Implementation of High-Sensitivity Cardiac Troponin: Challenges From the International Experience

Overview

Journal Crit Pathw Cardiol

Specialty Cardiology & Vascular Diseases

Date 2018 Nov 13

PMID 30418246

Citations 3

Authors

Stacey J Howell

Ezra A Amsterdam

Bryn E Mumma

Javier E Lopez

Nam K Tran

Affiliations

Soon will be listed here.

Abstract

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.

Citing Articles

Frequency, compliance, and yield of cardiac testing after high-sensitivity troponin accelerated diagnostic protocol implementation.

Baugh C, Blankstein R, Ganguli I, Januzzi J, Morrow D, Joseph J Am J Emerg Med. 2023; 72:64-71.

PMID: 37494772 PMC: 10616758. DOI: 10.1016/j.ajem.2023.07.014.

Impact of a rapid high-sensitivity troponin pathway on patient flow in an urban emergency department.

Suh E, Tichter A, Ranard L, Amaranto A, Chang B, Huynh P J Am Coll Emerg Physicians Open. 2022; 3(3):e12739.

PMID: 35571147 PMC: 9071237. DOI: 10.1002/emp2.12739.

Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay.

Mumma B, Casey S, Dang R, Polen M, Kaur J, Rodrigo J Ann Emerg Med. 2020; 76(5):566-579.

PMID: 32807538 PMC: 7606506. DOI: 10.1016/j.annemergmed.2020.06.047.

References

Reichlin T, Cullen L, Parsonage W, Greenslade J, Twerenbold R, Moehring B . Two-hour algorithm for triage toward rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Am J Med. 2014; 128(4):369-79.e4. DOI: 10.1016/j.amjmed.2014.10.032. View

Cullen L, Mills N . Point: The Use of Sex-Specific Cutpoints for High-Sensitivity Cardiac Troponin Assays. Clin Chem. 2016; 63(1):261-263. DOI: 10.1373/clinchem.2016.254672. View

Mueller-Hennessen M, Lindahl B, Giannitsis E, Biener M, Vafaie M, deFilippi C . Diagnostic and prognostic implications using age- and gender-specific cut-offs for high-sensitivity cardiac troponin T - Sub-analysis from the TRAPID-AMI study. Int J Cardiol. 2016; 209:26-33. DOI: 10.1016/j.ijcard.2016.01.213. View

Apple F, Jaffe A, Collinson P, Mockel M, Ordonez-Llanos J, Lindahl B . IFCC educational materials on selected analytical and clinical applications of high sensitivity cardiac troponin assays. Clin Biochem. 2014; 48(4-5):201-3. DOI: 10.1016/j.clinbiochem.2014.08.021. View

Shah A, Griffiths M, Lee K, McAllister D, Hunter A, Ferry A . High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study. BMJ. 2015; 350:g7873. PMC: 4301191. DOI: 10.1136/bmj.g7873. View

Roos A, Bandstein N, Lundback M, Hammarsten O, Ljung R, Holzmann M . Stable High-Sensitivity Cardiac Troponin T Levels and Outcomes in Patients With Chest Pain. J Am Coll Cardiol. 2017; 70(18):2226-2236. DOI: 10.1016/j.jacc.2017.08.064. View

Keller T, Zeller T, Peetz D, Tzikas S, Roth A, Czyz E . Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med. 2009; 361(9):868-77. DOI: 10.1056/NEJMoa0903515. View

Wildi K, Nelles B, Twerenbold R, Gimenez M, Reichlin T, Singeisen H . Safety and efficacy of the 0 h/3 h protocol for rapid rule out of myocardial infarction. Am Heart J. 2016; 181:16-25. DOI: 10.1016/j.ahj.2016.07.013. View

Morrow D . Clinician's Guide to Early Rule-Out Strategies With High-Sensitivity Cardiac Troponin. Circulation. 2017; 135(17):1612-1616. DOI: 10.1161/CIRCULATIONAHA.117.026717. View

10.

Roffi M, Patrono C, Collet J, Mueller C, Valgimigli M, Andreotti F . 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment.... Eur Heart J. 2015; 37(3):267-315. DOI: 10.1093/eurheartj/ehv320. View

11.

Giannitsis E . Counterpoint: Potential Concerns Regarding the Use of Sex-Specific Cutpoints for High-Sensitivity Troponin Assays. Clin Chem. 2016; 63(1):264-266. DOI: 10.1373/clinchem.2016.254680. View

12.

Roffi M, Patrono C, Collet J, Mueller C, Valgimigli M, Andreotti F . 2015 ESC Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-segment Elevation. Rev Esp Cardiol (Engl Ed). 2015; 68(12):1125. DOI: 10.1016/j.rec.2015.10.009. View

13.

Melki D, Lugnegard J, Alfredsson J, Lind S, Eggers K, Lindahl B . Implications of Introducing High-Sensitivity Cardiac Troponin T Into Clinical Practice: Data From the SWEDEHEART Registry. J Am Coll Cardiol. 2015; 65(16):1655-1664. DOI: 10.1016/j.jacc.2015.02.044. View

14.

Apple F, Jaffe A, Sharkey S, Kavsak P, Kontos M, Saenger A . Best Practices for Monitoring Cardiac Troponin in Detecting Myocardial Injury. Clin Chem. 2017; 63(1):37-44. DOI: 10.1373/clinchem.2016.257428. View

15.

Than M, Cullen L, Aldous S, Parsonage W, Reid C, Greenslade J . 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol. 2012; 59(23):2091-8. DOI: 10.1016/j.jacc.2012.02.035. View

16.

Twerenbold R, Boeddinghaus J, Nestelberger T, Wildi K, Gimenez M, Badertscher P . Clinical Use of High-Sensitivity Cardiac Troponin in Patients With Suspected Myocardial Infarction. J Am Coll Cardiol. 2017; 70(8):996-1012. DOI: 10.1016/j.jacc.2017.07.718. View

17.

Twerenbold R, Jaeger C, Gimenez M, Wildi K, Reichlin T, Nestelberger T . Impact of high-sensitivity cardiac troponin on use of coronary angiography, cardiac stress testing, and time to discharge in suspected acute myocardial infarction. Eur Heart J. 2016; 37(44):3324-3332. PMC: 5177796. DOI: 10.1093/eurheartj/ehw232. View

18.

Pickering J, Greenslade J, Cullen L, Flaws D, Parsonage W, Aldous S . Assessment of the European Society of Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction. Circulation. 2016; 134(20):1532-1541. DOI: 10.1161/CIRCULATIONAHA.116.022677. View

19.

Bandstein N, Ljung R, Lundback M, Johansson M, Holzmann M . Trends in admissions for chest pain after the introduction of high-sensitivity cardiac troponin T. Int J Cardiol. 2017; 240:1-7. DOI: 10.1016/j.ijcard.2017.04.028. View

20.

Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S . Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009; 361(9):858-67. DOI: 10.1056/NEJMoa0900428. View