Troponin is an integral component of the evaluation for acute coronary syndrome acs and occlusion myocardial infarction omi. Letter to the editor highsensitivity troponin is not a. Missed mi, major adverse cardiac event mace, or death search strategy an advances pubmed search was performed using the terms troponin and high. The aim of this study was to examine patterns of troponin testing in the emergency department of a large tertiary care hospital in. However, troponin may be elevated in conditions other than omi. Highsensitivity hs cardiac troponin ctn assays expedite the evaluation of patients with possible acute coronary syndromes acs in the emergency department. By now, associations between elevated troponins and poor outcomes are not novel nejm jw emerg med may 2019 and bmj 2019.
More recently, highsensitivity assays for troponin measurement have been developed. Department of emergency medicine, university of ottawa staff contributors stella yiu, md, ccfpem k. Acute myocardial infarction, emergency department, troponin. Troponin is a complex of three proteins, troponin c, troponin t and troponin i.
Research article diagnostic implications of an elevated troponin in the emergency department maameyaayiadom, 1 petrjarolim, 2 cathyjenkins, 3 stacye. Conditions in other parts of your body may cause troponin levels to rise. Of more than 8 million ed visits related to chest pain that occur annually in the united states, well less than a third will result in a final diagnosis of an acute coronary syndrome. What other testing should i consider in the emergency department. Blunt cardiac injury bci rebel em emergency medicine. An emergency medicine approach to troponin elevation due. Serum ctn testing is the biomarker of choice to test for myocardial infarction, one of the more critical conditions causing myocardial injury. Highsensitivity cardiac troponin i and clinical risk. Atypical presentation of thrombotic thrombocytopenic purpura in a patient with elevated troponin level in an emergency room and critical care unit setting bp mean. There is no standard definition of blunt cardiac injury bci.
Request pdf cardiac troponins 1 1 clinical laboratory in emergency medicine is coordinated by jonathan olshaker, md, of the university of maryland medical center, baltimore, maryland cardiac. The onehour high sensitivity troponin to ruleout mi. Highsensitivity troponin and the application of risk. Application of highsensitivity troponin in suspected myocardial. Traditional 6hour or 4hour or 3hour or 2hour serial cardiac enzymes outcome. Cardiac troponins 1 1 clinical laboratory in emergency.
Point of care testing in emergency departments jesse pines, md, mba, msce director, office for clinical practice innovation professor of emergency medicine and health policy the george washington university george hertner, md, facep medical director, memorial hospital. Highsensitivity troponin in the evaluation of patients with suspected acute coronary syndrome. We examined the records of all patients admitted to hospital for treatment of copd for serum troponin measurement, clinical features of myocardial ischaemia, oxygenation pulse oximetry, arterial blood gas analysis. Troponin health encyclopedia university of rochester. Chestpain patients and highsensitivity troponin tests. Troponin testing and coronary syndrome in geriatric patients with nonspecific complaints. To investigate the prevalence of serum troponin elevation in patients admitted to hospital with an exacerbation of chronic obstructive pulmonary disease copd. Cardiac troponins cardiac isoforms exist of troponin t and troponin i. High sensitivity troponin testing emergency medicine blog. Troponin is a muscle protein that is released into the circulation following acute myocardial injury ami. Nine papers were found to be relevant to the clinical question following the belowdescribed search strategies. Research article diagnostic implications of an elevated. Emergency medicine cases em cases is a free online medical education podcast, medical blog and website dedicated to providing online emergency medicine education and cme for physicians, residents, students nurses and paramedics.
Highsensitivity troponin hstni is widely used in europe to test for myocardial infarction mi and is becoming more common in the u. In the ed patient population a troponin serum assay ctn is used as a generic screen for myocardial injury 1, 2. Emergency medicine news has now published 2 mythbusting articles, disputing the value of highsensitivity troponin. Identifying emergency department july 2017 eb medicine. The results of a study conducted by researchers from indiana university school of medicine may not support troponin testing for acute coronary syndrome acs in. Troponin was 100% sensitive 95% confidence interval ci 48% to 100% and 81% specific 95% ci 77% to 85% for acs. Kosowsky 4 department of emergency medicine, vanderbilt university, nashville, tn, usa. Recently, newer assays for cardiac troponin ctn have been developed which are able to detect changes in concentration of the biomarker at or below the 99th percentile for a normal population. Prehospital evaluation of sensitive troponin presto. By itself, however, ctn cannot identify the cause of myocardial injury.
All patients with troponin elevation were admitted, but only one underwent angiography and no patients received reperfusion therapy. In general, bci refers to any blunt trauma to the heart. Troponinitis is the condition that leads clinicians to falsely assign a diagnosis of ami based only on the fact that a patient has an elevated ctn concentration. In the substudy, samples were also analyzed using the siemens atellica highsensitivity cardiac troponin i assay and roche elycsys highsensitivity cardiac troponin t assays. Necessary diagnostic investigations include a thorough patient history and. In the emergency department with high sensitivity troponin t. Algorithms using highsensitivity cardiac troponin jama. Troponin how to interpret elevated cardiac troponin levels mahajan, et al.
