Troponin Testing In Patients Research Articles

Outcomes associated with the high sensitivity cardiac troponin testing in patients presenting with non-cardiovascular disorders.

There are limited data regarding the utility of troponin testing in patients presenting with non-cardiovascular (CV) symptoms as the primary manifestation. The study population comprised 2057 patients who presented to the emergency department (ED) of a US healthcare system with non-CV symptoms as the primary manifestation between January and September 2018. We compared the effect of high-sensitivity cardiac troponin T (hs-cTnT) (n=901) after its introduction vs. 4th generation cTnT (n=1156) on the following outcomes measures: ED length of stay (LOS), coronary tests/procedures (angiography or stress test), and long-term mortality. Mean age was 64±17yrs., and 47% were female. Primary non-CV manifestations included pneumonia, obstructive pulmonary disease, infection, abdominal-complaint, and renal failure. Mean follow up was 9±4months. Patients' demographics and medical history were clinically similar between the two troponin groups. A second cTn test was obtained more frequently in the hs-cTnT than cTnT (84% vs. 32%; p<0.001), possibly leading to a longer ED stay (8.1±8.2h vs 5.6±3.4h, respectively; p<0.001). Coronary tests/procedures were performed at a significantly higher rate in the hs-cTnT than cTnT following the introduction of the hs-cTnT test (28% vs. 22%, p<0.001). Multivariate analysis showed that following the introduction of hs-cTnT testing, there was a significant 27% lower risk of long-term mortality from ED admission through follow-up (HR=0.73, 95%CI 0.54-0.98; p=0.035). In conclusion, we show that in patients presenting primarily with non-CV disorders, the implementation of the hs-cTnT was associated with a higher rate of diagnostic coronary procedures/interventions, possibly leading to improved long-term survival rates.

Cardiac Troponin Testing in Patients with COVID-19: A Strategy for Testing and Reporting Results.

BackgroundThe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged late in 2019 causing COVID-19 (coronavirus disease-2019) may adversely affect the cardiovascular system. Publications from Asia, Europe and North America have identified cardiac troponin as an important prognostic indicator for patients hospitalized with COVID-19. We recognized from publications within the first 6 months of the pandemic that there has been much uncertainty on the reporting, interpretation, and pathophysiology of an increased cardiac troponin concentration in this setting.ContentThe purpose of this mini-review is: a) to review the pathophysiology of SARS-CoV-2 and the cardiovascular system, b) to overview the strengths and weaknesses of selected studies evaluating cardiac troponin in patients with COVID-19, and c) recommend testing strategies in the acute period, in the convalescence period and in long-term care for patients who have become ill with COVID-19.SummaryThis review provides important educational information and identifies gaps in understanding the role of cardiac troponin and COVID-19. Future, properly designed studies will hopefully provide the much-needed evidence on the path forward in testing cardiac troponin in patients with COVID-19.

Identification of very low-risk acute chest pain patients without troponin testing

BackgroundThe HEART Pathway combines a History ECG Age Risk factor (HEAR) score and serial troponins to risk stratify patients with acute chest pain. However, it is unclear whether patients with...

Cost analysis of early discharge using combined copeptin/cardiac troponin testing versus serial cardiac troponin testing in patients with suspected acute coronary syndrome.

