I Have a Patient Who Is Presenting With Shortness of Breath, Non-cardiac Chest Pain, and Positive Troponin Levels. What Are Possible Causes for the Troponin Elevation, and What Is the Best Way to Treat This Patient?

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href="/web/20130501111009/http://www.healio.com/"> Healio</a> <span>›</span> <a href="/web/20130501111009/http://www.healio.com/cardiology"> Cardiology</a> <span>›</span> <a href="/web/20130501111009/http://www.healio.com/cardiology/curbside-consultation"> Curbside Consultation</a> </p>  <div class="content"> <h2> I Have a Patient Who Is Presenting With Shortness of Breath, Non-cardiac Chest Pain, and Positive Troponin Levels. What Are Possible Causes for the Troponin Elevation, and What Is the Best Way to Treat This Patient?</h2> <p class="curbside-author"> Jennifer Monti, MD, MPH</p> <p class="curbside-author"> Sammy Zakaria, MD, MPH</p> <p>Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) proteins have N-terminal extensions unique to heart muscle that distinguishes them from other muscle proteins. Clinically, high sensitivity cardiac-specific TnT or TnI assays are used to meet the diagnostic goals set by the universal definition of myocardial infarction and are helpful in detecting acute coronary syndromes early. However, not all troponin elevations are due to acute coronary syndromes, and it is important to consider all other possibilities for serum troponin elevation since treatment strategies are different. In other words, troponin elevations indicate the presence, but not the mechanism, of myocardial injury, and myocardial damage can occur from a variety of mechanisms, including the etiologies listed in Table 1.</p> <p><img width="413" height="286" alt="Table 1" src="/web/20130501111009im_/http://www.healio.com/~/media/Curbside/Cardiology/Prevention/Q8/Table 1.jpg"/></p> <p><strong>Workup and Differential of Non-cardiac Chest Pain, Shortness of Breath, and Abnormal Troponin Level</strong> </p> <p>Elevated troponin levels are concerning in any patient presenting with shortness of breath or non-cardiac chest pain. It is important to decide whether you think the patient is having an acute coronary syndrome (ACS)/myocardial infarction (MI). If ACS/MI is less likely, then you may address other causes for elevated troponin levels.</p> <p>Commonly, troponin elevation can occur with supply-demand mismatch, which occurs when there is increased cardiac oxygen demand with an inadequate ability to increase arterial blood supply. In patients with any type of congestive heart failure (CHF), troponin elevation often occurs and is generally modest, but troponin positivity is found to correlate with worse clinical and functional status. Acutely, 52% to 55% of patients will have elevated troponin due to increased wall tension and strain, while 15% to 23% of patients with chronic heart failure will have elevated troponins due to increased sympathetic activity and an increased renin-angiotensin axis.<sup>1</sup> In either case, the presence of detectable troponin in heart failure predicts worse long-term outcomes.<sup>2</sup> </p> <p>Supply-demand mismatch can also occur with any type of bradycardia or tachycardia, such as atrial fibrillation with a rapid heart rate, particularly in patients with existing coronary disease. Alternatively, elevated blood pressures can damage the heart and lead to elevation of troponin and symptoms, which would be considered a hypertensive emergency. In addition, aortic valve disease can be the cause when a stenotic valve leads to left ventricular hypertrophy with subsequent wall strain and troponin elevation, especially in the setting of reduced diastolic filling time with tachycardia.<sup>3</sup></p> <p>Inflammatory diseases like pericarditis and myocarditis can also present with these symptoms and troponin elevation due to direct inflammation of the heart or extension of inflammation from the pericardium to the epicardium. The 12-lead electrocardiogram (ECG) is particularly helpful in the diagnosis of pericarditis, as PR segment depression and concave ST elevation are often seen in most leads, although focal myopericarditis may not present with diffuse ST elevation. Usually the ECG pattern is distinct from the convex ST-segment elevation of an MI (STEMI), which appears in the territory of the affected coronary artery. In the case of myocarditis, early recognition, particularly in the case of giant cell myocarditis, may be beneficial.</p> <p>Uncommon causes of chest pain and troponin elevation include coronary vasospasm. These patients will often present with signs and symptoms similar to patients with ACS, but cardiac catheterization reveals no flow-limiting disease within the coronary arteries.