High-Sensitivity Cardiac Troponin-Based Strategies for the Assessment of Chest Pain Patients-A Review of Validation and Clinical Implementation Studies

• Published in: Clinical chemistry (Baltimore, Md.) Vol. 64; no. 11; pp. 1572 - 1585
• Main Authors: Eggers, Kai M, Jernberg, Tomas, Ljung, Lina, Lindahl, Bertil
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01-11-2018
• Subjects: Acute coronary syndromes; Algorithms; Calcium-binding protein; Chest; Clinical decision making; Decision making; Diagnostic systems; EKG; Electrocardiography; Emergency medical services; Emergency services; Heart; Heart attacks; Medicin och hälsovetenskap; Myocardial infarction; Pain; Patients; Sensitivity analysis; Strategy; Studies; Troponin
• ISSN: 0009-9147; 1530-8561; 1530-8561
• DOI: 10.1373/clinchem.2018.287342

The introduction of high-sensitivity cardiac troponin (hs-cTn) assays has improved the early assessment of chest pain patients. A number of hs-cTn-based algorithms and accelerated diagnostic protocols (ADPs) have been developed and tested subsequently. In this review, we summarize the data on the performance and clinical utility of these strategies.
We reviewed studies investigating the diagnostic and prognostic performance of hs-cTn algorithms [level of detection (LoD) strategy, 0/1-h, 0/2-h, and 0/3-h algorithms) and of hs-cTn-based ADPs, together with the implications of these strategies when implemented as clinical routine. The LoD strategy, when combined with a nonischemic electrocardiogram, is best suited for safe rule-out of myocardial infarction and the identification of patients eligible for early discharge from the emergency department. The 0/1-h algorithms appear to identify most patients as being eligible for rule-out. The hs-cTn-based ADPs mainly focus on prognostic assessment, which is in contrast with the hs-cTn algorithms. They identify smaller proportions of rule-out patients, but there is increasing evidence from prospective studies on their successful clinical implementation. Such information is currently lacking for hs-cTn algorithms.
There is a trade-off between safety and efficacy for different hs-cTn-based strategies. This trade-off should be considered for the intended strategy, along with its user-friendliness and evidence from clinical implementation studies. However, several gaps in knowledge remain. At present, we suggest the use of an ADP in conjunction with serial hs-cTn results to optimize the early assessment of chest pain patients.