Handling persistent cardiac troponin elevation in asymptomatic athletes: The role of macrocomplexes
Simon Wernhart1,2, Martin Halle1,2, Sebastian Zenk3
1Department for Preventive Sports Medicine and Sports Cardiology, TUM School of Medicine and Health, TUM University Hospital, Technical University of Munich (TUM), Munich, Germany.
Insights
Persistent elevated cardiac troponin I in athletes after myocarditis is often due to macrocomplexes. Polyethylene glycol (PEG) precipitation can identify these, preventing unnecessary exclusion from sports.
Area of Science:
- Sports Cardiology
- Clinical Biochemistry
- Immunology
Background:
- Return-to-play (RTP) decisions require cardiac troponin I (cTnI) normalization.
- Antibodies forming cTnI macrocomplexes can cause false elevations, leading to unwarranted athlete exclusion.
Purpose of the Study:
- To investigate the prevalence of cTnI macrocomplexes in athletes post-myocarditis.
- To evaluate polyethylene glycol (PEG) precipitation as a method to detect cTnI macrocomplexes.
Main Methods:
- Retrospective study of 12 asymptomatic athletes with elevated cTnI post-myocarditis.
- Analysis of cTnI levels using a high-sensitivity assay with and without PEG precipitation.
Main Results:
- 13 samples showed cTnI levels from 35.4 to 951 ng/L.
- PEG precipitation detected measurable cTnI in only 2 samples.
- 12 samples had <35% cTnI recovery post-PEG, indicating macrocomplex presence.
Conclusions:
- Macrocomplex formation is common in athletes recovered from acute myocarditis.
- PEG precipitation aids in diagnosing macrocomplexes, facilitating RTP decisions and preventing athlete exclusion.
Study Objective:
Return-to-play (RTP) decision includes cardiac troponin I returning to baseline. Formation of antibodies to cardiac troponin I (macrocomplexes) may lead to persistent, false positively elevated cardiac troponin I and may induce unnecessary exclusion from competitive sports.
Design:
Single-centre retrospective study.
Setting:
Sports cardiological outpatient clinic.
Participants:
We investigated 12 asymptomatic athletes who had clinically recovered from their first episode of acute myocarditis, but who showed persistently elevated cardiac troponin I levels without kinetics.
Interventions:
Testing for the presence of macrocomplexes using an Abbott high-sensitivity cardiac troponin I assay with and without polyethylene glycol (PEG) precipitation to precipitate any potential macrocomplexes present in the samples.
Main Outcome Measures:
Prevalence of a cardiac troponin I recovery rate in PEG precipitation.
Results:
13 samples from 12 athletes (mean age 36.2 ± 12.3 years) were examined with a cardiac troponin I range from 35.4 ng/L to 951 ng/L. After PEG precipitation, a measurable cardiac troponin I concentration was detected in only two cases. In 12 of the 13 samples examined, the cardiac troponin I recovery rate was below 35%, which suggests the presence of macrocomplexes. Mean time from diagnosis of acute myocarditis to assessment of macrocomplexes was 6.2 ± 3.6 months.
Conclusion:
Formation of macrocomplexes seems to be highly prevalent in athletes who have clinically recovered from acute myocarditis. PEG precipitation may be a feasible laboratory approach to help in the clinical decision-making of athletes to avoid unnecessary exclusion from competitive sports.
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