scholarly journals High-sensitivity troponin assays in the evaluation of patients with acute chest pain in the emergency department

2011 ◽  
Vol 49 (12) ◽  
Author(s):  
Michael Christ ◽  
Thomas Bertsch ◽  
Steffen Popp ◽  
Philipp Bahrmann ◽  
Hans-Jürgen Heppner ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Emergency Physician ◽  
Acute Chest Pain ◽  
High Sensitivity ◽  
Clinical Work ◽  
Life Threatening ◽  
Acute Mi ◽  
Minor Disease ◽  
Pain Patients

AbstractEvaluating patients with acute chest pain presenting to the emergency department remains an ongoing challenge. The spectrum of etiologies in acute chest pain ranges from minor disease entities to life-threatening diseases, such as pulmonary embolism, acute aortic dissection or acute myocardial infarction (MI). The diagnosis of acute MI is usually made integrating the triad of patient history and clinical presentation, readings of 12-lead ECG and measurement of cardiac troponins (cTn). Introduction of high-sensitivity cTn assays substantially increases sensitivity to identify patients with acute MI even at the time of presentation to the emergency department at the cost of specificity. However, the proportion of patients presenting with cTn positive, non-vascular cardiac chest pain triples with the implementation of new sensitive cTn assays increasing the difficulty for the emergency physician to identify those patients who are at need for invasive diagnostics. The main objectives of this mini-review are 1) to discuss elements of disposition decision made by the emergency physician for the evaluation of chest pain patients, 2) to summarize recent advances in assay technology and relate these findings into the clinical context, and 3) to discuss possible consequences for the clinical work and suggest an algorithm for the clinical evaluation of chest pain patients in the emergency department.

Chest pain in the emergency department and the chest pain unit

2021 ◽  
pp. 88-102
Author(s):  
Christiaan Vrints ◽  
Janina Stepinska ◽  
Marc J Claeys
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
Acute Chest Pain ◽  
High Sensitivity ◽  
Myocardial Cell ◽  
Accurate Identification ◽  
Avoidable Death ◽  
Life Threatening

The diagnosis and assessment of acute chest pain remain challenging. Inappropriate discharge of patients with unrecognised life-threatening acute cardiovascular disease such as acute myocardial infarction or acute aortic syndromes from the hospital can result in potentially avoidable death. By contrast, routine hospital admission of patients with non-significant chest pain can lead to unnecessary investigations and interventions, with associated potential harm and increased healthcare costs. As only a small minority of the patients presenting with acute chest pain will ultimately be diagnosed with an acute coronary syndrome or another life-threatening acute cardiovascular syndrome it is essential to use rapid and straightforward diagnostic methods that allow accurate identification of high-risk chest pain patients and safe and early discharge of low risk patients in order to avoid congestion in the emergency department. Triage and diagnosis of patients presenting with acute chest pain should rely on careful history taking, judicious interpretation of the 12 lead ECG on presentation and the use of rapid rule-in/rule out diagnostic algorithms of acute myocardial infarction using high sensitivity cardiac troponin assays for the detection of myocardial cell necrosis. Chest pain units (CPU) are organizational short-stay units with specific management protocols designed to facilitate and optimize the diagnosis of patients presenting with chest pain. Implementation of CPU has results in increased adherence to guidelines and an improved clinical outcome.

scholarly journals LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S61-S62 ◽  
Author(s):  
J. Andruchow ◽  
A. McRae ◽  
T. Abedin ◽  
D. Wang ◽  
G. Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Moderate Risk ◽  
Heart Score ◽  
High Sensitivity Troponin ◽  
High Sensitivity Troponin T ◽  
Pain Patients

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

Abstract 104: Survey of Emergency Physician Cardiac Imaging Technology and Guideline Knowledge

