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Implementation of High-Sensitivity Cardiac Troponin

Challenges From the International Experience

Howell, Stacey J., MD*; Amsterdam, Ezra A., MD; Mumma, Bryn E., MD, MAS; López, Javier E., MD, MAS; Tran, Nam K., PhD, MS, FACB§

Critical Pathways in Cardiology: December 2018 - Volume 17 - Issue 4 - p 173–178
doi: 10.1097/HPC.0000000000000156
Original Articles

Objective: Implementation of the newly approved high-sensitivity cardiac troponin (hs-cTn) in the United States presents a challenge for clinical practice. Sex-specific cutoffs, clinical protocols, and workflows will likely require modifications before implementation.

Methods: We conducted a cross-sectional survey of international physicians and laboratorians already utilizing hs-cTn for the evaluation of acute myocardial infarction.

Results: Twenty-two of 54 (41%) eligible participants completed the survey, representing 9 countries and 18 hospitals. All reported successful hs-cTn implementation and diagnostic utility (mean 8.6 + 1.2 out of 10 for best implementation). The major perceived benefit was more rapid evaluation of acute myocardial infarction (14/19, 74%), and the most frequently cited limitation was an increase in the number of measurable hs-cTn values that required further evaluation (8/18, 44%). Institutions using the hs-cTnI assay favored sex-specific cutoffs (5/6, 83%), whereas institutions employing the hs-cTnT assay favored a combined cutoff (12/12, 100%). Timing of serial hs-cTn measurements varied, with 0–3 hours (8/17, 47%) most frequent, followed by 0–2 hours (4/17, 24%), 0–1 hour (3/17, 18%), and other (2/17, 12%).

Conclusions: Our survey of hs-cTn implementation at international institutions reveals satisfaction with new assays but reflects important variations in clinical practice. The use of sex-specific vs. combined cutoffs and timing of serial hs-cTn measurements varies across institutions and are subjects that United States centers must define without consensus from international practices.

From the *Department of Internal Medicine, University of California Davis Health, Sacramento, CA

Division of Cardiovascular Medicine, University of California Davis Health, Sacramento, CA

Department of Emergency Medicine, University of California Davis Health, Sacramento, CA

§Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA.

Received for publication March 21, 2018; accepted May 15, 2018.

Supported in part by the National Center for Advancing Translational Sciences, National Institutes of Health, grant number UL1 TR001860 and linked award KL2 TR001859 (J.E.L.), Harold S. Geneen Charitable Trust Awards Program (J.E.L.), the Rosenfeld Heart Foundation (J.E.L.), and the National Heart, Lung, and Blood Institute (NHLBI) through grant #5K08HL130546 (B.E.M.).

Reprints: Stacey J. Howell, MD, Department of Internal Medicine, University of California Davis Medical Center, 4150 V Street, Suite 1100, Sacramento, CA 95817. E-mail:

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