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Interpretation of cardiac troponin levels regarding the fourth universal definition of myocardial infarction published in 2018

Anna Borzyszkowska, Agnieszka Mickiewicz, Izabela Pisowodzka, Marcin Gruchała, Marcin Fijałkowski
DOI: 10.5603/FC.a2020.0017

open access

Ahead of print
Review Papers
Published online: 2020-05-05

Abstract

Cardiac troponin (cTn) is a laboratory test routinely used in patients with suspected acute coronary syndrome (ACS). Unfortunately, wide variety of laboratory assays and different cut-off values regarding gender may result in difficulties with diagnosis and delay the treatment. Troponin I and less specific troponin T are used to diagnose ACS. Dynamic changes in cTn concentration are required to confirm the diagnosis of myocardial infarction (MI). The fourth universal definition of myocardial infarction defines five major types of MI — atherosclerotic plaque disruption, imbalance between myocardial oxygen supply and demand unrelated to acute coronary atherothrombosis, cardiac death with symptoms suggestive of myocardial ischaemia and new ischaemic electrocardiographic changes, MI connected with percutaneous coronary intervention or coronary bypass grafting. Considering this definition, increased cTn concentrations are not always related to abnormal findings in coronary angiography and can be associated with many conditions. Increased high sensitivity cTn values in healthy individuals can be induced by intense physical activity, which is confirmed by studies performed in marathoners. While elevated cTn levels are observed in 20–60% of patients with acute ischemic stroke and are associated with an increased long-term mortality, acute MI is diagnosed only in 3,5% of patients. Elevated cTn levels often accompany chronic kidney disease, however changes in serial testing are obligatory for acute MI diagnosis. Deterioration of kidney function is more connected with elevated TnT rather than TnI levels. Regardless of the reason, increased cTn concentration is a negative predictive factor. Patients with elevated cTn levels need further diagnosis, risk stratification and a long-term follow-up.

Abstract

Cardiac troponin (cTn) is a laboratory test routinely used in patients with suspected acute coronary syndrome (ACS). Unfortunately, wide variety of laboratory assays and different cut-off values regarding gender may result in difficulties with diagnosis and delay the treatment. Troponin I and less specific troponin T are used to diagnose ACS. Dynamic changes in cTn concentration are required to confirm the diagnosis of myocardial infarction (MI). The fourth universal definition of myocardial infarction defines five major types of MI — atherosclerotic plaque disruption, imbalance between myocardial oxygen supply and demand unrelated to acute coronary atherothrombosis, cardiac death with symptoms suggestive of myocardial ischaemia and new ischaemic electrocardiographic changes, MI connected with percutaneous coronary intervention or coronary bypass grafting. Considering this definition, increased cTn concentrations are not always related to abnormal findings in coronary angiography and can be associated with many conditions. Increased high sensitivity cTn values in healthy individuals can be induced by intense physical activity, which is confirmed by studies performed in marathoners. While elevated cTn levels are observed in 20–60% of patients with acute ischemic stroke and are associated with an increased long-term mortality, acute MI is diagnosed only in 3,5% of patients. Elevated cTn levels often accompany chronic kidney disease, however changes in serial testing are obligatory for acute MI diagnosis. Deterioration of kidney function is more connected with elevated TnT rather than TnI levels. Regardless of the reason, increased cTn concentration is a negative predictive factor. Patients with elevated cTn levels need further diagnosis, risk stratification and a long-term follow-up.

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Keywords

troponin; myocardial infarction; acute coronary syndrome

About this article
Title

Interpretation of cardiac troponin levels regarding the fourth universal definition of myocardial infarction published in 2018

Journal

Folia Cardiologica

Issue

Ahead of print

Published online

2020-05-05

DOI

10.5603/FC.a2020.0017

Keywords

troponin
myocardial infarction
acute coronary syndrome

Authors

Anna Borzyszkowska
Agnieszka Mickiewicz
Izabela Pisowodzka
Marcin Gruchała
Marcin Fijałkowski