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Carolyn Martin ◽  
Michael Lacey ◽  
James Spalding ◽  
Breanna Essoi
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Radionuclide Imaging ◽  
Cardiac Imaging ◽  
Emergency Physician ◽  
Emergency Physicians ◽  
Appropriate Use Criteria ◽  
Appropriate Use ◽  
Stress Echo ◽  
Pain Patients

Objectives: Chest pain is among the most common reasons for emergency room presentation. Providing emergency physicians with the tools necessary to evaluate and triage chest pain patients is a key component of health care efficiency. The study objective was to increase understanding of the clinical tools available to evaluate chest pain in the emergency setting. Methods: A total of 630 emergency physicians were invited to participate in a web-based survey. Eligible respondents must have had at least 3 years of experience and spend at least 30% of time providing direct patient care. Over the course of 2 days, 163 physicians responded; 101 were eligible and completed the survey. The survey consisted of 3 screening questions and 11 survey questions. Survey questions included: experience with chest pain patients, cardiac imaging technologies as well as knowledge and use of the appropriate use criteria (AUC) for cardiac radionuclide imaging. Findings: Over ¾ of all respondents were male, averaged 46 years of age, and had been practicing emergency medicine for nearly 15 years. On average, the respondents saw 20 chest pain patients per week and 72% of those were of unknown cardiac etiology. Diagnostic Catheterization and Stress ECG were the most common evaluation tools available in the emergency department (72% and 71% respectively). When available, stress ECG was the most commonly used evaluation tool in the emergency department. MPI-SPECT was only available to 27% of respondents, and of those, only used 44% of the time. Respondents selecting the “other” response most commonly reported that imaging evaluation was not done in the emergency department. Older physicians (> 61 years) were less likely to report access to stress ECHO; physicians with fewer years of experience (20 or less) were more likely to have access to stress ECHO and diagnostic catheterization. Rural physicians were less likely to report the availability of MPI, CT or diagnostic catheterization. Less than half of emergency physicians (42%) were familiar with the cardiac radionuclide imaging appropriate use criteria, and 80% rarely or never use them. AUC knowledge and use did not differ by years in practice but did differ by age. Physicians in rural practices were the least likely to have knowledge or use the AUC. Conclusions: Despite the frequency of chest pain patients presenting to the emergency department, access to imaging tools for evaluation of cardiac etiology is limited. Knowledge and use of AUC guidelines was also limited. These results question the current clinical paradigm which appears to limit the emergency physician knowledge and use of imaging technology to evaluate the chest pain patient despite the high frequency of presentation.

Abstract 46: Potential of Coronary CT Angiography to Optimize Medical Therapy in Patients Presenting With Acute Chest Pain

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Amit Pursnani ◽  
Christopher L Schlett ◽  
Pearl Zakroysky ◽  
Parmanand Singh ◽  
James L Januzzi ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Secondary Prevention ◽  
Ct Angiography ◽  
Medical Therapy ◽  
Coronary Ct Angiography ◽  
Acute Chest Pain ◽  
Coronary Ct ◽  
Prevention Guidelines ◽  
Pain Patients

Background: Coronary artery disease (CAD) detected by coronary CT angiography (CCTA) independently predicts cardiovascular events. We assessed the potential of CCTA to tailor aspirin (ASA) and statin medical therapy in acute chest pain patients presenting to the emergency department. Methods: We included all patients from the Rule Out Myocardial Infarction Using Computer Assisted Tomography (ROMICAT) Trial. This prospective double-blinded observational cohort study included patients presenting with chest pain to the emergency department with low-intermediate risk for acute coronary syndrome (ACS). Patients underwent CCTA prior to admission, followed by standard evaluation. Caretakers were blinded to CCTA results. We assessed medical therapy at presentation and discharge, and determined concordance of CAD status by CCTA with medical therapy dictated by standard care. Results: Complete data on medical therapy was available in 358/368 patients (99%), (53±12 years, 61% men) of whom 7 had a contraindication to ASA and 11 to statin. Standard of care included stress testing in 71% of patients. Prescription of ASA and statins increased from admission to discharge (See Figure). At discharge, 33% of patients without CAD were on ASA and 14% were on statin. Conversely, 46% of patients with nonobstructive CAD by CCTA did not receive ASA and 59% did not receive statin at discharge. Only 66% of patients with obstructive CAD were on statin and ASA at discharge. Based on 2011 American College of Cardiology/American Heart Association secondary prevention guidelines, there was discordance between CAD status by CCTA and medical therapy in 51% of patients. Conclusions: CCTA has great potential to optimize adherence to secondary prevention guidelines in chest pain patients presenting to the emergency department.

