Exercise-induced cardiac troponin release: real-life clinical confusion

Exercise training represents a successful and powerful strategy to prevent future cardiovascular disease. Paradoxically, performance of exercise is also associated with an increased risk of acute cardiac events. Accordingly, patients may present to hospital with cardiac symptoms following a bout of unaccustomed physical effort (e.g. exercise). Current guidelines for the identification of an acute myocardial infarction (AMI) importantly depend on the presence of cardiac troponin as a highly sensitive marker of cardiac damage. However, a number of studies have reported elevated cardiac troponin levels in asymptomatic, healthy subjects after endurance exercise (such as a marathon, prolonged cycling or prolonged walking). These observations indicate that elevated cardiac troponin levels can be the result of cardiac ischemia, and subsequent necrosis, but also may be related to strenuous exercise. In this paper, we present three different clinical cases of post-exercise elevations in cardiac troponins, each with a distinct clinical presentation. These case studies emphasize that a detailed assessment of all symptoms and a thorough patient-history are prerequisite for accurate interpretation of a positive cardiac troponin test following exercise.