Skip to main content
SpringerLink
Log in

Troponins and High-Sensitivity Troponins as Markers of Necrosis in CAD and Heart Failure

Troponine und hochsensitive Troponine als Nekrosemarker bei KHK und Herzinsuffizienz

  • Published:
Herz Aims and scope Submit manuscript

Abstract

For years, cardiac troponins (cTn) have been regarded as the preferred biomarkers for the diagnosis of myocardial infarction and for the risk stratification of patients with acute coronary syndromes, as well as for the selection of patients who need an early invasive strategy, and for the guidance of adjunctive pharmacological therapy. In addition, measurement of cTn has been found useful for detection of myocardial necrosis in conditions unrelated to myocardial ischemia including acute pulmonary embolism, myocarditis, heart failure, sepsis, and end-stage renal disease. In these conditions, an unfavorable prognosis is unequivocally associated with detectable concentrations of cTn.

A major limitation of most currently available cTn assays is the lack of adequate precision, i.e., to measure cTn concentrations at the 99th percentile value with a coefficient of variation < 10%. As a consequence, many manufacturers have developed more sensitive cTn assays that now comply with precision criteria required by the Joint European Society of Cardiology/ American College of Cardiology/American Heart Association/World Heart Federation Task Force for the Redefinition of Acute Myocardial Infarction.

Using assays with higher analytic sensitivity more patients will be seen in clinical practice with the high-sensitivity cardiac troponin T (TnThs) above the 99th percentile discriminator. The causes of these elevations may be due to acute, subacute and chronic cardiac disease such as heart failure or cardiomyopathies.

Zusammenfassung

Kardiale Troponine (cTn) sind seit Jahren der Referenzstandard für die Klassifikation und für die Risikostratifizierung von Patienten mit einem akuten Koronarsyndrom. Erhöhte Troponinwerte erlauben zudem, Patienten zu identifizieren, die von einer invasiven Therapiestrategie sowie einer intensiveren Antikoagulation und antithrombozytären Therapie profitieren.

Kardiales Troponin ist myokardspezifisch und tritt daher auch bei Erkrankungen des Herzens auf, die nicht durch ein akutes Koronarsyndrom bedingt sind, beispielsweise bei der akuten Lungenembolie, bei einer Myokarditis, bei einer schweren Niereninsuffizienz, bei dekompensierter Herzinsuffizienz oder hämodynamisch relevanter Aortenstenose sowie bei Kardiomyopathien. Die Höhe der Troponinfreisetzung spiegelt den Schweregrad dieser Erkrankungen wider und ist prognostisch relevant.

Eine Einschränkung der meisten kommerziell erhältlichen cTn-Assays ist die fehlende Präzision an der unteren Nachweisgrenze. So war es bislang nicht möglich, Konzentrationen an der 99. Perzentile einer gesunden Referenzpopulation mit einer Trennschärfe von < 10% Variationskoeffizient zu messen. Von einigen Herstellern werden jetzt Troponinassays angeboten, die niedrige Konzentrationen messen können (höhere analytische Sensitivität) und die Präzisionskriterien der neuen Infarktdefinition erfüllen. Andererseits ist zu erwarten, dass durch Erhöhung der Sensitivität die diagnostische Spezifität sinkt und jetzt vermehrt kardiale Erkrankungen erkannt werden, die bislang unerkannt geblieben waren.

Die Auswirkungen der Verwendung niedrigerer Troponinkonzentrationen bei Patienten mit akutem Koronarsyndrom für die Diagnose, Risikostratifizierung und Therapiesteuerung sowie die Bedeutung erhöhter Troponinwerte bei Patienten ohne akutes Koronarsyndrom, insbesondere bei Vorliegen einer Herzinsuffizienz, sind Gegenstand der vorliegenden Übersicht.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J 2007;28:1598–1660.

    Article  CAS  PubMed  Google Scholar 

  2. Hamm CW, Giannitsis E, Katus HA. Cardiac troponin elevations in patients without acute coronary syndrome. Circulation 2002;106:2871–2872.

    Article  PubMed  Google Scholar 

  3. Thygesen K, Alpert JS, White HD, et al., on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007;28:2525–2538.

    Article  PubMed  Google Scholar 

  4. Melanson SE, Morrow DA, Jarolim P. Earlier detection of myocardial injury in a preliminary evaluation using a new troponin I assay with improved sensitivity. Am J Clin Pathol 2007;128:282–286.

