ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations

Perspective:

The following are 10 points to remember from an Expert Consensus Document on interpretation of troponin elevations:

1. Even though elevated troponin is a sensitive and specific indication of cardiac myonecrosis, by itself, it does not indicate a myocardial infarction (MI) (myonecrosis due to ischemia) or any specific etiology.

2. The ‘Third Universal Definition of Myocardial Infarction’ (2012) classifies 5 types of MI: Type 1 is termed spontaneous, related to ischemia due to a primary coronary event (e.g., plaque rupture); Type 2 is secondary to increased oxygen demand or decreased supply; Type 3 is associated with sudden unexpected cardiac death; Type 4a is associated with percutaneous coronary intervention (PCI); Type 4b is associated with stent thrombosis; and Type 5 is associated with coronary artery bypass grafting (CABG) surgery.

3. An elevated troponin level that is ‘smoldering’ and relatively constant over an appropriate sampling interval is more likely to be caused by chronic diseases (e.g., heart failure) versus ischemia.

4. A 20% change at 3-6 hours from the baseline value may be suggestive of MI. That said, there is insufficient evidence to provide concrete guidelines on how to differentiate between acute coronary syndrome (ACS) and non-ACS ischemia-induced troponin elevations without accounting for the clinical circumstances.

5. It is imperative to incorporate troponin testing into global risk assessment. Those patients with an elevated troponin and a high pretest probability of ACS are most likely to derive benefit from a treatment strategy that targets coronary thrombosis.

6. The 2012 universal definition of MI recommends the following for defining a PCI-related MI (Type 4a): a troponin elevation within 48 hours post-procedure of >5x upper limit of normal (ULN) with either symptoms of myocardial ischemia, new ischemic electrocardiographic changes, or documented complications during the procedure.

7. The 2012 universal definition of MI recommends the following for CABG-related MI (Type 5): troponin elevation >10x ULN when there are corresponding changes on ECG, angiography, or imaging.

8. Currently, there is no established role for troponin testing in the diagnosis of pulmonary embolism. That said, in the absence of hemodynamic instability, troponin testing offers excellent negative predictive value for in-hospital death.

9. Regardless of the etiology of troponin elevation (or associated disease state), troponin elevation offers incremental prognostic value.

10. Troponin may be a useful tool to detect chemotherapy-associated cardiac toxicity, and may have a role in informing the use of treatment in those patients who develop cardiac myonecrosis following high-dose chemotherapy.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, ACS and Cardiac Biomarkers, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and ACS

Keywords: Prognosis, Myocardial Infarction, Acute Coronary Syndrome, Myocardial Ischemia, Biological Markers, Heart Failure, Coronary Thrombosis, Electrocardiography, Coronary Artery Bypass, Troponin, Percutaneous Coronary Intervention


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