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Elevated cardiac troponin concentration in the absence of an acute coronary syndrome

C Michael Gibson, MS, MD
David A Morrow, MD, MPH
Section Editor
Allan S Jaffe, MD
Deputy Editor
Gordon M Saperia, MD, FACC


The diagnosis of an acute myocardial infarction (MI) has traditionally relied upon the combination of chest pain, electrocardiographic (ECG) abnormalities, and elevations in serum biomarkers of cardiac injury. Symptoms and ECG abnormalities, however, may be absent or nonspecific. Thus, the diagnosis of an acute MI has increasingly depended upon evaluation of cardiac biomarkers, particularly cardiac troponins.

The 2012 Joint European Society of Cardiology/American College of Cardiology/American Heart Association/World Health Federation Task Force for the definition of MI emphasized the importance of both elevated cardiac biomarkers and clinical evidence for myocardial ischemia [1]. This expert consensus document suggests that the term “MI” should be used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia. In this setting, detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper reference limit is one of the criteria to diagnose MI together with symptomatic, ECG or echocardiographic evidence of myocardial ischemia [1,2]. (See "Criteria for the diagnosis of acute myocardial infarction", section on 'Third universal definition of MI'.)

Clinical evidence of myocardial ischemia is necessary because serum/plasma troponin elevations may reflect myocardial injury that is not necessarily due to an acute coronary syndrome (ACS). Increased blood concentrations of troponin can also be seen in a variety of other diseases, such as sepsis, atrial fibrillation, heart failure, pulmonary embolism, myocarditis, myocardial contusion, and renal failure.

Among patients with a high pretest probability of acute thrombotic coronary heart disease (CHD), the value of troponin for diagnosis, risk assessment, and therapeutic decision making is clear. However, in patients with a low pretest probability of CHD, troponin elevations are not specific to acute thrombotic disease and may, in some cases, divert attention from the true underlying clinical problem and lead to unnecessary invasive cardiac testing.

Potential causes of troponin elevation unrelated to coronary thrombosis, and the evaluation and management of patients with these conditions will be reviewed here. The biochemical characteristics of troponins and the utility of troponins for the diagnosis of acute MI are discussed in detail separately. (See "Excitation-contraction coupling in myocardium" and "Criteria for the diagnosis of acute myocardial infarction" and "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Cardiac biomarkers' and "Troponin testing: Analytical aspects", section on 'What is troponin'.)


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Literature review current through: Jul 2017. | This topic last updated: Jan 30, 2017.
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