Chest pain and high-sensitivity troponin: What is the evidence?
1Pinderfields General Hospital, The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK.
Insights
Diagnosing acute coronary syndromes is challenging. High-sensitivity cardiac troponin tests offer potential for faster, more accurate diagnosis in chest pain patients, improving management and reducing anxiety.
Area of Science:
- Cardiology
- Biomarker Research
- Diagnostic Imaging
Background:
- Increasing attendances for chest pain necessitate improved diagnostic tools.
- Current cardiac troponin testing for myocardial infarction has limitations in accuracy and speed.
- National guidelines recommend serial troponin measurements, but a more effective approach is needed.
Purpose of the Study:
- To enhance the accuracy of acute coronary syndrome diagnosis for earlier, cost-effective management.
- To provide more rapid diagnosis for patients experiencing chest pain, alleviating anxiety.
- To evaluate the utility of high-sensitivity cardiac troponin assays in clinical practice.
Main Methods:
- Discussion of existing literature on cardiac troponin testing for chest pain.
- Analysis of the role of high-sensitivity cardiac troponin in ruling out myocardial infarction.
- Assessment of the specificity of high-sensitivity troponin for differentiating causes of troponin elevation.
- Exploration of strategies for serial testing with high-sensitivity troponin.
Main Results:
- Many studies lack normal/reference populations, hindering comparisons.
- High-sensitivity cardiac troponin shows promise for ruling out myocardial infarction.
- Specificity of high-sensitivity troponin for differentiating causes of elevation requires further assessment, potentially necessitating serial testing.
Conclusions:
- High-sensitivity cardiac troponin assays represent a significant advancement in diagnosing acute coronary syndromes.
- Serial testing strategies using high-sensitivity troponin are crucial for accurate diagnosis and risk stratification.
- The application of high-sensitivity troponin is expected to evolve, impacting patient management for various conditions.
Abstract:
The number of attendances and admissions of patients with chest pain to hospitals in England and Wales is increasing. Initial assessment may be unrewarding. Consequently, cardiac troponin has become the mainstay of investigation for non-ST-segment-elevation myocardial infarction and unstable angina, although only a small proportion of patients are eventually diagnosed as such. Current National Institute for Healthcare and Clinical Excellence guidance recommends measuring cardiac troponin levels on presentation and 10-12 h after onset of symptoms. A more effective diagnostic tool is needed. The aims are twofold: to increase accuracy of acute coronary syndrome diagnosis thus implementing the most appropriate management at an earlier stage while reducing costs and to provide a more rapid diagnosis to ease the anxieties of patients. Three key issues have been highlighted. The first is that many current studies do not have a 'normal/reference' population, making comparison between two studies difficult to interpret. Second, whether newer 'high-sensitivity' cardiac troponin tests can be used to rule out a myocardial infarction in a patient with chest pain is discussed. Third, whether a 'high-sensitivity' cardiac troponin has great enough specificity to differentiate between the number of other causes of raised troponin in a single test or whether serial testing is needed is assessed. A strategy for such serial testing is discussed. Finally, use of 'high-sensitivity' cardiac troponin in risk stratification of other disease processes is highlighted, which is likely to become common practice, changing the way we manage patients with, and without, chest pain.
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