BackgroundSymptoms indicating acute coronary syndrome are commonly seen in emergency rooms, but only 10% of patients are actually diagnosed with acute myocardial infarction (AMI). The Guidelines for the diagnosis of patients with suspected AMI include either multiple testing of cardiac troponin (cTN) or a single combined test of cTN and copeptin, which facilitates earlier diagnosis or exclusion of AMI. The aim of the present analysis was to investigate the impact of combined copeptin/cTN testing on health care resource consumption and related costs both during and after initial hospital treatment.Methods and resultsThe analysis was based on the BIC-8 trial and financial data of participating study sites. A cost analysis was carried out primarily from the hospital perspective and secondarily from the perspective of German statutory health insurers. The underlying assumptions of the investigation were tested for robustness in additional sensitivity analyses. In total, the data of 713 patients (n = 359 combined copeptin/cTN testing, n = 354 serial cTN testing) were evaluated. From a hospital perspective, the combined copeptin/cTN testing showed a reduced number of medical procedures and a lower frequency of inpatient admissions. The average staff time was significantly reduced by a mean of 49 minutes (95% confidence interval (CI) 46 to 53) per patient, accompanied by a significant mean reduction of 131 minutes (95%CI 104 to 158) in the time patients stayed in the emergency room. The initial hospital treatment was less cost-intensive. Over the entire study period, no significant cost differences were observed between the groups for health insurance.ConclusionThe combined copeptin/cTN testing has the potential to save costs and staff time in acute care and for the entire hospital stay. The primary explanations for these findings are early identification and ruling out patients without AMI along with the associated reduced need for acute medical treatment.Trial registrationClinicalTrials.gov NCT01498731

Review article: Utility of troponin after syncope: A systematic review and meta-analysis.

The role of serum troponin testing in patients presenting to the ED after syncope is unclear. The aim of this systematic review was to examine the practice and utility of troponin testing among patients presenting to the ED after syncope. We conducted a search of MEDLINE, Embase, Cochrane Library, Web of Science and Scopus databases from 1990 to February 2017 using keyword and subject headings for syncope and troponin testing. Design and results of the included studies are extracted. Studies were assessed for heterogeneity and the pooled proportion of measured troponin and positive troponin result described. There were nine studies included for analysis. Significant statistical heterogeneity among studies was observed (P < 0.001). Using the random effects model, the pooled proportion of patients presenting to the ED after syncope who had troponin measured was 0.64 (95% CI 0.46-0.82). Among patients who had been troponin tested, the pooled proportion who had a positive result was 0.19 (95% CI 0.13-0.26). Variability among reported outcomes prevented further meta-analysis. Troponin testing was commonly performed for the assessment of patients with syncope with a substantial proportion returning positive results. The correlation between raised troponin and patient outcomes was not adequately reported. It is possible that an elevated troponin may indicate serious illness, rather than myocardial damage alone.

Frequency of Troponin Testing in Inpatient Versus Outpatient Settings

Troponin elevation is required to diagnose acute myocardial infarction (AMI), yet elevated values are often encountered in noncardiac disease states. We evaluated inpatient (IP) and outpatient (OP) encounters at 14 hospitals in calendar year 2014 and found that troponin assays were performed during 12% of all OP visits and 29% of all IP visits: 82,853 encounters in all. We employed an expert panel to estimate the likelihood of AMI based on primary International Statistical Classification of Diseases and Related Health Problems, 9th edition diagnoses. We compared IP and OP testing, finding that AMI would not be expected in most IP encounters. Sepsis was the most common diagnosis associated with IP troponin testing. Wefound an association between troponin testing in patients with sepsis and utilization ofelectrocardiography, echocardiography, and cardiac catheterization. Our data indicate that troponin testing has expanded beyond patient populations in whom AMI might be expected.

Symptom based approaches in point of care laboratory testing

Point of care testing (POCT) allows, among others, for efficient care of patients presenting with acute problems to primary care physicians. A combination of clinical information and laboratory results enables physicians to obtain posttest probabilities for the presence or absence of a specific disease. In order to rule in or rule out a disease, the physician has to know both the pretest probability for a disease in a patient as well as the analytical and diagnostic characteristics of the employed test. Pretest probability can be assessed by scores or by personal judgment of the experienced clinician. This article presents the basics of the Bayes theorem together with its clinical applications in acute scenarios in primary health care. These scenarios comprise the use of D-Dimer testing in ruling out venous thromboembolism, rapid testing of group A streptococci in the setting of acute pharyngitis, troponin testing in patients with thoracic pain, c-reactive protein (CRP) testing in patients presenting with acute cough and fever, as well as urine dipstick testing in suspected urinary tract infection. These examples illustrate, that risk stratification before conducting laboratory analysis is of utmost importance in order to obtain valid results for ruling in or ruling out diseases in POCT-settings.

