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Highly Sensitive Troponin and other Cardiac Biomarkers

Use of Highly Sensitive Troponin and other Cardiac Biomarkers in Suspected Myocardial Infarction/Acute Coronary Syndromes and Heart Failure


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by David B. Grossberg MD FACC and Stuart M Caplen MD FACEP


Diagnosing a classically presenting myocardial infarction(MI) or acute coronary syndrome(ACS) is relatively straightforward, but a dilemma for emergency department physicians and cardiologists has been how to avoid sending home an atypical MI/ACS. Patients may present with fatigue, shortness of breath, atypical chest pain or abdominal pain, and EKGs may be non-diagnostic in a non-ST segment elevation MI(NSTEMI), making a correct diagnosis difficult. In 2000 a study from ten U.S. emergency departments, and in 2006 one from all the hospitals in Ontario, Canada both reported exactly the same finding; that the missed MI rate in emergency departments averaged 2.1%.[1,2] According to the CDC there are an estimated 805,000 MIs per year in the U.S.[3] A 2.1% miss rate would mean almost 17,000 people in the U.S. who seek care in emergency departments would be mistakenly sent home with a missed MI, which is both an issue of patient morbidity, and a significant malpractice issue. In this article we will look at ways to decrease that MI miss rate, using highly sensitive troponins (also known as high sensitivity troponins), and rapid MI/ACS rule out protocols/algorithms. In addition, a more rapid MI/ACS rule in or out decreases length of stay, frees up beds, is better for patients, and can lead to cost savings.[4] We will also discuss troponin as a prognostic tool, new cardiac markers that may have some utility, and look at B-type natriuretic peptide (BNP); what can it tell you, and how accurate it is.


Troponin

In the past, cardiac markers such as LDH(lactate dehydrogenase), CKMB(creatine kinase-MB), and myoglobin were used to try to determine whether a chest pain patient had an MI/ACS.[5] Those markers are no longer in use, either due to the length of time it took for the marker to rise, not being sensitive enough to pick up mild disease, or they lacked specificity for cardiac disease, with many false positives requiring more testing and admissions.[6] CKMB may still be in use in some centers, due to physicians still ordering it, but the American College of Cardiology guidelines recommend that it no longer be used.[7] The currently recommended cardiac marker is troponin, and more recently, highly sensitive troponins...




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ABOUT THE AUTHORS

David B. Grossberg MD FACC

Dr. Grossberg is a retired cardiologist and former Chief of Cardiology at Laurel Regional Hospital and former Assistant Clinical Professor of Medicine, George Washington University School of Medicine, and former Adjunct Assistant Professor of Medicine at Baylor University School of Medicine.


Stuart M. Caplen, MD, FACEP, MSM

Dr. Caplen is a retired emergency medicine physician and former emergency department medical director, who also has a Master of Science in Management degree, and green belt certification in Lean/Six Sigma.


References


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