References (40)
  1. Ebashi S. Third component participating in the super precipitation of 'natural actomyosin'. Nature. 1963; 200: 1010.
  2. Eggers KM, Lindahl B. Application of cardiac troponin in cardiovascular diseases other than acute coronary syndrome. Clin Chem. 2017; 63(1): 223–235.
  3. Antman E, Bassand JP, Klein W, et al. Myocardial infarction redefined — a consensus document of the Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000; 36(3): 959–969.
  4. Thygesen K, Alpert JS, Jaffe AS, et al. [Fourth universal definition of myocardial infarction (2018)] [Article in Polish]. Kardiol Pol. 2018; 76(10): 1383–1415.
  5. Park KC, Gaze DC, Collinson PO, et al. Cardiac troponins: from myocardial infarction to chronic disease. Cardiovasc Res. 2017; 113(14): 1708–1718.
  6. Baker JO, Reinhold J, Redwood S, et al. Troponins: redefining their limits. Heart. 2011; 97(6): 447–452.
  7. Thygesen K, Mair J, Giannitsis E, et al. Study Group on Biomarkers in Cardiology of ESC Working Group on Acute Cardiac Care. How to use high-sensitivity cardiac troponins in acute cardiac care. Eur Heart J. 2012; 33(18): 2252–2257.
  8. Thygesen K, Mair J, Katus H, et al. Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Recommendations for the use of cardiac troponin measurement in acute cardiac care. Eur Heart J. 2010; 31(18): 2197–2204.
  9. Jaffe AS, Vasile VC, Milone M, et al. Diseased skeletal muscle: a noncardiac source of increased circulating concentrations of cardiac troponin T. J Am Coll Cardiol. 2011; 58(17): 1819–1824.
  10. Vestergaard KR, Jespersen CB, Arnadottir A, et al. Prevalence and significance of troponin elevations in patients without acute coronary disease. Int J Cardiol. 2016; 222: 819–825.
  11. Schmid J, Liesinger L, Birner-Gruenberger R, et al. Elevated cardiac troponin T in patients with skeletal myopathies. J Am Coll Cardiol. 2018; 71(14): 1540–1549.
  12. Apple FS, Jaffe AS, Collinson P, et al. International Federation of Clinical Chemistry (IFCC) Task Force on Clinical Applications of Cardiac Bio-Markers. IFCC educational materials on selected analytical and clinical applications of high sensitivity cardiac troponin assays. Clin Biochem. 2015; 48(4-5): 201–203.
  13. Apple FS, Sandoval Y, Jaffe AS, et al. IFCC Task Force on Clinical Applications of Cardiac Bio-Markers. Cardiac troponin assays: guide to understanding analytical characteristics and their impact on clinical care. Clin Chem. 2017; 63(1): 73–81.
  14. Collinson PO, Heung YM, Gaze D, et al. Influence of population selection on the 99th percentile reference value for cardiac troponin assays. Clin Chem. 2012; 58(1): 219–225.
  15. Collet J-P, Thiele H, Barbato E, et al. ESC Scientific Document Group , ESC Scientific Document Group , ESC Scientific Document Group . Questions and answers on workup diagnosis and risk stratification: a companion document of the 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020 [Epub ahead of print].
  16. Bjurman C, Larsson M, Johanson P, et al. Small changes in troponin T levels are common in patients with non-ST-segment elevation myocardial infarction and are linked to higher mortality. J Am Coll Cardiol. 2013; 62(14): 1231–1238.
  17. D'Souza M, Sarkisian L, Saaby L, et al. Diagnosis of unstable angina pectoris has declined markedly with the advent of more sensitive troponin assays. Am J Med. 2015; 128(8): 852–860.
  18. Giannitsis E, Katus HA. Cardiac troponin level elevations not related to acute coronary syndromes. Nat Rev Cardiol. 2013; 10(11): 623–634.
  19. Vilela EM, Bastos JCC, Rodrigues RP, et al. High-sensitivity troponin after running — a systematic review. Neth J Med. 2014; 72(1): 5–9.
  20. Richardson AJ, Leckie T, Watkins ER, et al. Post marathon cardiac troponin T is associated with relative exercise intensity. J Sci Med Sport. 2018; 21(9): 880–884.
  21. Leckie T, Richardson A, Watkins E, et al. High-sensitivity troponin T in marathon runners, marathon runners with heart disease and collapsed marathon runners. Scand J Med Sci Sports. 2019; 29(5): 663–668.
