Clinical impact of using a more sensitive troponin assay in patients with acute chest pain

Abstract

Background More sensitive troponin assays have the potential to better evaluate patients with suspected acute coronary syndrome (ACS). Meanwhile, they may result in avoidable diagnostic testing. Hypothesis Our aim was to determine the clinical impact of implementing a more sensitive cardiac troponin I (cTnI) assay in patients with acute non‐traumatic chest pain presenting to the emergency department (ED). Methods This is a pre‐post cohort study. A total of 1201 consecutive patients with acute non‐traumatic chest pain or equivalent ischemic symptoms suggestive of ACS were allocated to two groups according to the cTnI assay used. The outcomes included the ED length of stay (LOS), hospital admission rate, the use of procedures and the incidence of major adverse cardiac events (MACE) at 30 days. Results The introduction of the more sensitive troponin assay shortened ED LOS (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.28‐0.54) regarding patients discharged home directly, increased the hospital admission rate (OR 1.43, 95% CI 1.12‐1.84), the use of echocardiography (OR 1.58, 95% CI 1.22‐2.06), coronary computed tomography angiography (OR 1.78, 95% CI 1.04‐3.06), coronary angiography (OR 1.53, 95% CI 1.10‐2.12) and percutaneous coronary intervention (OR 2.42, 95% CI 1.58‐3.70) regarding patients discharged or admitted. The incidence of MACE did not decrease significantly (OR 0.61, 95% CI 0.27‐1.37). Conclusions The introduction of the more sensitive troponin assay appeared to result in less time spent in the ED regarding patients discharged home directly, but prompted more hospitalizations and procedures without impacting the incidence of MACE.

Comparison of usual care and the HEART score for effectively and safely discharging patients with low‐risk chest pain in the emergency department: would the score always help?

“…The possible reasons for these disparities may be the different definition of MACE and ACS prevalence. 32,37 After all, the percent of patients suffering 30-day MACE in our study was 28.2%, which was higher than that in most prior research. 36 There were several limitations in the study.…”

“…In our analysis, the incidence of MACE in patients with a low HEART score would have been much higher (5.2%) with lower sensitivity and specificity than the pooled values mentioned above. The possible reasons for these disparities may be the different definition of MACE and ACS prevalence . After all, the percent of patients suffering 30‐day MACE in our study was 28.2%, which was higher than that in most prior research …”

A Closer Look at the HEART Score

“…Most variants described usually involve interpreting various cardiac troponin assay protocols. The term "modified HEART score" usually refers to these variants [7,15,16,[22][23][24]. The term has been proposed when a high-sensitivity cardiac troponin (hs-cTn) assay is used in calculating the score in place of conventional troponin by some investigators.…”

“…Introduction of more sensitive troponin assay has been shown to increase the rate of coronary angiography [ 22 , 23 ] and PCI but did not have significant impact on MACE [ 17 ]. As mentioned above, one of the limitations of HEART score is its suboptimal ability to detect most low-risk patients.…”

Application of machine learning and laser optical-acoustic spectroscopy to study the profile of exhaled air volatile markers of acute myocardial infarction

“…The third AMI criterium is an increase in cardio-specific enzymes, particularly troponin, by at least one value exceeding the 99th percentile of the normal reference value. Quantitative determination of troponin in serum and plasma was determined using immunochemical system ACCESS (Test ACCESS AccuTnI), Beckman Coulter, Inc., Canada [31][32][33][34]. Quantitative determination of total CPK and its MB-fraction (CPK-MV) in serum and plasma as determined by an automatic biochemical analyzer Konelab 60i, Thermo Fisher Scientific Inc., USA [35][36][37].…”