Exploration of Cardiology

Table 3. Cardiac biomarkers affected by heterophile antibody interference.

Biomarker	Direction of interference	Typical clinical consequence	Key diagnostic clue
Cardiac troponins	False elevation (most common)	Unnecessary ACS treatment, angiography	Persistent elevation without expected rise-fall kinetics and discordance with clinical presentation
BNP	False elevation	Misdiagnosis of HF	Elevated BNP concentration inconsistent with imaging findings or clinical evidence of HF
NT-proBNP	False elevation or suppression	Inappropriate HF risk stratification	Marked inter-platform discordance or unexpected values inconsistent with clinical status
Digoxin	Markedly false elevation	Unnecessary antidote or therapy cessation	Markedly elevated digoxin level without compatible clinical toxicity findings
D-dimer	False elevation	Unnecessary thromboembolism workup	Persistently elevated D-dimer despite negative imaging for thromboembolism

Return to article view

ACS: acute coronary syndrome; BNP: B-type natriuretic peptide; NT-proBNP: N-terminal pro-B-type natriuretic peptide; HF: heart failure.

Declarations

Acknowledgments

The authors confirm that no AI or AI-assisted tools were used for interpreting the referenced article or for generating scientific content. Limited assistance was obtained solely for language editing, grammatical refinement, and preparation of Figure 1, without any involvement in data interpretation, analysis, or conceptual input.

Author contributions

ÖBÇ: Conceptualization, Writing—original draft. MK: Conceptualization, Writing—review & editing. AS: Conceptualization, Writing—original draft. MMY: Conceptualization, Investigation, Writing—original draft. OK: Conceptualization, Investigation, Writing—original draft. MY: Writing—review & editing. MCÇ: Conceptualization, Investigation, Writing—original draft. LB: Supervision, Validation. MY: Supervision, Validation. YK: Supervision, Validation. All authors read and approved the submitted version.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Ethical approval

Not applicable.

Consent to participate

Not applicable.

Consent to publication

Not applicable.

Availability of data and materials

Not applicable.

Funding

Not applicable.

Copyright

Publisher’s note

Open Exploration maintains a neutral stance on jurisdictional claims in published institutional affiliations and maps. All opinions expressed in this article are the personal views of the author(s) and do not represent the stance of the editorial team or the publisher.

References

Garg P, Morris P, Fazlanie AL, Vijayan S, Dancso B, Dastidar AG, et al. Cardiac biomarkers of acute coronary syndrome: from history to high-sensitivity cardiac troponin. Intern Emerg Med. 2017;12:147–55. [DOI] [PubMed] [PMC]

Reichlin T, Twerenbold R, Reiter M, Steuer S, Bassetti S, Balmelli C, et al. Introduction of high-sensitivity troponin assays: impact on myocardial infarction incidence and prognosis. Am J Med. 2012;125:1205–13.e1. [DOI] [PubMed]

Ward G, Simpson A, Boscato L, Hickman PE. The investigation of interferences in immunoassay. Clin Biochem. 2017;50:1306–11. [DOI] [PubMed]

Bolstad N, Warren DJ, Nustad K. Heterophilic antibody interference in immunometric assays. Best Pract Res Clin Endocrinol Metab. 2013;27:647–61. [DOI] [PubMed]

Lippi G, Aloe R, Meschi T, Borghi L, Cervellin G. Interference from heterophilic antibodies in troponin testing. Case report and systematic review of the literature. Clin Chim Acta. 2013;426:79–84. [DOI] [PubMed]

Januzzi JL Jr, McCarthy CP. Cardiac Troponin and the True False Positive. JACC Case Rep. 2020;2:461–3. [DOI] [PubMed] [PMC]

Lapić I, Rogić D, Šegulja D, Jakšić Jurinjak S, Vogrinc Ž, Kačkov S, et al. Interfering heterophile antibodies as the cause of persistently falsely elevated high-sensitivity troponin I on Alinity i: a case report. Biochem Med (Zagreb). 2025;35:021001. [DOI] [PubMed] [PMC]

Kricka LJ. Human anti-animal antibody interferences in immunological assays. Clin Chem. 1999;45:942–56. [PubMed]

Levinson SS, Miller JJ. Towards a better understanding of heterophile (and the like) antibody interference with modern immunoassays. Clin Chim Acta. 2002;325:1–15. [DOI] [PubMed]

10.

