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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine:
doi: 10.1097/HPC.0000000000000020
Original Articles

Noise Versus Signal: The Clinical Implications of an Increasingly Sensitive Troponin Assay for Patients With Suspected Acute Coronary Syndrome

Wolf, Sarah MD*; Kaur, Ramanjit MD; McKeown, William Patrick DO; Chan, Helen MD§; Dang, Allen MD; Kuston, Trevor MD; Leung, Waihin MD**; Purakal, John MS††; O’Neil, Brian J. MD‡‡; Levy, Phillip MD, MPH‡‡§§

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Objectives: To evaluate the clinical impact of a troponin assay switch in suspected acute coronary syndromes (ACS).

Methods: Retrospective analysis of ACS cases in the 3 months before and after changing to a contemporary, higher sensitivity troponin assay. Admitting diagnosis, proportion with a positive result, initial treatment and testing, coronary artery intervention, inhospital events, and final discharge diagnosis were compared by assay group.

Results: Seven hundred seventy patients were included: 319 (41.4%) preassay and 451 (58.6%) postassay. Preassay change, non-ST segment elevation myocardial infarction at admission (43.0% vs. 70.5%; diff [95% confidence interval (CI)] = −27.5 [−34.2, −20.6]) was diagnosed less often, and a positive troponin was less common (33.2% vs. 72.3%; diff [95% CI] = −39.1 [−45.4, −32.2]). However, anticoagulation (53.3% vs. 42.4%; diff [95% CI] = 10.9 [3.8, 18.0]) and cardiac catheterization use were more frequent (53.9% vs. 41.9%; diff [95% CI] = 12.0 [19.0, 48.5]). There was no difference in coronary intervention (41.9% vs. 40.7%; diff [95% CI] = 1.2 [−9.0, 11.2]) by assay period. Inhospital event were rare (unstable ventricular arrhythmia = 1.2%, cardiac arrest = 3.4%, death = 4.4%) with no difference between groups. A non-ACS diagnosis at discharge was more common in the postassay group (31.6% vs. 46.5%; diff [95% CI] = 14.9 [7.9, 21.6]).

Conclusions: Although non-ST segment elevation myocardial infarction diagnosis at admission and a positive troponin were more frequent postassay change, rates of anticoagulation and cardiac catheterization were lower and a non-ACS diagnosis at discharge was more common. These data suggest an evolving understanding and clinical impact of contemporary troponin assays when used in real-world settings.

© 2014 by Lippincott Williams & Wilkins


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