Usage of troponin in the real world: a lesson for the introduction of biochemical assays

Rajappan, Kim; Murphy, Elizabeth; Amber, Vian; Meakin, F.; Müller, Bruna Carolina; Fox, Kevin; Baker, Christopher

doi:10.1093/qjmed/hci052

Cited by 9 publications

(5 citation statements)

References 16 publications

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“…14,15 On the whole, the results of the current study confirmed those of similar studies conducted in other parts of the world. 16,17 18,19 Although these measures may help reduce patient wait times, it often results in unnecessary tests being ordered.…”

Section: Discussionsupporting

confidence: 89%

Troponin Testing in the Emergency Department: Real world experience

Almaskari

Al-Makhdami

Al-Lawati

et al. 2018

Sultan Qaboos Univ Med J

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abstract:Objectives: The aim of this study was to examine patterns of troponin testing in the emergency department of a large tertiary care hospital in Oman and to determine its effect on patient management, including length of hospital stay (LOS). Methods: This retrospective study analysed the medical records of all adult patients undergoing troponin testing in the emergency department of the Sultan Qaboos University Hospital, Muscat, Oman, during the month of July 2015. Patients who presented with an ST-elevation myocardial infarction were excluded. Results: A total of 4,845 patients attended the emergency department during the study period; of these, troponin tests were ordered for 588 patients. The majority of the patients had negative troponin test results (81.3%). Chest pain, palpitations and breathlessness were the most common presenting complaints for those with positive troponin results. However, 41.8% of patients did not have any cardiac symptoms. Individuals with positive troponin tests had a significantly longer LOS compared to those with negative tests (mean: three versus one day; P = 0.001). In total, only 28.2% of those with positive troponin test results had final diagnoses associated with a cardiac condition, such as heart failure, an acute coronary syndrome (ACS), atrial fibrillation or other types of arrhythmia. Conclusion: A positive troponin test was associated with increased LOS; however, only a small proportion of these patients had a final diagnosis associated with a cardiac condition. Guidelines should be provided to ensure that troponin testing is performed only in cases where an ACS is suspected.

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Section: Discussionsupporting

confidence: 89%

Troponin Testing in the Emergency Department: Real world experience

Almaskari

Al-Makhdami

Al-Lawati

et al. 2018

Sultan Qaboos Univ Med J

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“…Modern hs-Tn assays provide an opportunity to improve ACS diagnosis and patient outcomes, but, like any clinical tool, these need to be applied appropriately for optimum benefits. Data showed that the introduction of these tests at a UK hospital was suboptimal, with problems including inappropriate requests, 55 incomplete information in the laboratory request 56 and long turnaround times for results. 56 The Asia Pacific consensus group recommends regular education of personnel on the appropriate use of troponin tests in clinical practice, including: The analytical characteristics of the test used at that hospital/medical centre The need for serial testing in all patients The interpretation of the results in relation to the 99th percentile for that particular assay, including gender differences, the units used, changes over time versus stable levels The integration of hs-Tn results into the diagnostic algorithm, alongside other information from the patient's history, clinical signs, ECG and imaging results Caution in interpretation in presence of comorbidities.…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2017

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ObjectiveHigh-sensitivity troponin (hs-Tn) assays need to be applied appropriately to improve diagnosis and patient outcomes in acute coronary syndromes (ACS).MethodsExperts from Asia Pacific convened in 2015 to provide data-driven consensus-based, region-specific recommendations and develop an algorithm for the appropriate incorporation of this assay into the ACS assessment and treatment pathway.ResultsNine recommendations were developed by the expert panel: (1) troponin is the preferred cardiac biomarker for diagnostic assessment of ACS and is indicated for patients with symptoms of possible ACS; (2) hs-Tn assays are recommended; (3) serial testing is required for all patients; (4) testing should be performed at presentation and 3 hours later; (5) gender-specific cut-off values should be used for hs-Tn I assays; (6) hs-Tn I level >10 times the upper limit of normal should be considered to ‘rule in’ a diagnosis of ACS; (7) dynamic change >50% in hs-Tn I level from presentation to 3-hour retest identifies patients at high risk for ACS; (8) where only point-of-care testing is available, patients with elevated readings should be considered at high risk, while patients with low/undetectable readings should be retested after 6 hours or sent for laboratory testing and (9) regular education on the appropriate use of troponin tests is essential.ConclusionsWe propose an algorithm that will potentially reduce delays in discharge by the accurate ‘rule out’ of non-ACS patients within 3 hours. Appropriate research should be undertaken to ensure the efficacy and safety of the algorithm in clinical practice, with the long-term goal of improvement of care of patients with ACS in Asia Pacific.

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“…Exemplifying the need to learn from past mistakes, an early audit following introduction of troponin testing in a UK hospital, for example, demonstrated no advantage to patients or the NHS of the test in selecting patients for further cardiac investigation and/or reducing length of stay 34 . Reasons identified for this most unexpected conclusion were simple.…”

Section: Future Prospectsmentioning

confidence: 99%

Taking a new biomarker into routine use – A perspective from the routine clinical biochemistry laboratory

Sturgeon

Hill

Hortin

et al. 2010

Proteomics Clinical Apps

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There is increasing pressure to provide cost-effective healthcare based on “best practice.” Consequently, new biomarkers are only likely to be introduced into routine clinical biochemistry departments if they are supported by a strong evidence base and if the results will improve patient management and outcome. This requires convincing evidence of the benefits of introducing the new test, ideally reflected in fewer hospital admissions, fewer additional investigations and/or fewer clinic visits. Carefully designed audit and cost-benefit studies in relevant patient groups must demonstrate that introducing the biomarker delivers an improved and more effective clinical pathway. From the laboratory perspective, pre-analytical requirements must be thoroughly investigated at an early stage. Good stability of the biomarker in relevant physiological matrices is essential to avoid the need for special processing. Absence of specific timing requirements for sampling and knowledge of the effect of medications that might be used to treat the patients in whom the biomarker will be measured is also highly desirable. Analytically, automation is essential in modern high-throughput clinical laboratories. Assays must therefore be robust, fulfilling standard requirements for linearity on dilution, precision and reproducibility, both within- and between-run. Provision of measurements by a limited number of specialized reference laboratories may be most appropriate, especially when a new biomarker is first introduced into routine practice.

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Usage of troponin in the real world: a lesson for the introduction of biochemical assays

Cited by 9 publications

References 16 publications

Troponin Testing in the Emergency Department: Real world experience

Troponin Testing in the Emergency Department: Real world experience

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

Taking a new biomarker into routine use – A perspective from the routine clinical biochemistry laboratory

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