Clinical bottom line
High-sensitivity troponin (hs-cTn) assays have revolutionized the evaluation of chest pain in the emergency department (ED), allowing for more rapid and accurate rule-out of acute myocardial infarction (AMI). These assays enable clinicians to identify low-risk patients who can be safely discharged, reducing unnecessary hospital admissions and resource utilization. Implementation of hs-cTn pathways should be tailored to institutional protocols, balancing sensitivity and specificity to optimize patient outcomes.
What the evidence shows
High-sensitivity troponin assays are more sensitive than conventional troponin tests, allowing for earlier detection of myocardial injury. A meta-analysis by Pickering et al. (2017) demonstrated that hs-cTn assays, when used in combination with clinical decision pathways, can safely rule out AMI in a significant proportion of patients within one to three hours of ED presentation (PMID: 28753450).
The High-STEACS trial, conducted by Shah et al. (2018), showed that implementing hs-cTn testing in clinical practice reduced the time to diagnosis and increased the identification of myocardial infarction, without increasing adverse outcomes (PMID: 30145935). This trial highlighted the potential of hs-cTn to improve diagnostic accuracy and patient flow in the ED.
Current guidelines from the European Society of Cardiology (ESC) (2020) recommend the use of hs-cTn assays as part of a rapid rule-out protocol for patients presenting with chest pain, emphasizing their role in improving diagnostic efficiency and patient safety (PMID: 32860058).
Caveats and uncertainty
While hs-cTn assays offer significant advantages, there are caveats to consider. The increased sensitivity of these assays can lead to the detection of troponin elevations unrelated to acute coronary syndromes, such as in cases of chronic kidney disease or heart failure. This can result in false-positive results and potential over-treatment.
The optimal timing and frequency of hs-cTn measurements remain areas of ongoing research, with variability in protocols across institutions. Clinicians must be aware of the specific assay characteristics and cut-off values used in their practice to accurately interpret results.
Additionally, while hs-cTn pathways can reduce unnecessary admissions, they require integration with clinical judgment and other diagnostic tools to ensure comprehensive patient assessment.
How this may change practice
The adoption of hs-cTn pathways in the ED has the potential to streamline the evaluation of chest pain, allowing for more efficient use of resources and improved patient outcomes. Clinicians should consider incorporating hs-cTn assays into their diagnostic protocols, using them in conjunction with clinical assessment and other diagnostic modalities.
In practice, this may lead to more rapid discharge of low-risk patients, reducing ED congestion and healthcare costs. As new evidence emerges, clinicians should remain informed about updates to guidelines and integrate these into their practice to ensure effective and safe management of patients presenting with chest pain.