Abstract 350: Assessment of Clinicians’ Attitudes and Knowledge About Cardiac Troponin Testing

Abstract

In the United States, the positive predictive value (PPV) of cardiac troponin for type 1 myocardial infarction is substantially lower than in Europe (15% vs. 50%). Further, even with publication of the 4 th Universal Definition of Myocardial Infarction, recent studies have shown that inaccurate classification of myocardial injury is common among clinicians in the United States. These findings are at least partly attributable to clinicians’ knowledge and attitudes about cardiac troponin testing; a survey of these parameters has never been conducted. Clinicians at the University of Colorado completed a brief 8-question multiple-choice survey related to troponin use, definitions of myocardial infarction and clinical assessment of elevated troponin levels. The survey was distributed via secure email and administered electronically using the Qualtrics™ platform. Responses were anonymous, completion was estimated to take 3 minutes and a lottery award system was used as an incentive for participation. Respondents included trainees, advanced practice providers and attending physicians from internal medicine, emergency medicine and medical subspecialties. We plan to obtain a total of 300 responses with descriptive findings of preliminary results included below. The survey was completed by 114 clinicians: 37 interns (32%), 45 residents (39%), 9 advanced practice providers (8%), 11 fellows (10%), and 12 attending physicians (11%). Regarding indications for troponin testing, 93% (106/114) indicated that they “usually” or “always” check troponin levels in patients with chest pain. More interestingly, 46% (52/112) reported checking troponin on “undifferentiated patients” at least half the time. For troponin interpretation, 97% (110/114) of participants identified that troponin levels alone cannot rule in or rule out coronary artery disease. In contrast, only 36% (41/114) and 55% (63/114), respectively, identified the NPV and PPV of a contemporary troponin assay for type 1 MI. Further, only 50% (57/114) of respondents identified that the likelihood of type 1 MI increases as troponin levels increase. Three brief clinical vignettes revealed that, while 78% (89/114) and 74% (45/61) of participants, respectively, identified type 1 MI and type 2 MI presentations, only 40% (21/53) of respondents correctly identified a vignette for non-ischemic myocardial injury. Concordant with this finding, 54% (61/114) of clinicians correctly identified the 4 th Universal Definition of Myocardial Infarction. These preliminary findings highlight important facets of clinician attitudes and knowledge about troponin testing that help explain the poor PPV for troponin and diagnostic misclassification observed among U.S. clinicians. These results could help guide curricular and clinical decision support interventions designed to improve the use and interpretation of cardiac troponin testing.