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Troponin T, High Sensitivity (hs-TnT)
This test is used to refine cardiovascular risk assessment.
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Test Summary

 

Troponin T, High Sensitivity (hs-TnT) 

Test Code: 38685

 

Clinical use

  • Assess risk of cardiovascular disease (CVD)
  • Diagnose myocardial injury and myocardial infarction

Clinical background

Cardiac troponin proteins (including cardiac troponins T [cTnT] and I [cTnI]) are biomarkers of myocardial injury. Cardiac troponins are normally involved in heart muscle contraction, but when heart muscle cells die, they release proteins into the blood. In appropriate symptomatic patients, these proteins are biomarkers for CVDs related to myocardial ischemia or infarction (ie, acute coronary syndrome [ACS]). High levels of cardiac troponin in the blood (ie, above the 99th percentile upper reference limit [URL]) identify patients with likely myocardial ischemia who would benefit from expedited cardiac care.1-3 For this reason, tests for either cTnT or cTnI are routinely used to evaluate symptomatic patients with ACS for myocardial injury and myocardial infarction.3,4

In asymptomatic patients, high-sensitivity (hs) cTnT tests have utility for risk assessment. Studies have shown that high to even moderate cTnT levels, which are less accurately detected by older-generation troponin tests,5 are associated with risk of incident CVD6-9 and death.6-8,10,11 This association is independent of conventional CVD risk factors, and risk increases with cTnT concentration.6-12 Additionally, increasing cTnT across multiple years is associated with increased risk, while decreasing cTnT is associated with decreased risk.12,13 Elevated cTnT is also predictive of cardiovascular events and death among patients with CVD (ie, chronic heart failure,14 coronary heart disease,15 ACS16).

CVD risk assessment can be improved by including risk-enhancing factors, especially among people at borderline or intermediate risk calculated from conventional risk factors.17 Improved risk assessment can help identify people who may benefit from more or less intensive interventions.17 Incorporating hs-cTnT results has been shown to improve models of CVD risk and death for the purposes of both delaying the onset6,10,13,18 and progression14,15,18,19 of disease.

Individuals suitable for testing

  • Individuals who may benefit from refinement of CVD risk assessment
  • Individuals with symptoms that are associated with suspected ACS

Method

  • Electrochemiluminescence immunoassay
  • Reportable range: 6-10,000 ng/L

Interpretive information

CVD risk

In asymptomatic patients, an hs-cTnT result in the moderate or high relative-risk range (Table) indicates an increased risk of CVD and death. The cutoff between optimal and moderate risk is the lower limit of quantitation (LLOQ) of the assay. This is because even an hs-cTnT result at the LLOQ is associated with risk of CVD and death, and risk increases with cTnT concentration.6-12 The cutoff between moderate and high risk is the sex-specific 99th percentile URL of this assay.20 In symptomatic patients, high levels of cTnT correspond to the highest risk of CVD and death6-8,10-12 and also identify patients with likely myocardial ischemia.4

Table. Relative Risk Ranges of hs-cTnT Concentrations

Relative risk

Men, ng/L

Women, ng/L

Optimal

<6

<6

Moderate

6-22

6-14

High

>22

>14

An hs-cTnT result in the optimal range indicates the lowest risk of CVD and death relative with higher values.

Myocardial injury

In symptomatic patients, an hs-cTnT result >99th percentile URL (high relative risk range) indicates myocardial injury.4 Hs-cTnT results that indicate acute myocardial injury in a patient with clinical evidence of ischemia are consistent with myocardial infarction.4 Results of repeated tests that show a rising and/or falling pattern over time with ≥1 high result indicate acute myocardial injury (ie, myocardial infarction, trauma).4 Results of repeated tests that are high but unchanging indicate chronic myocardial injury (ie, stable coronary heart disease, chronic heart failure, structural heart disease).4

Given the timeline of cTnT release during acute myocardial injury or myocardial infarction, an hs-cTnT result may be in the optimal or moderate range (≤99th percentile URL) at first evaluation.4 For this reason, a second cTnT test is recommended 3 to 6 hours following initial evaluation of patients with ACS; additional tests beyond 6 hours may be needed.4

Assay interferences

Falsely lowered results can be caused by hemolysis, hemoglobin, and biotin.20 Patients taking biotin supplements should have samples taken ≥8 hours after the last biotin supplement (72 hours for mega-doses of biotin).20 Falsely elevated results can be obtained in certain neuromuscular conditions when cTnT is expressed and released by diseased skeletal muscle.4

