One-Hour High Sensitivity Troponin Testing: A Safe and Effective Triage Tool for the Emergency Department

Abstract

The latest European Society of Cardiology guideline on the management of acute coronary syndromes without persistent ST-elevation stipulates several acceptable pathways through which patients presenting with chest pain can be assessed for unstable coronary disease. This article reviews the data behind the “rule-in and rule-out algorithm,” which can exclude acute myocardial infarction within 1 hour of presentation through the use of fifth generation high-sensitivity troponin assays.

Recent advances in cardiac biomarkers detection: From commercial devices to emerging technologies

“…The report explained that these current measurements are now sufficiently sensitive that minor troponin concentration variations, such as a few ng/L, can be detected, allowing for a more accurate diagnosis [24,27,31,40,47,50,78]. Hence, an earlier risk stratification of AMI likelihood is now possible [27,31,35,40,78,89,92]. Thanks to these new assays, the delay between the two troponin measurements may be reduced to 1 hour [27,31,38,89,93]: the first measurement should be performed upon apatient's admission to the ED, the second being taken one hour later.…”

“…Since 2010, high-sensitivity troponin assays are available [88]. They allow a more rapid [35,38,49,78,89] and more accurate detection [27,31,35,38] compared to conventional assays, offering a reduction of the detection limit from µg/L to ng/L [27,37,47,50,89]. These highly-sensitive troponin measurements are very efficient at the first stage of the myocardial infarction because they allow the identification of early necrosis [29,50].…”

“…Hence, an earlier risk stratification of AMI likelihood is now possible [27,31,35,40,78,89,92]. Thanks to these new assays, the delay between the two troponin measurements may be reduced to 1 hour [27,31,38,89,93]: the first measurement should be performed upon apatient's admission to the ED, the second being taken one hour later. Such a protocol may be sufficient to rule-out patients with very low troponin level or rule-in patients with very high level or large increase after one hour [24,29].…”

“…Such a protocol may be sufficient to rule-out patients with very low troponin level or rule-in patients with very high level or large increase after one hour [24,29]. However, different diagnostic protocols exist [31,89,93] and there is still no consensus to define a unique cutoff allowing the exclusion of patients who have absolutely no risk of myocardial infarction [26,27,38,40]. Different factors like age or sex can influence troponin concentration [9,27,31,38,40] and thus should be taken into account for cutoff definition.…”

“…Finally, a prognostic utility of cardiac troponin was demonstrated [27,35,89]. The troponin value gives information about the risk of death [25,31,34] and helps for risk stratification [37,38,47,93,96].…”