Conceptual Model for Clinical Distribution of Elevated Troponin
ACS = acute coronary syndrome; AMI = acute myocardial infarction; CAD = coronary artery disease; CHF = congestive heart failure; CM = cardiomyopathy; CT = cardiothoracic; PCI = percutaneous coronary intervention; PE = pulmonary embolism; STEMI = ST-segment elevation myocardial infarction.
Troponin Positivity and the Universal Definition of MI. Classification of MI Type
ACS = acute coronary syndromes; AMI = acute myocardial infarction; BP = blood pressure; CABG = coronary artery bypass grafting; CAD = coronary artery disease; CT = cardiothoracic; MI = myocardial infarction; PCI = percutaneous coronary intervention; SCD = sudden cardiac death; STEMI = ST-segment elevation myocardial infarction.Destaco lo mas importante. La verdad estos expertos complican todo.
Proposed Algorithm for Troponin in Therapeutic Decision Making
Global risk should be estimated via formal clinical risk scores (TIMI, GRACE, or PURSUIT) or a combination of the following high-risk features: recurrent angina/ischemia at rest or low-level activity, heart failure or worsening mitral regurgitation, high-risk stress test, hemodynamic instability, sustained ventricular tachycardia, diabetes mellitus, PCI within 6 months, prior CABG or LV ejection fraction <0.40. ACS = acute coronary syndromes; CABG = coronary artery bypass grafting; ECG = electrocardiogram; LV = left ventricular; PCI = percutaneous coronary intervention.
Frequently Asked Questions Regarding the Use of Troponin in the Clinical Setting
| What does an elevated troponin level mean? |
| •Elevated troponin is a sensitive and specific indication of cardiac myonecrosis, with troponin release from myocytes into the systemic circulation.•In and of itself, elevated troponin does not indicate MI (myonecrosis due to ischemia); rather, it is nonspecific relative to the etiology of cardiac myonecrosis.•Troponin elevation occurs in many nonischemic clinical conditions. As assays become more sensitive, more conditions that result in low-level troponin elevations will be identified. |
| When should a troponin level be obtained? |
| •Because it is not specific for MI, troponin evaluation should be performed only if clinically indicated for suspected MI.•An elevated troponin level must always be interpreted in the context of the clinical presentation and pre-test likelihood that it represents MI.•Troponin is recommended for diagnosis of MI in CKD patients with symptoms of MI (regardless of the severity of renal impairment). Dynamic changes in troponin values of ≥20% over 6 to 9 h should be used to define acute MI in ESRD patients.•In the absence of specific interventions based on the results, routine troponin testing is not recommended for nonischemic clinical conditions except: ∘FDA-approved troponin testing for prognosis in CKD patients.∘Treatment of patients undergoing chemotherapy who have drug-induced cardiac injury. |
| What is the prognostic significance of an elevated troponin level? |
| •Troponin elevation imparts a worse prognosis, irrespective of the underlying etiology.•For patients with non-ST-segment elevation ACS, global risk assessment rather than any single risk marker, best informs prognosis and is preferred to guide therapeutic decisions. |
Referencia:
Newby LK, Jesse RL, Babb JD, Christenson RH, De Fer TM, Diamond GA, et al. ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. Journal of the American College of Cardiology. 2012. Texto completo
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