Is it time to use rapid troponin test in triage room?

Abstract

With great interest, we read the notable publication in the recent Eur Heart J Acute Cardiovasc Care from Miró et al, entitled ‘External validation of an emergency department triage algorithm for chest pain patients’.1 In their study, the researchers developed a five-item triage algorithm composed of five clinical high-risk variables to identify patients with low-risk chest pain, presented in three models of A, B, and C. Data were collected from multicenter databases (The CLINIC BARCELONA and APACE cohorts). Low efficacy ranging from 2.7% to 6.2% was achieved in case of keeping sensitivity <99% in Model A.1 Allowing the presence of one clinical high-risk variable resulted in an efficacy of 23.1% instead of a sensitivity fall to 96.7%, raises a substantial limitation in the algorithm. In all three models both groups achieve high sensitivity with very low efficiency. It suggests that trust on medical history (high-risk clinical factors) to identify patients with chest pain is associated with poor efficacy over and over again. The results also cast doubt on the appliance of the algorithm, especially in patients above 40 with an odd ratio of 6.60, suggesting that the results may be influenced by the age, while other items showed lower odd ratio, less than 3 (2.56, 1.86, 1.83, 1.23). As chest pain may not be a significant risk factor in patients aged below 40, history alone may be neither effective nor efficient in diagnostic process of patients with chest pain. To increase efficiency, adding electrocardiogram (ECG) to the history has been suggested to significantly increase in effectiveness for identifying patients with low-risk chest pain, Patients with HEAR scores < 3 represent a low-risk group with a sensitivity of 92.5%, an efficacy of 38%, and a MACE rate less than 1% are reported.2 Although the sensitivity of 92.5% still raises concerns, and using electrocardiogram is a relatively time-consuming compared to rapid hscTn testing, it is still routine for diagnosing high-risk patients with acceptable effectiveness. Now, the question is whether hs-cTn could be considered as an alternative to ECG in the triage room.