<sup>4</sup> This may also occur in patients with stress cardiomyopathy, who have a characteristic pattern of reduced left ventricular function that improves within a few weeks. Rarely, troponin elevation can be due to aortic dissection extending into the coronary arteries, most frequently into the right coronary artery, but the pain is generally sudden in onset and severe, with significant patient distress.</p> <p>It is also essential to include trauma and procedure-related complications in the differential. Blunt trauma to the chest can lead to cardiac contusion and troponin elevation. Coronary artery bypass surgery or stenting can cause increased troponin levels, as well as other cardiac surgeries or electrophysiological procedures. Internal or external cardiac defibrillation can lead to troponin elevation. </p> <p>Not all causes of symptoms and troponin elevation are due to intrinsic cardiac cause. It is important to consider pulmonary embolism (PE) as a cause of symptoms and troponin elevation. While small PEs are not associated with increased troponin, elevations have been shown to occur in patients with moderate to large or massive PE because of right heart strain.<sup>5</sup> Also, 50% of patients in renal failure, on dialysis or not, have elevated troponin levels, and this is associated with higher rates of future cardiovascular events.<sup>6</sup> This is probably due to higher rates of asymptomatic cardiac disease. However, if an end-stage renal disease (ESRD) patient presents to the hospitals with symptoms, think of an acute cardiac condition first, such as ACS; do not simply attribute symptoms to ESRD. </p> <p>Troponin elevations in the setting of other illness can be difficult to interpret, particularly when patients are unable to communicate symptoms. For example, troponin can be elevated in the setting of subarachnoid hemorrhage, ischemic or hemorrhage stroke, or direct neurotrauma. These patients may also have ECG abnormalities and depressed left ventricular function. Another condition, sepsis, can lead to troponin elevation due to direct cytotoxic effects, inflammation, and supply-demand mismatch in the setting of increased work due to tachycardia and fever. Also, profound anemia or thyroid disease can cause stress on the heart that leads to symptoms and troponin elevations. Finally, hypertrophic cardiomyopathy, infiltrative disease like sarcoidosis or hemochromatosis, drugs like cocaine that cause adrenergic surges, and extreme exertion can all cause elevated troponin. </p> <p>It should be noted that false positive troponins are rare but can occur in the setting of rheumatologic disease because the troponin immunoassay may cross-react with other antibodies.<sup>7</sup> Of course, false elevations must be considered in the clinical context. A good clue is that the levels of troponin stay elevated irrespective of the clinical situation. </p> <p><strong>Workup of Non-cardiac Chest Pain, Shortness of Breath, and Elevated Serum Troponin Level</strong> </p> <p>Sensible workup of this presentation relies on a firm history and physical that will often provide clues to the correct diagnosis. Because MI can quickly be devastating and excellent treatments are available, it is paramount to address this possible diagnosis first by including ECG in the initial assessment of the patient. Those with STEMI require immediate intervention and should be considered for cardiac catheterization or thrombolytic therapy. Remember also that there are STEMI equivalents, particularly in women who may be presenting with the described symptoms, troponin elevation, and an ECG with new left bundle branch block. If there are no ST-elevations, then the patients with a troponin elevation may have an NSTEMI, which may or may not go urgently to the catheterization laboratory. It is important to continue to check serial ECGs on these patients, particularly if they continue to have chest pain despite medical management. A patient may not immediately have ST-elevation; if you catch it on a later ECG, you can expedite percutaneous intervention. </p> <p>Several laboratory studies may be helpful to the clinician trying to determine the etiology of this presentation. A lipid panel can aid in risk stratification of patients with angina or unstable angina. A complete blood cell count with a differential, a comprehensive metabolic panel, and a thyrotropin test can help determine if anemia, infection, or renal failure are playing a role. Pro-basic natriuretic peptide (BNP) or BNP measurement can be helpful to support a clinical diagnosis of heart failure. For example, BNP is 90% sensitive and 74% specific in diagnosing CHF at a cutoff of >100 pg/mL.