Use of cardiac biomarker testing in the emergency department
1Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.
Insights
Cardiac biomarker testing is common in emergency departments (EDs), even without acute coronary syndrome symptoms. High volumes of other tests increase biomarker use, indicating a need for better strategies.
Area of Science:
- Emergency Medicine
- Cardiology
- Clinical Diagnostics
Background:
- Cardiac biomarker testing in the ED is not routinely recommended due to low utility and risks of false positives.
- Current utilization rates for cardiac biomarker testing in the ED are not well-established.
Purpose of the Study:
- To determine the overall use of cardiac biomarker testing in emergency departments.
- To analyze testing rates stratified by patient disposition and other clinical characteristics.
Main Methods:
- Retrospective study utilizing data from the 2009-2010 National Hospital Ambulatory Medical Care Survey.
- Analysis included adult ED visits, focusing on patient, visit, and ED characteristics as exposures.
- The primary outcome measured was the receipt of cardiac biomarker testing during the ED visit.
Main Results:
- Cardiac biomarkers were tested in 16.9% of 44,448 ED visits (28.6 million visits nationally).
- Testing occurred in 8.2% of visits without acute coronary syndrome (ACS) symptoms (8.5 million visits).
- The number of other tests performed strongly predicted biomarker testing, independent of ACS symptoms, with >10 tests associated with a 59.55-fold increased odds of testing.
Conclusions:
- Cardiac biomarker testing is frequently performed in EDs, even in patients lacking ACS symptoms.
- Testing is also common in visits with numerous other diagnostic services, irrespective of clinical presentation.
- There is a critical need to develop strategies for the appropriate utilization of cardiac biomarkers in the ED.
Importance:
Cardiac biomarker testing is not routinely indicated in the emergency department (ED) because of low utility and potential downstream harms from false-positive results. However, current rates of testing are unknown.
Objective:
To determine the use of cardiac biomarker testing overall, as well as stratified by disposition status and selected characteristics.
Design, Setting, And Participants:
Retrospective study of ED visits by adults (≥18 years old) selected from the 2009 and 2010 National Hospital Ambulatory Medical Care Survey, a probability sample of ED visits in the United States.
Exposures:
Selected patient, visit, and ED characteristics.
Main Outcomes And Measures:
Receipt of cardiac biomarker testing during the ED visit.
Results:
Of 44,448 ED visits, cardiac biomarkers were tested in 16.9% of visits, representing 28.6 million visits. Biomarker testing occurred in 8.2% of visits in the absence of acute coronary syndrome (ACS)-related symptoms, representing 8.5 million visits, almost one-third of all visits with biomarker testing. Among individuals subsequently hospitalized, cardiac biomarkers were tested in 47.0% of all visits. In this group, biomarkers were tested in 35.4% of visits despite the absence of ACS-related symptoms. Among all ED visits, the number of other tests or services performed was the strongest predictor of biomarker testing independent of symptoms of ACS. Compared with 0 to 5 other tests or services performed, more than 10 other tests or services performed was associated with 59.55 (95% CI, 39.23-90.40) times the odds of biomarker testing. The adjusted probabilities of biomarker testing if 0 to 5, 6 to 10, or more than 10 other tests or services performed were 6.3%, 34.3%, and 62.3%, respectively.
Conclusions And Relevance:
Cardiac biomarker testing in the ED is common even among those without symptoms suggestive of ACS. Cardiac biomarker testing is also frequently used during visits with a high volume of other tests or services independent of the clinical presentation. More attention is needed to develop strategies for appropriate use of cardiac biomarkers.
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