  22. Shave R, Baggish A, George K, et al. Exercise-induced cardiac troponin elevation: evidence, mechanisms, and implications. J Am Coll Cardiol. 2010; 56(3): 169–176.
  23. Faiz KW, Thommessen B, Einvik G, et al. Determinants of high sensitivity cardiac troponin T elevation in acute ischemic stroke. BMC Neurol. 2014; 14: 96.
  24. Anders B, Alonso A, Artemis D, et al. What does elevated high-sensitive troponin I in stroke patients mean: concomitant acute myocardial infarction or a marker for high-risk patients? Cerebrovasc Dis. 2013; 36(3): 211–217.
  25. Scheitz JF, Mochmann HC, Erdur H, et al. Prognostic relevance of cardiac troponin T levels and their dynamic changes measured with a high-sensitivity assay in acute ischaemic stroke: analyses from the TRELAS cohort. Int J Cardiol. 2014; 177(3): 886–893.
  26. Scheitz JF, Nolte CH, Laufs U, et al. Application and interpretation of high-sensitivity cardiac troponin assays in patients with acute ischemic stroke. Stroke. 2015; 46(4): 1132–1140.
  27. Wrigley P, Khoury J, Eckerle B, et al. Prevalence of positive troponin and echocardiogram findings and association with mortality in acute ischemic stroke. Stroke. 2017; 48(5): 1226–1232.
  28. Mochmann HC, Scheitz JF, Petzold GC, et al. TRELAS Study Group. Coronary angiographic findings in acute ischemic stroke patients with elevated cardiac troponin: the troponin elevation in acute ischemic stroke (TRELAS) study. Circulation. 2016; 133(13): 1264–1271.
  29. Yaghi S, Chang AD, Ricci BA, et al. Early elevated troponin levels after ischemic stroke suggests a cardioembolic source. Stroke. 2018; 49(1): 121–126.
  30. van der Linden N, Cornelis T, Kimenai DM, et al. Origin of cardiac troponin T elevations in chronic kidney dDisease. Circulation. 2017; 136(11): 1073–1075.
  31. Jacobs LH, van de Kerkhof J, Mingels AM, et al. Haemodialysis patients longitudinally assessed by highly sensitive cardiac troponin T and commercial cardiac troponin T and cardiac troponin I assays. Ann Clin Biochem. 2009; 46(Pt 4): 283–290.
  32. deFilippi C, Seliger SL, Kelley W, et al. Interpreting cardiac troponin results from high-sensitivity assays in chronic kidney disease without acute coronary syndrome. Clin Chem. 2012; 58(9): 1342–1351.
  33. Klinkenberg LJJ, Wildi K, van der Linden N, et al. Diurnal rhythm of cardiac troponin: consequences for the diagnosis of acute myocardial infarction. Clin Chem. 2016; 62(12): 1602–1611.
  34. Fridén V, Starnberg K, Muslimovic A, et al. Clearance of cardiac troponin T with and without kidney function. Clin Biochem. 2017; 50(9): 468–474.
  35. Januzzi JL, Filippatos G, Nieminen M, et al. Troponin elevation in patients with heart failure: on behalf of the third Universal Definition of Myocardial Infarction Global Task Force: Heart Failure Section. Eur Heart J. 2012; 33(18): 2265–2271.
  36. Stacy SR, Suarez-Cuervo C, Berger Z, et al. Role of troponin in patients with chronic kidney disease and suspected acute coronary syndrome: a systematic review. Ann Intern Med. 2014; 161(7): 502–512.
  37. Mair J, Lindahl B, Müller C, et al. What to do when you question cardiac troponin values. Eur Heart J Acute Cardiovasc Care. 2018; 7(6): 577–586.
  38. Chapman AR, Shah ASV, Lee KK, et al. Long-term outcomes in patients with type 2 myocardial infarction and myocardial injury. Circulation. 2018; 137(12): 1236–1245.
  39. Chapman AR, Lee KK, McAllister DA, et al. Association of high-sensitivity cardiac troponin I concentration with cardiac outcomes in patients with suspected acute coronary syndrome. JAMA. 2017; 318(19): 1913–1924.
  40. Bularga A, Lee KK, Stewart S, et al. High-sensitivity troponin and the application of risk stratification thresholds in patients with suspected acute coronary syndrome. Circulation. 2019; 140(19): 1557–1568.

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