ACC 2019: Benefits and drawbacks of high-sensitivity troponin use in low-risk patients with chest pain

March 16, 2019 – High-sensitivity troponin, an assay that is relatively new in the U.S., allows providers to assess low-risk chest pain patients more quickly and determine whether they have had a heart attack or myocardial infarction.

High-sensitivity troponin presents opportunities to rule out myocardial infarction or a heart attack more quickly for chest pain patients, thereby reducing hospital stays and alleviating overcrowded emergency departments or observation units.

DCRI Fellow Jennifer Rymer, MD, MBA, gave an invited talk Saturday at the American College of Cardiology Scientific Sessions on the use of high-sensitivity troponin in low-risk patients who come to the emergency room with chest pain. Both Rymer and DCRI Fellow Angela Lowenstern, MD, assisted with the recent high-sensitivity troponin roll-out at Duke.

Although high-sensitivity troponin has been available in Europe, Australia, and Canada for some time, it had not been approved by the U.S. Food and Drug Administration until recently. Thus far, only a few centers have rolled out use of high-sensitivity troponin, and Duke is in the process of implementing its use.

When patients come into the emergency department with chest pain, they undergo a series of labs to determine the cause of the pain. With conventional troponin, patients often wait up to 12 hours before they are told they have not had a heart attack. Because the algorithms and protocols of high-sensitivity troponin work more quickly, this process can be shortened to a couple of hours.

This accelerated pathway has the potential to have huge impacts, Rymer said. Because length of hospital stay decreases with use of high-sensitivity troponin, so does the cost to the health system. Utilization of other resources could also potentially decrease — for example, fewer patients may need to be observed in observation units, but instead may be safe for close outpatient follow-up or discharge.

Duke was one of the first institutions in the world to successfully integrate high-sensitivity troponin into its electronic medical record. Rymer said she hopes lessons learned will make the process easier for other institutions trying to go through the same process.

Although the use of high-sensitivity troponin is safe, the real challenge lies in knowing which patients to order the test for. In her presentation, Rymer said that it is critical to examine the pre-test probability for myocardial infarction prior to ordering the high-sensitivity troponin test. She also emphasized the importance of knowing that elevations in high sensitivity troponin can be caused by many other causes besides a heart attack, so close clinical history and physical are imperative.

“We know these assays are much more sensitive to pick up any sort of elevation in troponin leak that may be caused by having a myocardial infarction or heart attack,” Rymer said. “It’s quite safe, specific, and sensitive and can pick up heart attacks very quickly.”