Association between an educational intervention and a reduction in inappropriate troponin testing in patients presenting to an adult emergency department.

High-sensitivity troponin replaced the fourth generation assay at our institution in July 2010. Prior experience suggested that the number of positive tests with the new assay may double, and that many troponin requests were inappropriate. Primarily, this study aims to design and measure the effect of an educational intervention to reduce the number of inappropriate troponin tests. Second, other objectives are to compare weekly totals of troponin tests before and after the intervention, to note patients with missed acute coronary syndrome (ACS) during the study period and to survey clinicians regarding their likely troponin ordering practices in certain clinical scenarios. A staff survey informed the content of the educational intervention. Criteria for inappropriate testing were defined prior to the study. Retrospective notes review of pre-and post-intervention cohorts were used to determine the reduction in inappropriate troponin tests. Ninety-six patients were in each cohort. The proportion of inappropriate tests fell from 43% (95% confidence interval (CI) 33-53) pre-intervention to 22% (95% CI 14-31) post-intervention, P = 0.002. Weekly total of troponin tests performed decreased from a mean of 298 (95% CI, 290-307) pre-intervention to 244 (95% CI 232-255) post-intervention, P < 0.001. No cases of missed ACS were found; all cause mortality was unchanged following the intervention. Our educational intervention was associated with a reduction in inappropriate use of troponin tests and a reduction in the total number of tests requested, with no known missed ACS. Others faced with a change to a high-sensitivity assay should consider a similar intervention.

Prognostic value of cardiac troponin in patients with chronic kidney disease without suspected acute coronary syndrome: a systematic review and meta-analysis.

Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS). To systematically review the literature on troponin testing in patients with CKD without ACS. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014. Studies examining elevated versus normal troponin levels in patients with CKD without ACS. Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Meta-analyses were conducted when studies had sufficient homogeneity of key variables. Ninety-eight studies met inclusion criteria. Elevated troponin levels were associated with all-cause and cardiovascular mortality among patients receiving dialysis (moderate SOE). Pooled hazard ratios (HRs) for all-cause mortality from studies that adjusted for age and coronary artery disease or a risk equivalent were 3.0 (95% CI, 2.4 to 4.3) for troponin T and 2.7 (CI, 1.9 to 4.6) for troponin I. The pooled adjusted HRs for cardiovascular mortality were 3.3 (CI, 1.8 to 5.4) for troponin T and 4.2 (CI, 2.0 to 9.2) for troponin I. Findings were similar for patients with CKD who were not receiving dialysis, but there were fewer studies. No study tested treatment strategies by troponin cut points. Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up. In patients with CKD without suspected ACS, elevated troponin levels were associated with worse prognosis. Future studies should focus on whether this biomarker is more appropriate than clinical models for reclassifying risk of patients with CKD and whether such classification can help guide treatment in those at highest risk for death. Agency for Healthcare Research and Quality.

Biomarker Diagnostics in Acute Cardiac and Noncardiac Dyspnea: Is There a Role for Point-of-Care Testing?

The use of biomarkers in acute chest pain and dyspnea is well established and point-of-care testing (POCT) is increasingly used in emergency departments and chest pain units for this purpose. However, few data give evidence that POCT has advantages for the patient or the medical process over central laboratory testing. Especially for troponin testing in patients with myocardial infarction, the newest guidelines define prerequisites on diagnostic test quality which most POC assays do not fulfill. Additionally, no data are available showing that POCT has relevant effect on a change of physician’s diagnostic and therapeutic thinking compared to laboratory testing. Regarding patient outcomes and societal costs, central laboratory testing seems to be even superior to POCT. The main limit of currently available POC troponin assays is the higher limit of detection and higher imprecision compared to the new high sensitive laboratory assays. However, new upcoming POC technologies may perform comparable to today’s laboratory analyzers.