“Hey, doc, no biggie, but his trop is TWO MILLION”

Here's a case that might stun even the most seasoned clinicians: A patient with a high-sensitivity troponin level of 2,115,170 ng/L. For context, most healthy individuals have levels under 14 ng/L, and even in large myocardial infarctions (MIs), values rarely exceed 50,000–100,000.

The possibility of a level this high was brought about by Alex Kim's social media post, and it's left multiple commenters wondering how this is even possible, and what now?

High-sensitivity troponin refresher

Troponin is a cardiac biomarker released into the bloodstream when there is injury to heart muscle, most often due to myocardial infarction. High-sensitivity assays can detect even minute elevations and are now standard in most emergency and inpatient settings.

Typical values:

• <14 ng/L: Normal

• >50–100 ng/L: Suggests myocardial injury

• >10,000–100,000 ng/L: Seen in large infarcts or myocarditis

But 2,115,170 ng/L is an extreme outlier—suggesting near-total or catastrophic myocardial necrosis.

What could cause this?

A handful of rare, devastating conditions might explain this, including:

• Massive myocardial infarction with extensive tissue death

• Prolonged cardiac arrest with successful resuscitation but severe reperfusion injury

• Fulminant myocarditis, potentially viral or autoimmune in origin

• Severe septic shock, with multi-system organ failure, including the heart

• Lab artifact or error, which should always be ruled out with re-testing

Is the patient alive?

With troponin levels this astronomically high, survival is unlikely—but not impossible.

A level in the millions suggests massive, widespread cardiac cell death, most commonly seen in patients post-cardiac arrest, those in cardiogenic shock, or with complete coronary artery occlusion left untreated for an extended period. The patient may be:

• Unresponsive or intubated in an ICU, requiring full hemodynamic support

• On ECMO (extracorporeal membrane oxygenation) if cardiac function is nearly absent

• Or possibly deceased, depending on timing and access to emergency care

If the patient is alive, they are almost certainly critically ill and in need of aggressive, multi-organ supportive therapy.

What would you do in this case?

In a scenario like this, the physician’s approach would be immediate and aggressive.

1. Confirm the result: Rule out lab error or hemolysis. Recheck hs-troponin with a fresh sample.

2. Assess the patient’s status: Is the patient hemodynamically stable? Are they conscious? Is there EKG or echocardiographic evidence of infarct or dysfunction?

3. Initiate full cardiac workup, including:

   • EKG

   • STAT echocardiogram

   • Coronary angiography if MI is suspected

   • Consider viral panel or biopsy if myocarditis is suspected

4. Begin life support measures:

   • Vasopressors/inotropes

   • Intubation and mechanical ventilation if needed

   • Consider ECMO or mechanical circulatory support

The overarching goal would be to stabilize the patient, identify and treat the cause, and determine reversibility. If the damage is irreversible, palliative discussions may follow depending on prognosis.