References

  1. Daubert MA, Jeremias A. The utility of troponin measurement to detect myocardial infarction: review of the current findings. Vasc Health Risk Manag. 2010;6:691-699. doi:10.2147/vhrm.s5306
  2. Bhatt DL, Lopes RD, Harrington RA. Diagnosis and treatment of acute coronary syndromes: a review. JAMA. 2022;327(7):662-675. doi:10.1001/jama.2022.0358
  3. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes. Circulation. 2014;130(25):e344-e426. doi:10.1161/CIR.0000000000000134
  4. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40(3):237-269. doi:10.1093/eurheartj/ehy462
  5. Twerenbold R, Boeddinghaus J, Nestelberger T, et al. Clinical use of high-sensitivity cardiac troponin in patients with suspected myocardial infarction. J Am Coll Cardiol. 2017;70(8):996-1012. doi:/10.1016/j.jacc.2017.07.718
  6. Willeit P, Welsh P, Evans JDW, et al. High-sensitivity cardiac troponin concentration and risk of first-ever cardiovascular outcomes in 154,052 participants. J Am Coll Cardiol. 2017;70(5):558-568. doi:10.1016/j.jacc.2017.05.062
  7. de Lemos JA, Drazner MH, Omland T, et al. Association of troponin T detected with a highly sensitive assay and cardiac structure and mortality risk in the general population. JAMA. 2010;304(22):2503-2512. doi:10.1001/jama.2010.1768
  8. Saunders JT, Nambi V, de Lemos JA, et al. Cardiac troponin T measured by a highly sensitive assay predicts coronary heart disease, heart failure, and mortality in the Atherosclerosis Risk in Communities Study. Circulation. 2011;123(13):1367-1376. doi:10.1161/CIRCULATIONAHA.110.005264
  9. Seliger SL, Hong SN, Christenson RH, et al. High-sensitive cardiac troponin T as an early biochemical signature for clinical and subclinical heart failure: MESA (Multi-Ethnic Study of Atherosclerosis). Circulation. 2017;135(16):1494-1505. doi:10.1161/CIRCULATIONAHA.116.025505
  10. van der Linden N, Klinkenberg LJ, Bekers O, et al. Prognostic value of basal high-sensitive cardiac troponin levels on mortality in the general population: a meta-analysis. Medicine (Baltimore). 2016/12/30 ed. 2016:chap 52. https://www.ncbi.nlm.nih.gov/pubmed/28033267
  11. Oluleye OW, Folsom AR, Nambi V, et al. Troponin T, B-type natriuretic peptide, C-reactive protein, and cause-specific mortality. Ann Epidemiol. 2013;23(2):66-73. doi:10.1016/j.annepidem.2012.11.004
  12. deFilippi CR, de Lemos JA, Christenson RH, et al. Association of serial measures of cardiac troponin T using a sensitive assay with incident heart failure and cardiovascular mortality in older adults. JAMA. 2010;304(22):2494-2502. doi:10.1001/jama.2010.1708
  13. McEvoy JW, Chen Y, Ndumele CE, et al. Six-year change in high-sensitivity cardiac troponin T and risk of subsequent coronary heart disease, heart failure, and death. JAMA Cardiol. 2016;1(5):519-528. doi:10.1001/jamacardio.2016.0765
  14. Aimo A, Januzzi JL, Jr, Vergaro G, et al. Prognostic value of high-sensitivity troponin T in chronic heart failure: an individual patient data meta-analysis. Circulation. 2018;137(3):286-297. doi:10.1161/CIRCULATIONAHA.117.031560
  15. Beatty AL, Ku IA, Christenson RH, et al. High-sensitivity cardiac troponin T levels and secondary events in outpatients with coronary heart disease from the Heart and Soul Study. JAMA Intern Med. 2013;173(9):763-769. doi:10.1001/jamainternmed.2013.116
  16. Weber M, Bazzino O, Navarro Estrada JL, et al. Improved diagnostic and prognostic performance of a new high-sensitive troponin T assay in patients with acute coronary syndrome. Am Heart J. 2011;162(1):81-88. doi:10.1016/j.ahj.2011.04.007
  17. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678
  18. Biener M, Giannitsis E, Kuhner M, et al. Prognostic value of high-sensitivity cardiac troponin T compared with risk scores in stable cardiovascular disease. Am J Med. 2017;130(5):572-582. doi:10.1016/j.amjmed.2016.11.028
  19. Lindholm D, Lindbäck J, Armstrong PW, et al. Biomarker-based risk model to predict cardiovascular mortality in patients with stable coronary disease. J Am Coll Cardiol. 2017;70(7):813-826. doi:10.1016/j.jacc.2017.06.030
  20. Elecsys Troponin T Gen 5 STAT. package insert. Roche Diagnostics; 2019.

Content reviewed 11/2022

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38685 - Troponin T, High Sensitivity (hs-TnT)

Diagnosis of Acute Myocardial Infarction (MI). Assessment of cardiovascular disease risk.
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Reference ranges are provided as general guidance only. To interpret test results use the reference range in the laboratory report.

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