<sup>8</sup> In patients who already have a diagnosis of CHF, it is useful to compare BNP values from a previous admission, since an acutely elevated value occurs with an CHF exacerbation. The D-dimer test is sensitive for the diagnosis of PE, though it is rarely negative in patients with acute illness or advanced age. </p> <p>Imaging may also play a critical role. Chest radiography is valuable in assessing pulmonary edema and other possible pulmonary causes. A contrast-enhanced computed tomography (CT) can be used to detect PE, though certain patients with an allergy to dye or renal failure may not be able to undergo this test. In this setting, a ventilation-perfusion scan can be specifically used to diagnose PE, but the results can be difficult to interpret if chronic obstructive pulmonary disease and/or pulmonary edema are present. Most importantly, echocardiography should be considered as it is a valuable tool that can assess wall motion abnormalities in patients with suspected MI, as well as detect other structural heart abnormalities. Cardiac CT may be used to assess the burden of atherosclerotic disease in the coronary vessels, and it can also detect other abnormalities in the thorax.</p> <p><strong>Management<br/> </strong></p> <p>Because the possible causes of this presentation are so diverse, treatment recommendations will depend greatly on what emerges from a thorough workup. A summary of initial general treatment options for each diagnosis is shown in Table 2.</p> <p><img width="413" height="569" alt="Table 2" src="/web/20130501111009im_/http://www.healio.com/~/media/Curbside/Cardiology/Prevention/Q8/Table 2.jpg"/></p> <p>The presence of an elevated troponin in the setting of potential cardiovascular symptoms is a common problem faced by clinicians and has a large differential diagnosis. Using the history, physical and targeted diagnostic studies help guide the most appropriate treatment strategy in these patients.</p> <p><strong>References</strong> </p> <p>1. Korff S, Katus HA, Giannitsis E. Differential diagnosis of elevated troponins. <em>Heart</em>. 2006;92(7):987-993. doi:10.1136/hrt.2005.071282</p> <p>2. Perna ER, Macín SM, Parras JI, et al. Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. <em>Am Heart J</em>. 2002;143(5):814-820. </p> <p>3. Rajappan K, Rimoldi OE, Camici PG, Bellenger NG, Pennell DJ, Sheridan DJ. Functional changes in coronary microcirculation after valve replacement in patients with aortic stenosis. <em>Circulation</em>. 2003;107(25):3170-3175. doi:10.1161/01.CIR.0000074211.28917.31</p> <p>4. Wang CH, Kuo LT, Hung MJ, Cherng WJ. Coronary vasospasm as a possible cause of elevated cardiac troponin I in patients with acute coronary syndrome and insignificant coronary artery disease. <em>Am Heart J</em>. 2002;144(2):275-281. </p> <p>5. Roongsritong C, Warraich I, Bradley C. Common causes of troponin elevations in the absence of acute myocardial infarction: incidence and clinical significance. <em>Chest</em>. 2004;125(5):1877-1884. </p> <p>6. Khan NA, Hemmelgarn BR, Tonelli M, Thompson CR, Levin A. Prognostic value of troponin T and I among asymptomatic patients with end-stage renal disease: a meta-analysis. <em>Circulation</em>. 2005;112(20):3088-3096. doi:10.1161/CIRCULATIONAHA.105.560128</p> <p>7. Jaffe AS. Troponin—past, present, and future. <em>Curr Probl Cardiol</em>. 2012;37(6):209-228. doi:10.1016/j.cpcardiol.2012.02.002</p> <p>8. Morrison LK, Harrison A, Krishnaswamy P, Kazanegra R, Clopton P, Maisel A. Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. <em>J Am Coll Cardiol</em>. 2002;39(2):202-209.</p>   <p> <div class="fb-like" data-href="" data-send="true" data-width="450" data-show-faces="true"></div> </p> <ul class="share"> <li><a href="#" id="twitter">Tweet</a></li> <li><a href="#" id="facebook">Share</a></li> <li><a href="#" id="linkedin">Link</a></li> <li><a href="#" id="digg">Digg</a></li> <li><a href="#" id="email">Email</a></li> <li class="last"><a href="#" onclick="javascript:window.print();" id="print">Print</a></li> </ul> </div>   <div id="respond"> <h4> Comments</h4> <script language="javascript" type="text/javascript"> var idcomments_acct = 'aa6ff53f9870e40f92f83e1b5df3cddf'; var idcomments_post_id = '{28E25935-C751-4B31-A20A-C39EADAFC140}'; var idcomments_post_url; </script> <span id="IDCommentsPostTitle" style="display: none"></span> <script type="text/javascript" src="https://web.archive.org/web/20130501111009js_/http://www.intensedebate.com/js/genericCommentWrapperV2.js"></script> <p class="comment-notes"> Healio is intended for health care provider use and all comments will be posted at the discretion of the editors. 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I Have a Patient Who Is Presenting With Shortness of Breath, Non-cardiac Chest Pain, and Positive Troponin Levels. What Are Possible Causes for the Troponin Elevation, and What Is the Best Way to Treat This Patient?