ohman EM, Armstrong PW, Christenson RH, et al. Cardiac troponin T levels for risk stratification in acute myocardial ischemia. GUSTO IIA Investigators. N Engl J Med 1996; 335:1333.
- Hamm CW, Goldmann BU, Heeschen C, et al. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med 1997; 337:1648.
- Lindahl B, Diderholm E, Lagerqvist B, et al. Mechanisms behind the prognostic value of troponin T in unstable coronary artery disease: a FRISC II substudy. J Am Coll Cardiol 2001; 38:979.
- Heeschen C, Hamm CW, Bruemmer J, Simoons ML. Predictive value of C-reactive protein and troponin T in patients with unstable angina: a comparative analysis. CAPTURE Investigators. Chimeric c7E3 AntiPlatelet Therapy in Unstable angina REfractory to standard treatment trial. J Am Coll Cardiol 2000; 35:1535.
- Lindahl B, Toss H, Siegbahn A, et al. Markers of myocardial damage and inflammation in relation to long-term mortality in unstable coronary artery disease. FRISC Study Group. Fragmin during Instability in Coronary Artery Disease. N Engl J Med 2000; 343:1139.
- Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000; 284:835.
- James SK, Armstrong P, Barnathan E, et al. Troponin and C-reactive protein have different relations to subsequent mortality and myocardial infarction after acute coronary syndrome: a GUSTO-IV substudy. J Am Coll Cardiol 2003; 41:916.
- Kontos MC, Shah R, Fritz LM, et al. Implication of different cardiac troponin I levels for clinical outcomes and prognosis of acute chest pain patients. J Am Coll Cardiol 2004; 43:958.
- Mueller C, Neumann FJ, Perruchoud AP, et al. Prognostic value of quantitative troponin T measurements in unstable angina/non-ST-segment elevation acute myocardial infarction treated early and predominantly with percutaneous coronary intervention. Am J Med 2004; 117:897.
- Newby LK, Christenson RH, Ohman EM, et al. Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes. The GUSTO-IIa Investigators. Circulation 1998; 98:1853.
- Apple FS, Murakami MM. Cardiac troponin and creatine kinase MB monitoring during in-hospital myocardial reinfarction. Clin Chem 2005; 51:460.
- POSSIBLE ACUTE MYOCARDIAL INJURY
- Suspected ACS
- - Differential diagnosis
- Use after revascularization
- Use after noncardiac surgery
- SENSITIVE COMPARED WITH HIGHLY SENSITIVE TESTS
- Pitfalls with hs assays
- AFTER MI
- Infarct size
- Prognosis after MI
- GENERAL POPULATION
- STABLE ISCHEMIC HEART DISEASE
- USE IN RENAL FAILURE