When troponin results lie: A narrative review and practical approach to spurious hypertroponinemia.

BACKGROUND: Cardiac troponins are universal biomarkers for the diagnosis of acute coronary syndromes. Hypertroponinemia is defined as elevated troponin levels > 99th percentile of upper reference limit. An acute rise and/or fall in troponin with clinical/imaging evidence of myocardial ischemia is diagnostic of acute myocardial infarction. However, in extremely rare circumstances, spurious hypertroponinemia-falsely elevated troponin in the absence of myocardial injury/ischemia-can also occur due to pre-analytical, analytical and post-analytical factors. We provide a review of reported causes of spurious hypertroponinemia from published literature, and categorize them into pre-analytical (sample collection, handling and processing), analytical (assay- and antibody-related) and post-analytical (reporting and interpretative) factors, and propose a clinical approach to suspected spurious hypertroponinemia.

METHODS: We conducted a narrative review of PubMed and Scopus publications between 1st January 2005 to 1st December 2025. 783 articles were retrieved after removing duplicates, of which 91 relevant articles pertaining spurious hypertroponinemia were selected. We performed a qualitative summary and narrative synthesis of available evidence.

RESULTS: We identified pre-analytical (fibrin clot formation, hemolysis, lipemia), analytical (analytical platform malfunctions, macrotroponins, heterophile antibodies, rheumatoid factor, signal generating alkaline phosphatase, myopathies) and post-analytical (99th percentile interpretation) causes of spurious hypertroponinemia.

CONCLUSIONS: Spurious hypertroponinemia is a clinically important phenomenon in the era of high-sensitivity troponin testing. In our narrative review, we summarized the diverse causes of spurious hypertroponinemia and proposed a simple, pragmatic three-step approach to guide clinicians faced with discordant troponin results.