Troponin Elevation Without Obstructive Coronary Disease: A Diagnostic Framework for the Acute Take
DOI:
https://doi.org/10.5281/zenodo.22305509Keywords:
Troponin, Myocardial infarction, Type 2 myocardial infarction, MINOCA, Takotsubo cardiomyopathy, MyocarditisAbstract
High-sensitivity troponin assays have made an elevated result a routine finding in acute medical practice, but only a small
minority of elevated results represent a Type 1 myocardial infarction: in one large community cohort, 13.7% of unselected
acute attendees had a troponin above the 99th percentile, yet only 1.6% met criteria for Type 1 myocardial infarction, a
positive predictive value of just 11.8%. The Fourth Universal Definition of Myocardial Infarction distinguishes Type 1 (plaque
rupture or thrombosis) from Type 2 (oxygen supply-demand mismatch without plaque disruption) and from myocardial injury
(troponin elevation without ischemic symptoms or signs at all), a distinction with real prognostic weight: patients with Type 2
myocardial infarction and myocardial injury have substantially worse five-year mortality than those with Type 1 myocardial
infarction, driven mainly by non-cardiovascular causes, despite carrying a lower burden of obstructive coronary disease. This
review sets out a diagnostic framework for troponin elevation without obstructive coronary disease at the acute take, covering
myocardial infarction with non-obstructive coronary arteries (MINOCA), takotsubo cardiomyopathy, myocarditis, and the
non-cardiac causes, chiefly sepsis, pulmonary embolism and renal impairment, that collectively account for most elevated
troponin results. It also sets out the honest complication at the center of this framework: there remains no randomized-trial
evidence for how to treat Type 2 myocardial infarction once diagnosed, and the classification system underpinning this entire
framework is itself being replaced, with a Fifth Universal Definition of Myocardial Infarction published in August 2026
abandoning the numbered Type 1-5 system altoge
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