Consequences of high-sensitivity troponin T testing applied in a primary care population with chest pain compared with a commercially available point-of-care troponin T analysis: an observational prospective study

Abstract

BackgroundThere is a demand for a highly sensitive and specific point-of care test to detect acute myocardial infarction (AMI). It is unclear if a high-sensitivity troponin assay will have enough discriminative power to become a decision support in primary care. The aim of this study was to evaluate a high-sensitivity troponin T assay performed in three primary health care centres in southeast Sweden and to compare the outcome with a point-of-care troponin T test.MethodsThis study included 115 patients who consulted their general practitioner for chest pain, dyspnoea on exertion, unexplained weakness and/or fatigue in the last 7 days. Troponin T was analysed by a point-of-care test and a high-sensitivity method together with N-terminal pro-B-type natriuretic peptide (NT-proBNP) and creatinine. All patients were checked for AMI or unstable angina (UA) within 30 days of study enrolment. Univariate and multivariate logistic regression was carried out to examine possible connections between troponin T ≥ 15 ng/L, clinical variables and laboratory findings at baseline. In addition, 21 patients with troponin T ≥ 15 ng/L and no signs of AMI or UA were followed up for 2–3 years.ResultsThree patients were diagnosed with AMI and three with UA. At the ≥ 15 ng/L cut-off, the troponin T method had 100% sensitivity, 75% specificity for AMI and a positive predictive value of 10%. The troponin T point-of-care test missed one case of AMI and the detection limit was 50 ng/L. Troponin T ≥ 15 ng/L was correlated to age ≥65 years (odds ratio (OR), 10.9 95% CI 2.28–51.8) and NT-proBNP in accordance with heart failure (OR 8.62 95% CI 1.61–46.1). Fourteen of the 21 patients, without signs of AMI or UA at baseline, still had increased troponin T at follow-up after 2–3 years.ConclusionsA high-sensitivity troponin T assay could become useful in primary care as a point-of-care test for patients <65 years. For patients older than 65–70 years, a higher decision limit than ≥15 ng/L should be considered and used in conjunction with clinical parameters and possibly with NT-proBNP.

Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care

“…Of the remaining 17 articles, three additional articles were eliminated after full text evaluation, since no relevant data were obtainable from these papers (Sox et al ., 1990; Soler et al ., 2012a; Haasenritter et al ., 2015). Two articles reported as references in the remaining 14 articles were added, resulting in a final number of 16 articles that were included (Supplementary Material Figure S1) (Rosser et al ., 1990; Klinkman et al ., 1994; Svavarsdottir et al ., 1996; Nilsson et al ., 2003; Carroll et al ., 2003; Bakx et al ., 2005; Ruigomez et al ., 2006; Koek et al ., 2007; Verdon et al ., 2008; Bosner et al ., 2009; Yeh et al ., 2010; Haasenritter et al ., 2012; Soler et al ., 2012b; Bruins Slot et al ., 2013; Andersson et al ., 2015; Frese et al ., 2016). In addition, data from regional and national Dutch and Belgian databases were used (Okkes et al ., 2005; Academic Hospital Maastricht, 2013; Catholic University Leuven, 2013; Dutch Heart Foundation, 2013; CBS, 2014a; 2014b; 2014c; 2014d).…”

Characteristics of patients with acute myocardial infarction contacting primary healthcare before hospitalisation: a cross-sectional study

“…In addition to the existing clinical European guidelines on cardiovascular prevention in PHC [ 9 ], GPs are in need of validated diagnostic tools to help distinguish patients with chest pain for referral to the ED, particularly since the medical history, symptom presentation, and findings from the ECG are not always indicative [ 11 , 27 ]. The use of troponin testing - a biomarker used to assess myocardial injury - may reduce emergency referrals but probably at the cost of an increased risk of overdiagnoses, especially among older patients with acute MI and often chronically increased troponin levels [ 2 ], and is therefore not encouraged in GP offices [ 28 , 29 ]. However, a more in-depth medical history, detailed symptom assessment and physical examination using a clinical prediction score could possibly assist the GP to rule out coronary heart disease in PHC patients with chest pain [ 30 , 31 ].…”

Asia-Pacific consensus statement on the optimal use of high-sensitivity troponin assays in acute coronary syndromes diagnosis: focus on hs-TnI

“…POC troponin tests are less sensitive than hs-Tn laboratory assays, 51 52 with PPV only around 50%. 52 Therefore, any patient with an elevated troponin level on POC testing should be considered as being at high risk of having ACS. These patients should undergo further assessment according to the algorithm outlined in figure 2.…”