High sensitivity troponin in cardiovascular disease. Is there more than a marker of myocardial death?

Cardiovascular disease is the leading cause of death worldwide and coronary artery disease is its most prevalent manifestation, associated with high mortality and morbidity. In clinical practice cardiac troponins (cTn) are the cornerstone of the diagnosis, risk stratification and thus selection of the optimal treatment strategy in patients with acute coronary syndrome. According to the third update of the universal definition of myocardial infarction (MI) cTn is the preferred cardiac biomarker of myocardial necrosis in the setting of acute myocardial ischemia. Over the last years newer high sensitivity cardiac troponin (hs-cTn) assays have been developed that are more sensitive than conventional assays, have low limit of detection, low imprecision and low reference limits, but due to variability, the deployment of a standardization and harmonization method is required before their wide use in clinical practice. Recent studies have shown that their utilization seems to improve the diagnostic accuracy detecting MI in patients presenting with chest pain. However, the improved sensitivity comes along with a decreased specificity, though serial cTn measurements and the detection of early changes could improve the specificity and the overall diagnostic performance. Moreover, apart from their use in the diagnosis and risk stratification of MI and acute coronary syndromes, hs-cTn assays seem to have a key role in risk stratification and short and long-term prognosis in a variety of cardiovascular modalities such as stable coronary disease, heart failure and acute pulmonary embolism. In addition, studies have suggested that cTns may be used as a biomarker in the primary prevention of cardiovascular disease leading to the identification of high-risk populations or individuals with silent heart disease.