Tate J, Ward G. Interferences in immunoassay. Clin Biochem Rev. 2004;25:105–20. [PubMed] [PMC]

11.

Martins TB, Pasi BM, Litwin CM, Hill HR. Heterophile antibody interference in a multiplexed fluorescent microsphere immunoassay for quantitation of cytokines in human serum. Clin Diagn Lab Immunol. 2004;11:325–9. [DOI] [PubMed] [PMC]

12.

Bjerner J, Børmer OP, Nustad K. The war on heterophilic antibody interference. Clin Chem. 2005;51:9–11. [DOI] [PubMed]

13.

Ismail AA. On the interpretation of affirmative follow-up tests in immunoassays: what must not be done? Ann Clin Biochem. 2006;43:249–51. [DOI] [PubMed]

14.

Kazmierczak SC, Catrou PG, Briley KP. Transient nature of interference effects from heterophile antibodies: examples of interference with cardiac marker measurements. Clin Chem Lab Med. 2000;38:33–9. [DOI] [PubMed]

15.

Wauthier L, Plebani M, Favresse J. Interferences in immunoassays: review and practical algorithm. Clin Chem Lab Med. 2022;60:808–20. [DOI] [PubMed]

16.

Köhler G, Milstein C. Continuous cultures of fused cells secreting antibody of predefined specificity. Nature. 1975;256:495–7. [DOI] [PubMed]

17.

Hammarsten O, Warner JV, Lam L, Kavsak P, Lindahl B, Aakre KM, et al. Antibody-mediated interferences affecting cardiac troponin assays: recommendations from the IFCC Committee on Clinical Applications of Cardiac Biomarkers. Clin Chem Lab Med. 2023;61:1411–9. [DOI] [PubMed]

18.

Ismail AA, Walker PL, Cawood ML, Barth JH. Interference in immunoassay is an underestimated problem. Ann Clin Biochem. 2002;39:366–73. [DOI] [PubMed]

19.

Graça Santos L, Ribeiro Carvalho R, Montenegro Sá F, Soares F, Pernencar S, Castro R, et al. Circulating Heterophile Antibodies Causing Cardiac Troponin Elevation: An Unusual Differential Diagnosis of Myocardial Disease. JACC Case Rep. 2020;2:456–60. [DOI] [PubMed] [PMC]

20.

Lakusic N, Sopek Merkas I, Lucinger D, Mahovic D. Heterophile antibodies, false-positive troponin, and acute coronary syndrome: a case report indicating a pitfall in clinical practice. Eur Heart J Case Rep. 2021;5:ytab018. [DOI] [PubMed] [PMC]

21.

Millhouse J, Kamalanathan H, Jayasinghe R. Elevated cardiac troponin secondary to heterophile antibodies: a case series highlighting an underrecognized differential. Eur Heart J Case Rep. 2024;8:ytae624. [DOI] [PubMed] [PMC]

22.

Lippi G, Ardissino D, Aloe R, Cervellin G. A false positive case of cardiac troponin I identified with CK-MB reflex testing. Int J Cardiol. 2014;176:e3–4. [DOI] [PubMed]

23.

Jin CD, Kim MH, Guo LZ, Li SH, Han JY. Falsely high B-type natriuretic peptide concentration in patients without heart failure attributed to AxSYM assay: case series of eight subjects. ESC Heart Fail. 2015;2:37–9. [DOI] [PubMed] [PMC]

24.

