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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‡‡§§

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine: September 2014 - Volume 13 - Issue 3 - p 89–95
doi: 10.1097/HPC.0000000000000020
Original Articles

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.

From the *Department of Emergency Medicine, Emory University, Atlanta GA; Department of Internal Medicine, Wayne State University, Detroit, MI; Department of Emergency Medicine, Metro Health Hospital—Statewide Campus System, Michigan State University College of Osteopathic Medicine, Wyoming, MI; §Oakwood Heritage Transitional Year Residency Program/Oakwood Healthcare, Taylor, MI; Department of Internal Medicine, Loma Linda University, Loma Linda, CA; Department of Emergency Medicine, St. John Hospital and Medical Center, Detroit, MI; **Department of Internal Medicine, California Pacific Medical Center, San Francisco, CA; ††Wayne State University School of Medicine, Detroit, MI; ‡‡Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI; and §§Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, MI.

Oral Presentation at the American Heart Association Scientific Assembly, November 7–10, 2012, Los Angeles, CA.

Phillip Levy contributed in conception and design of the study, analysis and interpretation of data, drafting of the manuscript and revising it critically for important intellectual content, and final approval of the submitted manuscript. Sarah Wolf contributed in design of the study, analysis and interpretation of data, critical manuscript revision for important intellectual content, and final approval of the submitted manuscript. William Patrick McKeown contributed in design of the study, analysis and interpretation of data, and final approval of the submitted manuscript. Ramanjit Kaur contributed in design of the study, analysis and interpretation of data, and final approval of the submitted manuscript. Brian J. O’Neil contributed in interpretation of data, critical manuscript revision for important intellectual content, and final approval of the submitted manuscript. Helen Chan, Allen Dang, Trevor Kuston, Waihin Leung, and John Purakal contributed in data collection and final approval of the submitted manuscript.

Reprints: Sarah Wolf, MD, Emory University School of Medicine, 49 Jesse Hill, Jr. Drive, Atlanta, GA 30303. E-mail: CStrader@scpcp.org

© 2014 by Lippincott Williams & Wilkins