    Article  CAS  PubMed  Google Scholar 

  5. Giannitsis E, Kurz K, Hallermayer K, et al. The new high sensitive cardiac troponin T assay. Clin Chem 2009:in press.

  6. Apple FS, Smith SW, Pearce LA, et al. Use of the Centaur TnI-Ultra assay for detection of myocardial infarction and adverse events in patients presenting with symptoms suggestive of acute coronary syndrome. Clin Chem 2008;54:723–728.

    Article  CAS  PubMed  Google Scholar 

  7. Morrow DA, Cannon CP, Jesse RL, et al. National Academy of Clinical Biochemistry laboratory medicine practice guidelines: clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Clin Chem 2007;53:552–574.

    Article  CAS  PubMed  Google Scholar 

  8. Macrae AR, Kavsak PA, Lustig V, et al. Assessing the requirement for the 6-hour interval between specimens in the American Heart Association Classification of Myocardial Infarction in Epidemiology and Clinical Research Studies. Clin Chem 2006;52:812–818.

    Article  CAS  PubMed  Google Scholar 

  9. Apple FS, Pearce LA, Smith SW, et al. Role of monitoring changes in sensitive cardiac troponin I assay results for early diagnosis of myocardial infarction and prediction of risk of adverse events. Clin Chem 2009;55:930–937.

    Article  CAS  PubMed  Google Scholar 

  10. Eggers KM, Oldgren J, Nordenskjöld A, et al. Diagnostic value of serial measurement of cardiac markers in patients with chest pain: limited value of adding myoglobin to troponin I for exclusion of myocardial infarction. Am Heart J 2004;148:574–581.

    Article  CAS  PubMed  Google Scholar 

  11. Kontos MC, Fritz LM, Anderson FP, et al. Impact of the troponin standard on the prevalence of acute myocardial infarction. Am Heart J 2003;146:446–452.

    Article  CAS  PubMed  Google Scholar 

  12. Kavsak PA, MacRae AR, Lustig V, et al. The impact of the ESC/ACC redefinition of myocardial infarction and new sensitive troponin assays on the frequency of acute myocardial infarction. Am Heart J 2006;152:118–125.

    Article  PubMed  Google Scholar 

  13. Heidenreich PA, Alloggiamento T, Melsop K, et al. The prognostic value of troponin in patients with non-ST elevation acute coronary syndromes: a meta-analysis. J Am Coll Cardiol 2001;38:478–485.

    Article  CAS  PubMed  Google Scholar 

  14. James S, Armstrong P, Califf R, et al. Troponin T levels and risk of 30-day outcomes in patients with the acute coronary syndrome: prospective verification in the GUSTO-IV trial. Am J Med 2003;115:178–184.

    Article  CAS  PubMed  Google Scholar 

  15. Morrow DA, Cannon CP, Rifai N, et al. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST-elevation myocardial infarction. results from a randomized trial. JAMA 2001;286:2405–2412.

    Article  CAS  PubMed  Google Scholar 

  16. Diderholm E, Andrén B, Frostfeldt G, et al., Fast Revascularisation during InStability in Coronary artery disease (FRISC II) Investigators. The prognostic and therapeutic implications of increased troponin T levels and ST depression in unstable coronary artery disease: the FRISC II invasive troponin T electrocardiogram substudy. Am Heart J 2002;143:760–767.

    Article  CAS  PubMed  Google Scholar 

  17. Venge P, Lagerqvist B, Diderholm E, et al. Clinical performance of three cardiac troponin assays in patients with unstable coronary artery disease (a FRISC II substudy). Am J Cardiol 2002;89:1035–1041.

    Article  CAS  PubMed  Google Scholar 

  18. Morrow DA, Rifai N, Sabatine MS, et al. Evaluation of the AccuTnI cardiac troponin I assay for risk assessment in acute coronary syndromes. Clin Chem 2003;49:1396–1968.

    Article  CAS  PubMed  Google Scholar 

  19. Kontos MC, Shah R, Fritz LM, et al. Implication of different cardiac troponin I levels for clinical outcomes and prognosis of acute chest pain patients. J Am Coll Cardiol 2004;43:958–965.

    Article  CAS  PubMed  Google Scholar 

  20. Kavsak PA, Newman AM, Lustig V, et al. Long-term health outcomes associated with detectable troponin I concentrations. Clin Chem 2007;53:220–227.

    Article  CAS  PubMed  Google Scholar 

  21. Eggers KM, Lagerqvist B, Venge P, et al. Prognostic value of biomarkers during and after non-ST-segment elevation acute coronary syndrome. J Am Coll Cardiol 2009;54:357–364.

