By Adel Eldin, MD, FACC, FACP
Troponin is a Cardiac muscle enzyme which is used for evaluation of Cardiac etiology for chest pain and ruling out Acute Heart Attacks. If it is found to be elevated in the setting of chest pain presentation, this would indicate damage of myocardial cells that has resulted in leaking the enzyme into the blood stream and thus could be measured with a blood test.Troponins measured serially a few hours apart and if found to be elevated above normal levels, this would then indicate a heart attack in the proper context of clinical history, physical exam and electrocardiographic changes to make the diagnosis.
Acute heart attacks comes in two forms, the first is called ST Elevation Myocardial Infarction( STEMI) with complete occlusion of the artey supplying a certain territrory of the heart muscle and the second type is (Non-STEMI) as the artery causing the acute heart attack is not completely occluded. It sill has some flow of blood even if minimal through the artery with narrowing or blockage due to cholesterol/plaque build up. Troponin Test is the more sensitive than other Cardiac biomarkers of muscle injury such as CK-MB or Myoglobin. Thus, Troponin is ordered when symptoms of chest pain, cardiac arrythmias, shortness of breath, cold sweats, pain in neck, jaw or back occurs.
Troponin rise will certainly get immediate attention to the patient cardiac status as if the trend of troponin elevation continues along with propoer clinical presentation. We need to exercise caution here as to not interpret every Troponin rise as acute heart attack . There are a number of cardiac and non cardiac conditions would cause Troponin rise such as myocarditis, weak Heart Muscle ( Cardiomyopathy), pulmonary embolism ( blood clot in the lung), drop of blood pressure due to infection or dehydration , severe rise of blood pressure, kidney failure as Troponin is being cleared through the Kidneys, fast or irregular heart beats such as Atrial Fibrillations when the heart does not get enough time to relax. Also, Myocardial contusion due to blunt trauma to the heart and chestwall frequently takes place with car accidents. Similarly Aortic dissection, Broken Heart syndrome mostly affecting female patients after experienceing severe emotional trauma. Troponin can be elevated also after Cardiac surgeries, procedures like Angioplasty/stenting or Ablation. Similarly, Troponin can be elevated after acute strokes, hypothyroidism, severe Gastrointestinal bleeding, or pulmonary hypertension( elevated pressure inside the lung due to various causes).
It is very important to avoid the inaccurate diagnosis of Acute Heart Attack with just isolated elevation of Troponin levels, but rather in the proper setting of clinical presentation and Electrocardiogic findings that goes along with the patient symptoms making the diagnosis of (Acute Coronary Syndrome) as this will be triggering a cascade of different management Algorithms to start treating patients with Anti-platelet therapy such as Aspirin and Plavix, additional blood thinners, lipid lowering therapy, blood pressure medications and Nitrate therapy to alleviate chest pain. Then most likely, proceed to further testing such as Cardiac Catheterization with possible Angioplasty and deployment of intra-coronary stent if significant blockage/narrowing in one artery was found or even CoronaryArtery Bypass Surgery if many significant blockages are found.
On the other hand, if Troponin elevation was due to other causes rather than a heart attack, then treatment of the underlying cause will be the proper management strategy in a totally separate track. For example, if elevated Troponin is due to infection or sepsis then treatment with appropriate Antibiotic coverage and Intravenous fluids to bring blood pressure up will be the correct way to go about addressing elevated Troponin level in those cases.
The proper evidence-based clinical management of minimally elevated Troponin which is being encountered on daily basis, will certainly lead to better patient clinical outcome in addition to saving billions of Healthcare dollars. Proper diagnosis, coding and following a relevant treatment pathway will help us with the daily common challenge of how to appropriately manage elevated Troponins clinically.
Adel Eldin, MD, is a Board Certified Cardiologist and Founder/CEO of ProntoCare. Visit www.prontocare.co
