Understanding troponin elevation:

● normal reference range is listed as 0.00 – 0.40

● 0.41 is technically positive although very weakly so
● levels above the reference range may mean heart damage BUT there are many causes
○ Non- Acute coronary syndrome elevation of troponin I is not uncommon = about
50% of patients admitted to ED had positive cTn but no ACS

■
Possible causes:
● Arrhythmia
○ Troponin elevation:
■ Mechanism = shortening of diastole with subsequent
subendocardial ischemia
● As well as = myocardial stretch
● troponins can be released because of tachycardia alone in the
absence of myodepressive factors, inflammatory mediators, and
coronary artery disease
■ direct correlation between rise in cardiac BNP (B-Type Natriuretic
Peptide) and troponins in patients with various tachycardias
■ Common presentation:
● complaints of chest discomfort and were found to have regular
supraventricular tachycardia or atrial fibrillation or ventricular
tachycardia
● All these patients had elevated troponin I
● Coronary angiography revealed normal epicardial coronary
arteries
● Example of a few patients:

○
○ Symptoms:
 ■ Fatigue or weakness
■ Dizziness
■ Shortness of breath
■ Palpitations, rapid heartbeat, or a feeling of heart pounding in chest
■ Anxiety
■ presyncope/lightheadedness
■ Chest pain
○ Tests
■ Holter monitor
● Or event monitor
■ ECG
● Will miss if event not occuring
● Possibly = Adenosine administration = if ECG is unclear
○ adenosine transiently blocks atrioventricular node
○ atrial flutter is more easily diagnosed on ECG
■ Echo
● TTE
■ Stress test
■ Tilt-table test
■ Electrophysiologic testing EP study
■ Recheck
● TSH and free T4
● Electrolytes
○ Possible types
■ SVTs
● atrial fibrillation
● atrial flutter
● focal atrial tachycardia
● atrioventricular reentrant tachycardia
● atrioventricular nodal reentrant tachycardia
● Wolff-Parkinson-White syndrome
■ VTs
● Pulmonary embolism
○ Troponin elevated because
■ Right ventricular strain
■ Seen in 50% of cases
○ Symptoms
■ dysnea (most common)
■ pleuritic chest pain
■ cough
■ Syncope
○ Tests
■ Ct angiography
 ■ Ecg
■ ABG
■ D-dimer
● pericarditis/myocarditis
○ Troponin elevated
■ elevated in 32–49% of cases of pericarditis
● even though troponins not in pericardium
○ Underdiagnosed
○ Symtpoms
■ sharp pleuritic chest pain that is worsened by inhalation
■ pain is also relieved by sitting up and leaning forward
■ shoulder pain (referred pain)
○ Diagnosis
■ Rule out MI
● Coronary angiography
■ ↑ erythrocyte sedimentation rate
■ ↑ C-reactive protein
■ may have ↑ troponin I
■ Electrocardiogram (ECG)
● Often normal
● takotsubo cardiomyopathy
○ More than 90% of reported cases are in women ages 58 to 75
○ Up to 5% of women evaluated for a heart attack actually have this disorder,
which has only recently been reported in the United States and may go largely
unrecognized. Fortunately, most people recover rapidly with no long-term heart
damage
○ Symptoms:
■ Chest pain and shortness of breath after severe stress (emotional or
physical)
■ Electrocardiogram abnormalities that mimic those of a heart attack
● Often normal
■ No evidence of coronary artery obstruction
● Movement abnormalities in the left ventricle
● Possible = Ballooning of the left ventricle
○ Causes
■ as the result of severe emotional or physical stress
○ Treatment
○ is generally supportive in nature, for it is considered a transient disorder
● Strenuous exercise