Troponin Elevation in Type 2 Myocardial Infarction: A Systematic Review on Who May Benefit From Coronary Evaluation

Type 2 myocardial infarction (T2MI) is characterized by acute myocardial ischemia caused by an imbalance between oxygen supply and demand without established acute coronary atherothrombosis.Although cardiac troponin elevation indicates myocardial injury and is associated with adverse outcomes, it does not reliably define coronary anatomy or identify which patients require invasive evaluation.This systematic review examined the prevalence, predictors, and clinical relevance of obstructive coronary artery disease (CAD) in adults with type 2 myocardial infarction or closely related troponin-positive supplydemand ischemic presentations.PubMed/MEDLINE, Embase, Scopus, and Web of Science were searched for studies published from January 1, 2007, through September 20, 2026, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.Eight observational studies met the eligibility criteria and were synthesized narratively because of substantial clinical and methodological heterogeneity.In cohorts undergoing systematic coronary imaging, coronary atherosclerosis was identified in 68%-92% of patients, whereas obstructive disease was present in approximately 26%-30%.Estimates were higher in clinically selected angiography cohorts, ranging from approximately 41% to 55%, reflecting differences in patient selection and coronary verification.Computed tomography (CT)-derived fractional flow reserve identified focal, hemodynamically significant stenosis in 26% of patients and excluded lesion-specific ischemia in 38% of those with at least 50% anatomical stenosis.Imaging also identified acute plaque rupture or prompted diagnostic reclassification in a minority of patients.Peripheral vascular disease and multiple cardiovascular risk factors were associated with obstructive disease in selected populations; however, predictor performance was inconsistent, and no troponin threshold or clinical model was sufficiently validated to determine the need for angiography independently.Four studies had moderate risk of bias, and four had high risk, primarily because of selective coronary verification, retrospective designs, and inconsistent definitions.The available evidence does not establish a benefit from routine invasive coronary evaluation in all patients with type 2 myocardial infarction.Troponin elevation should prompt structured cardiovascular assessment, while the decision to pursue coronary imaging should integrate ischemic features, underlying coronary risk, procedural suitability, and the likelihood that the findings will alter management.