High-Sensitivity Troponin Testing: Reducing Guesswork in Emergency Cardiac Diagnosis
700,000 Americans suffer from heart attacks annually.
Accurate testing is needed to pin-point at-risk patients.
High-sensitivity troponin is reducing the guesswork in heart attack diagnosis.
Heart attacks cost the U.S. millions of dollars each day, a fact which is driving preventative efforts, as well as improved communication about safety, risk, and what to do in case of an emergency.
The reason for this urgency is clear: Every 40 seconds someone in the U.S. has a heart attack, and, according to the U.S. Centers for Disease Control (CDC), that accounts for nearly 800,000 heart attacks every year.1
Communication and outreach have made people more aware of heart attack symptoms and the importance of getting help when experiencing chest pain. As a result, more individuals are seeking medical attention sooner. This increase, however, has challenged hospital emergency departments (EDs), which saw over 4.7 million people for chest pain in 2014 in the U.S. alone, according to a 2017 study by the Healthcare Cost and Utilization Project (HCUP).2
This statistic call for accurate, sensitive test methods that can quickly pinpoint the patients with chest pain who are most likely to have heart attacks, and ensure they receive the right treatment at the proper time.
In order to drive continuous improvement, clinicians and laboratory leaders alike must address these important questions:
- How effective is your ED's chest-pain protocol and what impact is it having on overall workflow and patient outcomes?
- What impact are chest-pain complaints having on ED workflow, testing and imaging requirements, and bed utilization?
- How many patients are readmitted for chest pain after they have been released from the ED?
- What tests are you using to help ED physicians sift through the confusing matrix of symptoms that may or may not indicate a heart attack?
At Geisinger Healthcare Systems in Pennsylvania, a collaborative effort involving laboratory leaders, clinicians, and a new, more accurate diagnostic tool enabled rapid change in the ED. The adoption of the diagnostic tool—high sensitive troponin—required new procedures and protocols that are already beginning to show results.
A Move in the Right Direction
These tests first appeared in the 1990s, allowing physicians to detect levels of troponin, a protein that is released into the bloodstream when heart tissue is damaged. Levels of the protein reach their highest point a few hours after a heart attack. Together with patient observation and electrocardiogram results, these tests allowed doctors to focus on high-risk patients.
The problem with the early generations of troponin tests, however, was that they could result in false negatives. As a result, some patients were discharged before troponin could be found and suffered heart attacks after they were sent home.3
In 2009, more sensitive and precise troponin assays became available outside the U.S., which could measure troponin levels at one-tenth the detection limit of the previous generation of tests.4 FDA approved the tests for use in the U.S. in 2017.
High-sensitivity assays, with high NPV's, offer insights into which patients are not having a heart attack, allowing them to be safely discharged sooner. Currently, the American Heart Association calls for three to six-hour patient monitoring after troponin testing, but few hospitals evaluate and discharge after three hours due to the risk of readmission. High sensitivity troponin offers a solution to this with the high NPV and precision the assay provides.
High sensitivity Troponin T is the only FDA approved method that meets high sensitivity levels defined by the International Federation of Clinical Chemistry and Laboratory Medicine, and precision levels defined by the Third Universal Definition of Myocardial Infarction.*
Geisinger was able to make the change to Troponin T in only six months. The process wasn't always easy, but clear and upfront communication, as well as close collaboration between lab professionals and clinicians, made it possible.
As emergency cardiac care continues to evolve in the U.S., high-sensitivity troponin assays are helping to take the guesswork out of heart attack diagnosis, and achieving two goals that often seem at cross purposes in healthcare today: aiding medical decision-making and reducing costs by more efficiently managing patients in the ED. By considering your organization's practices and evaluating alternatives, you can drive the improvements you want to see in patient management and organizational effectiveness.
*Roche Troponin T Gen 5 STAT: Greater than 50% of healthy population detected between LoD and 99th URL on cobas e 601 and e 602.
1. "Heart Attack." Centers for Disease Control and Prevention, Aug. 2017. https://www.cdc.gov/heartdisease/heart_attack.htm.
2. Moore, Brian J., et al. “Trends in Emergency Department Visits, 2006–2014." Healthcare Cost and Utilization Project (HCUP), Sept. 2017, www.hcup-us.ahrq.gov/reports/statbriefs/sb227-Emergency-Department-Visit-Trends.pdf.
3. Beshansky, Joni R., et al. "Missed Diagnoses of Acute Myocardial Infarction in the Emergency Department: Results From a Multicenter Study." Annals of Emergency Medicine, 1993. https://www.ncbi.nlm.nih.gov/pubmed/8442548?dopt=Abstract.
4. Alazzoni, Aashraf, et al. "Performance of the High-Sensitivity Troponin Assay in Diagnosing Acute Myocardial Infarction: Systematic Review and Meta-Analysis." CMAJ Open, July-Sept. 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4183183/.
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