Abstract Body (Do not enter title and authors here): The significance of elevated troponin in patients with rhabdomyolysis is debated. While some suggest skeletal muscle injury contributes to elevation, most studies indicate that elevated troponin reflects myocardial damage and is associated with worse outcomes. Prior research has
largely focused on conventional troponin assays, with limited data on high-sensitivity troponin (hs-Tn) and its association with acute coronary syndrome (ACS) in this population.

Methods
We used the TriNetX research platform to perform a retrospective, propensity-matched cohort study of adult patients diagnosed with rhabdomyolysis. Patients were divided into two groups: those with elevated hs-Tn and those with normal troponin. The primary outcome was incidence of ACS within 7 days of rhabdomyolysis diagnosis. After matching, both groups included 2,443 patients.

After 1:1 propensity matching, each group included 2,443 patients. ACS occurred in 159 patients (6.51%) in the elevated troponin group versus 31 patients (1.27%) in the control group. This corresponded to a risk difference of 5.2% (95% CI: 4.2–6.3%), a risk ratio of 5.13 (95% CI: 3.51–7.49), and an odds ratio of 5.42 (95% CI: 3.69–7.95), all statistically significant (p < 0.0001). Kaplan–Meier analysis demonstrated significantly reduced ACS-free survival in the elevated troponin group (log-rank p < 0.001), with a hazard ratio of 5.26 (95% CI: 3.58–7.73).

In conclusion, In patients with rhabdomyolysis, elevated hs-troponin is associated with a fivefold higher risk of ACS, supporting the interpretation that troponin elevation reflects true myocardial injury rather than skeletal muscle release. Early cardiac evaluation may be warranted in this population.