Yin Q, Wang F, Zhang C, Pan Y. Case report: False-positive B-type natriuretic peptide results with the cyclic amplified fluorescence immunoassay. J Int Med Res. 2025;53:3000605251325942. [DOI] [PubMed] [PMC]

25.

Janssen MJ, Velmans MH, Heesen WF. A patient with a high concentration of B-type natriuretic peptide (BNP) but normal N-terminal proBNP concentration: A case report. Clin Biochem. 2014;47:1136–7. [DOI] [PubMed]

26.

Ingels M, Rangan C, Morfin JP, Williams SR, Clark RF. Falsely elevated digoxin level of 45.9 ng/mL due to interference from human antimouse antibody. J Toxicol Clin Toxicol. 2000;38:343–5. [DOI] [PubMed]

27.

Hermida-Cadahía EF, Calvo MM, Tutor JC. Interference of circulating endogenous antibodies on the Dimension® DGNA digoxin immunoassay: elimination with a heterophilic blocking reagent. Clin Biochem. 2010;43:1475–7. [DOI] [PubMed]

28.

Lippi G, Ippolito L, Tondelli MT, Favaloro EJ. Interference from heterophilic antibodies in D-dimer assessment. A case report. Blood Coagul Fibrinolysis. 2014;25:277–9. [DOI] [PubMed]

29.

Milić M, Brkić Barbarić D, Lukić I, Kirin M, Buljanović V, Šerić V. D-dimer assay interference detected by the discrepancy in D-dimer concentrations at different dilutions: a case report. Biochem Med (Zagreb). 2024;34:031001. [DOI] [PubMed] [PMC]

30.

Verboogen D, Granzen B, Hudig C, van de Kerkhof D, Verhezen P, de Boer D, et al. Heterophilic antibodies leading to falsely positive D-dimer concentration in an adolescent. Res Pract Thromb Haemost. 2022;7:100017. [DOI] [PubMed] [PMC]

31.

Wu Y, Xiao Y, Huang T, Zhang X, Zhou H, Zhang X, et al. What makes D-dimer assays suspicious-heterophilic antibodies? J Clin Lab Anal. 2019;33:e22687. [DOI] [PubMed] [PMC]

32.

Ismail AA. When laboratory tests can mislead even when they appear plausible. Clin Med (Lond). 2017;17:329–32. [DOI] [PubMed] [PMC]

33.

Ismail AA. On detecting interference from endogenous antibodies in immunoassays by doubling dilutions test. Clin Chem Lab Med. 2007;45:851–4. [DOI] [PubMed]

34.

Sandoval Y, Jaffe AS. Using High-Sensitivity Cardiac Troponin T for Acute Cardiac Care. Am J Med. 2017;130:1358–65.e1. [DOI] [PubMed]

35.

Collinson P. High-sensitivity troponin measurements: challenges and opportunities for the laboratory and the clinician. Ann Clin Biochem. 2016;53:191–5. [DOI] [PubMed]

36.

Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al.; Executive Group on behalf of the Joint European Society of Cardiology (ESC); American College of Cardiology (ACC); American Heart Association (AHA); World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). Circulation. 2018;138:e618–51. [DOI] [PubMed]

37.

Salvatici M, Gaimarri M, Rispoli F, Bianchi B, Sansico DF, Matteucci E, et al. Troponin Test, Not Only a Number: An Unusual Case of False Positive. Int J Mol Sci. 2024;25:11937. [DOI] [PubMed] [PMC]

38.

Halsall DJ. Antibody interference in immunoassay: know your enemy. Ann Clin Biochem. 2013;50:397–9. [DOI] [PubMed]

39.

Nevraumont A, Deltombe M, Favresse J, Guillaume L, Chapelle V, Twerenbold R, et al. Interferences with cardiac biomarker assays: understanding the clinical impact. Eur Heart J. 2022;43:2286–8. [DOI] [PubMed]

40.

