Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay

Mumma, Bryn E.; Casey, Scott D.; Dang, Robert K.; Polen, Michelle K.; Kaur, Jasmanpreet C.; Rodrigo, John; Tancredi, Daniel J.; Narverud, Robert A.; Amsterdam, Ezra A.; Tran, Nam K.

doi:10.1016/j.annemergmed.2020.06.047

Cited by 10 publications

(8 citation statements)

References 54 publications

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“…Clinicians may be subject to medical malpractice suits for missed or delayed diagnoses of AMI as AMI is one of the most common diagnoses in lawsuits against EM physicians 8 . Professional societies such as the American Heart Association (AHA) and European Society of Cardiology (ESC) currently differ in their guidelines for the use of a single troponin, with the AHA recommending serial troponins and the ESC providing an option for a single troponin to exclude AMI, 15,43,44 and physicians are using single conventional and high‐sensitivity cardiac troponin testing in clinical practice 45,46 …”

Section: Questionmentioning

confidence: 99%

“…high-sensitivity cardiac troponin testing in clinical practice. 45,46 These differences in guidelines likely reflect differences in the adoption of high-sensitivity troponin assays, which have been used internationally for nearly a decade but only approved for use in the United States in 2017. Despite the increased incorporation of high-sensitivity troponin into accelerated diagnostic protocols, the authors acknowledge that many EDs may currently only have access to conventional troponin at this time.…”

Section: Decision Criteria and Additional Considerationsmentioning

confidence: 99%

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Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department

Musey

Bellolio

Upadhye

et al. 2021

Academic Emergency Medicine

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This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE‐1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low‐risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low‐risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high‐sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non‐obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high‐sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

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Section: Questionmentioning

confidence: 99%

Section: Decision Criteria and Additional Considerationsmentioning

confidence: 99%

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department

Musey

Bellolio

Upadhye

et al. 2021

Academic Emergency Medicine

Self Cite

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“…Moreover, this limitation led to the selection of a population at higher CV risk and for whom a troponin dosage was considered necessary by the treating physician. Secondly, our series was based on conventional troponin I dosage, leading to a possible underestimation of myocardial injury compared with other studies using high-sensitivity cardiac troponin T [ 11 , 18 , 44 ]. The most recent guidelines do indeed recommend the preferential use of high-sensitivity methods [ 16 , 45 , 46 ].…”

Section: Discussionmentioning

confidence: 99%

Troponin Elevation in Older Patients with Acute Pneumonia: Frequency and Prognostic Value

Putot

Bouhey

Tetu

et al. 2020

JCM

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Cardiovascular (CV) events are particularly frequent after acute pneumonia (AP) in the elderly. We aimed to assess whether cardiac troponin I, a specific biomarker of myocardial injury, independently predicts CV events and death after AP in older inpatients. Among 214 consecutive patients with AP aged ≥75 years admitted to a university hospital, 171 with a cardiac troponin I sample in the 72 h following diagnosis of AP were included, and 71 (42%) were found to have myocardial injury (troponin > 100 ng/L). Patients with and without myocardial injury were similar in terms of age, gender and comorbidities, but those with myocardial injury had more severe clinical presentation (median (interquartile range) Pneumonia Severity Index: 60 (40–95) vs. 45 (30–70), p = 0.003). Myocardial injury was strongly associated with in-hospital myocardial infarction (25% vs. 0%, p < 0.001), CV mortality (11 vs. 1%, p = 0.003) and all-cause mortality (34 vs. 13%, p = 0.002). After adjustment for confounders, myocardial injury remained a strong predictive factor of in-hospital mortality (odds ratio (95% confidence interval): 3.32 (1.42–7.73), p = 0.005) but not one-year mortality (1.61 (0.77–3.35), p = 0.2). Cardiac troponin I elevation, a specific biomarker of myocardial injury, was found in nearly half of an unselected cohort of older inpatients with AP and was associated with a threefold risk of in-hospital death.

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“…Although 7% more of these patients underwent angiography, MI and cardiovascular death remained unchanged, introducing some concern for overdiagnosis leading to increased unnecessary testing and potential for iatrogenic complications 8 . Similarly, a prospective observational study in the United States found that when hs‐cTnT assay was used, 16% of patients were classified as myocardial injury 9 . These studies demonstrate that, compared with conventional troponin assays, a significantly higher proportion of patients undergoing testing with hs‐cTn assays will have elevated baseline troponin values, but this should not necessarily be mistaken for ACS.…”

Section: Interpretationsmentioning

confidence: 99%

Use of high‐sensitivity cardiac troponin in the emergency department: A policy resource and education paper (PREP) from the American College of Emergency Physicians

et al. 2023

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This Policy Resource and Education Paper (PREP) from the American College of Emergency Physicians (ACEP) discusses the use of high‐sensitivity cardiac troponin (hs‐cTn) in the emergency department setting. This brief review discusses types of hs‐cTn assays as well as the interpretation of hs‐cTn in the setting of various clinical factors such as renal dysfunction, sex, and the important distinction between myocardial injury versus myocardial infarction. In addition, the PREP provides one possible example of an algorithm for the use of a hs‐cTn assay in patients in whom the treating clinician is concerned about potential acute coronary syndrome.

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Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay

Cited by 10 publications

References 54 publications

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department

Troponin Elevation in Older Patients with Acute Pneumonia: Frequency and Prognostic Value

Use of high‐sensitivity cardiac troponin in the emergency department: A policy resource and education paper (PREP) from the American College of Emergency Physicians

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