    Article  PubMed  Google Scholar 

  22. Latini R, Masson S, Anand IS, et al. Prognostic value of very low plasma concentrations of troponin T in patients with stable chronic heart failure. Circulation 2007;116:1242–1249.

    Article  CAS  PubMed  Google Scholar 

  23. Omland T, Lemos JA, Christophi C, et al. Distribution and determinants of very low levels of cardiac troponin T in patients with stable coronary artery disease: The PEACE trial. Presented at the ESC 2008, Munich, August 30 to September 3, 2008:abstract.

  24. Zethelius B, Johnston N, Venge P. Troponin I as a predictor of coronary heart disease and mortality in 70-year-old men: a community-based cohort study. Circulation 2006;113:1071–1078.

    Article  CAS  PubMed  Google Scholar 

  25. Eggers KM, Lind L, Ahlström H, et al. Prevalence and pathophysiological mechanisms of elevated cardiac troponin I levels in a population-based sample of elderly subjects. Eur Heart J 2008;29:2252–2258.

    Article  CAS  PubMed  Google Scholar 

  26. Lindahl B, Venge P, Wallentin L. Troponin T identifies patients with unstable coronary artery disease who benefit from long-term antithrombotic protection. Fragmin in Unstable Coronary Artery Disease (FRISC) Study Group. J Am Coll Cardiol 1997;29:43–48.

    Article  CAS  PubMed  Google Scholar 

  27. Morrow DA, Antman EM, Tanasijevic M, et al. Cardiac troponin I for stratification of early outcomes and the efficacy of enoxaparin in unstable angina: a TIMI-11B substudy. J Am Coll Cardiol 2000;36:1812–1817.

    Article  CAS  PubMed  Google Scholar 

  28. Newby LK, Ohman EM, Christenson RH, et al. Benefit of glycoprotein IIb/IIIa inhibition in patients with acute coronary syndromes and troponin t-positive status: the paragon-B troponin T substudy. Circulation 2001;103:2891–2896.

    CAS  PubMed  Google Scholar 

  29. Frey N, Dietz A, Kurowski V, et al. Angiographic correlates of a positive troponin T test in patients with unstable angina. Crit Care Med 2001;29:1130–1136.

    Article  CAS  PubMed  Google Scholar 

  30. Kastrati A, Mehilli J, Neumann FJ, et al., Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 2 (ISAR-REACT 2) Trial Investigators. Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial. JAMA 2006;295:1531–1538.

    Article  CAS  PubMed  Google Scholar 

  31. Olivetti G, Giordano G, Corradi D, et al. Gender differences and aging: effects on the human heart. J Am Coll Cardiol 1995;26:1068–1079.

    Article  CAS  PubMed  Google Scholar 

  32. Giannitsis E, Muller-Bardorff M, Kurowski V, et al. Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism. Circulation 2000;102:211–217.

    CAS  PubMed  Google Scholar 

  33. Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 2007;116:427–433.

    Article  CAS  PubMed  Google Scholar 

  34. Müller-Bardorff M, Weidtmann B, Giannitsis E, et al. Release kinetics of cardiac troponin T in survivors of confirmed severe pulmonary embolism. Clin Chem 2002;48:673–675.

    PubMed  Google Scholar 

  35. Giannitsis E, Katus HA. Risk stratification in pulmonary embolism based on biomarkers and echocardiography. Circulation 2005;112:1520–1521.

    Article  PubMed  Google Scholar 

  36. Lankeit M, Dellas C, Katus HA, et al. Additive prognostische Information durch die Verwendung eines hoch sensitiven Assays für Troponin T bei Patienten mit akuter Lungenembolie. Clin Res Cardiol 2009;98:Suppl 1:P1015.abstract.

    Google Scholar 

  37. Lankeit M, Dellas C, Panzenboeck A, et al. Heart-type fatty acid-binding protein for risk assessment of chronic thromboembolic pulmonary hypertension. Eur Respir J 2008;31:1024–1029.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany

    Evangelos Giannitsis &  Hugo A. Katus

  2. Medizinische Klinik III Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany

    Hugo A. Katus

Authors
  1. Evangelos Giannitsis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hugo A. Katus
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hugo A. Katus.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Giannitsis, E., Katus, H.A. Troponins and High-Sensitivity Troponins as Markers of Necrosis in CAD and Heart Failure. Herz 34, 600–606 (2009). https://doi.org/10.1007/s00059-009-3306-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00059-009-3306-6

Key Words:

Schlüsselwörter:

Search

Navigation