Exercise-induced cardiac troponin elevation: An update on the evidence, mechanism and implications

Post-exercise cardiac troponin (cTn) elevation is a recognised phenomenon which historically has been detected using standard sensitivity assays. More recently high-sensitivity assays have been developed and are now the gold standard for detection of cTn in the clinical setting. Although the assay's enhanced sensitivity confers benefits it has created new challenges for clinicians. By evaluating the change in cTn values over time, taking into account biological and analytical variation, the clinician is able to differentiate between a pathological and normal cTn value. As a result, serial cTn testing has become a fundamental component of the clinical assessment of chest pain patients and is included in the most recent definition for myocardial infarction and the latest guidelines for the management of acute coronary syndromes without persistent ST-segment elevation. A review of the cTn kinetics literature demonstrates a pattern of elevation and peak within the first 4 h after exercise dropping within 24 h. In contrast myocardial necrosis demonstrates a later cTn peak with a slower downslope occurring over several days. Understanding cTn kinetics facilitates clinician's decision making when presented with a chest pain patient post-exercise. Furthermore, it helps elucidate the underlying mechanism and establish the clinical significance of post-exercise cTn elevation, which in all other situations confers negative prognostic value. We recommend serial cTn testing in this scenario with a suggested algorithm included in this review.