Utilization of cardiac troponin assays in adult and pediatric populations: Guideline recommendations vs. reality

Role of Troponin Determination to Diagnose Chest Pain in the Pediatric Emergency Department

“…Both myocarditis and pericarditis can occur with chest pain and elevated TN plasma levels, because the inflammation process causes degradation of the cell membrane of the myocardiocytes, resulting in TN release into the bloodstream. 7 Coronary abnormalities are the most important causes of myocardial ischemia in adolescents. Although coronary abnormalities are rare, it is important defining their origin correctly through diagnostics images.…”

“…1,2 Although the incidence of cardiac pain is low, the fear of a severe underlying cardiac pathology and the subsequent risk of a sudden death determined the increase of plasma troponin (TN) determination as basic evaluation in pediatric patients admitted to ED with chest pain. [2][3][4][5][6][7][8][9] The alarm elements for cardiac chest pain, considered as "red flags," are represented by chest pain during exercise (in the initial and peak phases), association with syncope during physical exercise, nausea and vomiting, vertigo, and irradiation and/or increasing in the supine position. 10,11 Abnormalities on the physical examination that were considered as red flags included pathological heart murmur, palpitations, pericardial rub, abnormal second heart sound, distant heart sounds, hepatomegaly, decreased femoral or peripheral pulses, peripheral edema, painful or swollen extremities, tachypnea, and fever.…”

“…On the other hand, in the presence of fever and/or ECG modifications, the TN determination is a diagnostic tool for myocarditis, even if without significant prognostic value. 2,3,5,[7][8][9] The aim of our study was to evaluate the utility of TN plasma level determination in children admitted to pediatric emergency department for chest pain and to find a possible correlation between TN values, ECG recording, and medical history and clinical presentation, considered as "red flags" of chest pain of cardiac origin. 4,[12][13][14]…”

Adopting ‘ng/L’ as the units for high-sensitivity cardiac troponin assays and commitment by the entire health-care team could be the key for adopting recommendations

“…1 The findings of this survey of the UK and Ireland, together with those of a recent US survey on cTn testing, highlight significant gaps and variation in laboratory practice with respect to cTn. 1,2 The Annals publication makes 12 recommendations for improving the application of high-sensitivity cTn (hs-cTn) assays in clinical practice, of which recommendation number 5 we feel is essential: 'Laboratories should report hs-troponin as ng/L'. 1 Originally, the recommendation to adopt the International System of Units (SI units) for hs-cTn assays was made in order to avoid errors in the reporting of hs-cTn concentrations and misunderstanding about which kind of cTn assay was used (i.e.…”

Establishing consensus-based, assay-specific 99th percentile upper reference limits to facilitate proper utilization of cardiac troponin measurements

“…The upper reference limit for cTn is also sometimes selected based on historical, or even empirical, clinical evidence and/or the analytical characteristics of a particular assay. The variability in laboratory practices for defining the upper reference limit of cTn assays has been documented by a few key studies that surveyed a diverse group of laboratories across several European and/or North American countries [18][19][20]. These data indicate that the 99th percentile upper reference limit has not been universally adopted.…”