Emerson JF, Ngo G, Emerson SS. Screening for interference in immunoassays. Clin Chem. 2003;49:1163–9. [DOI] [PubMed]

41.

Cheng F, Chen J, Wu BL, Yang X, Huang YS. A Rare Case of Falsely Elevated High-Sensitivity Cardiac Troponin T due to Antibody Interference and a Literature Review. Clin Lab. 2023;69:8. [DOI] [PubMed]

42.

Salvatici M, Sommese C, Corsi Romanelli MM, Drago L. Review of Literature and Recommended Procedures for Management of Unusual Cases of False Positive Troponin Tests. Int J Mol Sci. 2025;26:1045. [DOI] [PubMed] [PMC]

43.

Bionda C, Rousson R, Collin-Chavagnac D, Manchon M, Chikh K, Charrié A. Unnecessary coronary angiography due to false positive troponin I results in a 51-year-old man. Clin Chim Acta. 2007;378:225–6. [DOI] [PubMed]

44.

Zaidi A, Cowell R. False positive cardiac troponin elevation due to heterophile antibodies: more common than we recognise? BMJ Case Rep. 2010;2010:bcr1120092477. [DOI] [PubMed] [PMC]

45.

Herman DS, Kavsak PA, Greene DN. Variability and Error in Cardiac Troponin Testing: An ACLPS Critical Review. Am J Clin Pathol. 2017;148:281–95. [DOI] [PubMed]

46.

Broz P, Racek J, Prokop P, Novak J, Rajdl D, Trefil L. Macrotroponins cause discrepancy in high-sensitivity examination. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2024;168:187–90. [DOI] [PubMed]

47.

Desaegher A, Marin V, Beauvieux M, Colombiès B, Lauga M, Alloug S, et al. Exploring strategies to rapidly identify false positives in high-sensitivity cardiac troponin I assay: A prospective study. Clin Chim Acta. 2025;565:119996. [DOI] [PubMed]

48.

Sturgeon CM, Viljoen A. Analytical error and interference in immunoassay: minimizing risk. Ann Clin Biochem. 2011;48:418–32. [DOI] [PubMed]

49.

Clerico A, Belloni L, Carrozza C, Correale M, Dittadi R, Dotti C, et al. A Black Swan in clinical laboratory practice: the analytical error due to interferences in immunoassay methods. Clin Chem Lab Med. 2018;56:397–402. [DOI] [PubMed]

50.

Lyons KS, Herity N, Lee G, Talbot C, McKeeman G. Assay interference as a cause of false positive troponin T elevation in emergency department patients. Int J Cardiol. 2023;389:131165. [DOI] [PubMed]

51.

Hou H, Zhang R, Li J. Artificial intelligence in the clinical laboratory. Clin Chim Acta. 2024;559:119724. [DOI] [PubMed]

52.

Lin Y, Mensah IK, Doering M, Shean RC, Spies NC. Machine learning-based error detection in the clinical laboratory: a critical review. Crit Rev Clin Lab Sci. 2025;62:535–47. [DOI] [PubMed]

53.

Chen Y, Jiang M, Xia C, Zhao H, Ke P, Chen S, et al. A novel deep learning system for STEMI prognostic prediction from multi-sequence cardiac magnetic resonance. Sci Bull (Beijing). 2025;70:4241–52. [DOI] [PubMed]

54.

Chen Y, Xu W, Zhang W, Tong R, Yuan A, Li Z, et al. Plasma metabolic fingerprints for large-scale screening and personalized risk stratification of metabolic syndrome. Cell Rep Med. 2023;4:101109. [DOI] [PubMed] [PMC]

55.

Zhang J, Chen Y, Zhong Y, Wang Y, Huang H, Xu W, et al. Intermittent fasting and cardiovascular health: a circadian rhythm-based approach. Sci Bull (Beijing). 2025;70:2377–89. [DOI] [PubMed]