Exercise-Induced Cardiac Troponin Elevation in Endurance Athletes: Distinguishing Physiological Release from Myocardial Injury – A Narrative Review

Abstract

Introduction and purpose. This narrative review examines the prevalence, kinetics and clinical significance of exercise-associated cardiac troponin (cTn) release and outlines how to distinguish an expected post-exercise response from pathological myocardial injury.

Materials and methods. PubMed/MEDLINE-indexed literature on cardiac troponin, high-sensitivity troponin, endurance exercise, kinetics and myocardial injury was reviewed. Priority was given to systematic reviews, meta-analyses, consensus definitions, serial biomarker studies and prognostic cohorts available through August 2026. No systematic-review protocol, meta-analysis or risk-of-bias assessment was performed.

Results. Exercise-associated cTn elevation is common and depends on assay. A 2026 meta-analysis of 129 studies involving 7,289 athletes found values above the upper reference limit in 36%, with higher prevalence for high-sensitivity assays, cTnT versus cTnI, and endurance disciplines. cTn usually peaks early after exercise and declines during recovery. Elevation cannot, however, automatically be considered benign. Symptoms, ECG findings, serial kinetics and imaging are essential to exclude myocarditis, acute coronary syndrome, pulmonary embolism and other causes of myocardial injury.

Conclusion. Elevated hs-cTn after endurance exercise should be interpreted in clinical context. An early rise followed by a clear decline in an asymptomatic athlete is compatible with exercise-associated release. Persistent or rising concentrations, ischemic symptoms, arrhythmia, hemodynamic compromise or abnormal imaging should prompt evaluation for pathological myocardial injury. Serial assessment is more informative than a single post-race value.