Perspective:

Cardiac troponins are currently the preferred biomarkers for diagnosis of myocardial infarction because of their high sensitivity and specificity for myocardial injury. However, even with current assays, acute and chronic conditions distinct from acute coronary syndrome (ACS) may lead to small elevations in troponin levels. The recently developed highly sensitive troponin assays will likely lead to further increase in the proportion of detectable troponin levels attributable to non-ACS conditions, and will present myriad challenges for clinicians evaluating patients with chest pain. Novel algorithms with highly sensitive assays, incorporating baseline troponin values and changes in values over 1-2 hours, may allow rapid exclusion of myocardial infarction and help to address specificity concerns, but must be prospectively validated in appropriate target populations. Future studies will need to clarify the clinical value and identify the best approach to incorporating these assays for population screening. In addition, recommendations for additional testing and referral for patients with increased cardiac troponin levels and a low clinical suspicion for ACS will need to be developed. An attractive application of highly sensitive troponin assays would be for detection of low-level chronic myocardial injury in the ambulatory setting to enhance risk stratification for heart failure and cardiac death.