Troponin for surveillance of immune checkpoint inhibitor–associated myocarditis and post-therapy cardiovascular risk stratification: a systematic review and meta-analysis

Background: Immune checkpoint inhibitors (ICIs) have transformed cancer therapy but are associated with immune-related adverse events, including myocarditis, a rare complication with high morbidity and mortality. ICI-associated myocarditis often presents with nonspecific clinical features, making early recognition challenging. Cardiac troponin is a widely available biomarker of myocardial injury and is increasingly used in cardio-oncology surveillance pathways; however, its performance for identifying ICI-associated myocarditis and its prognostic value for subsequent cardiovascular outcomes remain incompletely defined. Objectives: To evaluate the performance of cardiac troponin in the surveillance and identification of ICI-associated myocarditis and to assess its prognostic value for major adverse cardiovascular events (MACE) and mortality. Methods: We conducted a systematic review and meta-analysis in accordance with PRISMA 2020 guidelines. Medline (PubMed), Embase, Cochrane CENTRAL, and Scopus were searched from inception to October 2025 for diagnostic and prognostic studies evaluating troponin (I or T; conventional or high-sensitivity) in adults receiving ICIs. Random-effects models were used to pool effect estimates. Performance for identifying ICI-associated myocarditis was assessed using odds ratios (ORs), and prognostic associations were summarized using hazard ratios (HRs). Results: Across diagnostic studies, troponin elevation was associated with confirmed ICI-associated myocarditis (pooled log OR 4.14, 95% CI 2.80-5.48), with no significant between study heterogeneity. However, false-positive troponin elevations were common, resulting in modest positive predictive value despite high sensitivity. In prognostic analyses, elevated troponin levels were associated with an increased risk of MACE (pooled HR 6.14, 95% CI 3.61-10.45) and all-cause mortality (pooled HR 1.95, 95% CI 1.36-2.81). These associations were consistent across studies with varying designs, troponin assays, and outcome definitions. Conclusions: Troponin elevation in patients receiving ICIs is associated with ICI-related myocarditis and with increased risk of adverse cardiovascular outcomes and mortality, supporting its role as an accessible biomarker for early clinical evaluation, surveillance, and risk stratification. However, because false-positive elevations are common and diagnostic performance varies by assay type, threshold, and timing, troponin should not be interpreted as a standalone diagnostic test. Prospective studies are needed to define optimal troponin-guided surveillance strategies. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251176007 identifier CRD420251176007.