Myocardial infarction mi in emergency department ed patients is a frequently suspected but infrequently made diagnosis. Clinical and economic effects of the istat poct solution. Antibodies have been raised against these cardiac isoforms. Other types of heart injury may cause a rise in troponin levels. Circulation 2011 accf 2012 expert consensus document on practical considerations in the interpretation of troponin elevations newby, et al. Highsensitivity versus conventional troponin in the. Patients aged 65 years and older presenting to the emergency department with nonspecific chief complaints who underwent troponin testing. Performance of highsensitivity troponin assays in u.
Emergency medicinetroponin wikibooks, open books for an. If the troponin is negative does this patient need to be admitted. Emergency room triage of patients with acute chest pain by. This designation refers e66 annals of emergency medicine volume 72, no. Chest pain is one of the most common reasons for emergency department ed attendance. To meet this stringent requirement, several measures are necessary. In suspected acs, care based on highsensitivity vs. The increasing sensitivity of troponin assays has lowered the number of potentially missed acs diagnoses, but this has also created a diagnostic challenge due to a decrease in the specificity of the test.
Jean chen, md, ccfpem edmund kwok, md, mha, msc, frcpcem brian weitzman, mdcm, frcpcem department of emergency medicine, university of ottawa first edition, march 2018. It is important not to interpret an elevated hs troponin t in isolation. Highsensitivity cardiac troponin in the evaluation of. Of all biomarkers of myocardial injury currently used in clinical practice, cardiac troponins ctni and ctnt are the most sensitive and. Theres been a clear shift in the emergency medicine mindset toward chest pain over the past few years, including an explosion of literature and professional guidance in support of the history, electrocardiogram, age, risk factors, and troponin heart score. Deputy medical director, traumaone flight program, university of florida college of medicine jacksonville, jacksonville, fl.
A randomized trial of a 1hour troponin t protocol in. An emergency medicine approach to troponin elevation due to. Risk stratification using serial highsensitivity troponin. Troponin testing and coronary syndrome in geriatric. The european society of cardiology 3hour pathway uses a single diagnostic threshold 99th percentile, whereas the highsteacs highsensitivity troponin. A variety of clinical observations see table 1 suggest that ctn release occurs in situations where myocardial necrosis is unlikely. Adult patients presenting to the ed with chest pain intervention. Troponin assays are now available for trop i and t levels at varying degrees of sensitivity with very high sensitivity tests now available and in regular use. Biochemical markers for diagnosis of myocardial infarction. The complex is located on the thin filament of the sarcomere and is involved in the regulation of muscle contraction. The author, date and country of publication, patient group studied. This piece is in response to an article in emergency medicine news, in the series myths in emergency medicine. The troponin only manchester acute coronary syndromes tmacs decision rule is a. Introduction within the uk, chest pain is one of the most common reasons for emergency 999 ambulance calls and the most common reason for emergency hospital admission.
Emergency department assessment of chest pain score troponin. Elevation of cardiac troponins in exacerbation of chronic. Diagnosing acute coronary syndromes acs in a patient with chest pain in the prehospital setting by a paramedic is challenging. The objective of this study was to compare the diagnostic performance of a new highsensitivity troponin t hstnt assay to that of conventional ctni for the diagnosis of acute myocardial infarction. Original article from the new england journal of medicine emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin t or troponin i logo32 logo40. This may be the most important recent sentence in modern emergency medicine. Cardiac troponin ctn is a highly specific biomarker of myocardial injury and is central to the diagnosis of acute myocardial infarction ami. As emergency cardiac care continues to evolve in the u. Nonspecific was designed a priori as including weak or weakness, dizzy or dizziness. However, this online tool may allow specific risk assessment for individual clinical scenarios. The consensus among cardiology and emergency medicine em physicians is that cardiac markers should be available within one hour of specimen collection, and optimally within 30 minutes or less see recommendation 10, table 2. Diagnostic implications of an elevated troponin in the. Question can a negative highsensitivity troponin assay at 0 and 3 hours following emergency department presentation identify patients at less than 1% risk of 30day adverse cardiac events findings in this multicenter evaluation, a single highsensitivity troponin level less than 6 ngl ruled out myocardial infarction, while serial levels at 19 ngl or less identified patients at.
Acep now is an official publication of the american college of emergency physicians. Onehour serial troponin using a high sensitivity assay comparison. Causes of elevated cardiac troponins in the emergency. We call them fake news, and em news would not allow rebuttal. Efficacy of highsensitivity troponin t in identifying. Optimizing troponin tats with poc testing can help expedite. Although somewhat awkward to use in its current version, the tool may be especially helpful when deciding the. Rapid screening protocols with hsctn have been proposed for patients for whom rulingin or rulingout acute myocardial infarction ami is the primary issue. Both laboratory and point of care poc tests are available. Study calls into question the troponin testing for acs in. Troponin tests during the first and the second phase of the study, the central lab used a highsensitive troponin t hstnt test with a cutoff of 0. The poct device used a contemporary troponin i test ctni with a cutoff of 0.814 1402 317 3 1428 325 485 199 241 344 109 1297 159 372 463 1289 1226 1085 1338 1051 1416 587 1152 764 876 1188 1242