scholarly journals Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients

2013 ◽  
Vol 34 (suppl 1) ◽  
pp. 21-21
Author(s):  
B. Meller ◽  
L. Cullen ◽  
W. A. Parsonage ◽  
J. Greenslade ◽  
S. Aldous ◽  
...  
Keyword(s):  
Chest Pain ◽  
Cardiac Troponin ◽  
Troponin T ◽  
Acute Chest Pain ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Diagnostic Protocol ◽  
Pain Patients

LO57: Very low concentrations of high-sensitivity troponin T at presentation can rapidly exclude acute myocardial infarction in a significant proportion of ED chest pain patients

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S26-S27
Author(s):  
J. E. Andruchow ◽  
T. S. Boyne ◽  
S. Vatanpour ◽  
D. Wang ◽  
A. D. McRae
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Chest Pain ◽  
Emergency Physician ◽  
Troponin T ◽  
High Sensitivity ◽  
High Sensitivity Troponin ◽  
Low Concentrations ◽  
High Sensitivity Troponin T ◽  
Pain Patients

Introduction: Chest pain is one of the most common presenting complaints to emergency departments (EDs) across the world, and the exclusion of acute myocardial infarction (AMI) using troponin testing is central to the care of many of these patients. While testing strategies using conventional troponin assays require repeat testing over many hours to avoid missed diagnoses, high-sensitivity troponin (hs-cTn) assays may be able to exclude AMI in a large proportion of patients with a single result at presentation. This objective of this study is to validate the ability of very low concentrations of hs-cTn at presentation to exclude AMI in ED chest pain patients. Methods: This prospective cohort study was conducted at a single urban tertiary center and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. A high-sensitivity troponin result (Roche Elecsys hs-cTnT) was obtained in all patients at presentation. The primary outcome was AMI on the index visit. Secondary outcomes included 30-day AMI and major adverse cardiac events (MACE - including AMI, revascularization or cardiac death). Electronic medical records were reviewed and telephone follow-up was obtained for all patients at 30-days to ensure relevant events were captured. Two physician adjudication (board-certified emergency physician and cardiologist) was obtained for all outcomes. This study was REB approved. Results: A total of 1,167 patients were enrolled from August 2014 September 2016, of which 191 (16.3%) patients had an initial troponin below the limit of blank (LoB, <3 ng/L) and 416 (32.8%) were below the limit of detection (LoD, <5 ng/L). The sensitivity of a single troponin below the LoB (<3 ng/L) for index AMI was 100% (95% CI 96.2%-100%) and for 30-day AMI was 100% (95% CI 96.4-100%). The sensitivity of a troponin below the LoD (<5 ng/L) for index AMI was 97.9% (95% CI 92.7%-99.8%) and for 30-day AMI was 98.0% (95% CI 93.0-99.8%). Sensitivity for 30-day MACE at both cutoffs was lower: 98.4% (95% CI 94.3-99.8%) for <3 ng/L, and 94.4% (95% CI 88.8-97.7%) for <5 ng/L, respectively; however, negative predictive values remained high at both cutoffs: <3 ng/L, 99.0% (95% CI 96.3-99.9%) and <5 ng/L, 98.3% (95% CI 96.6-99.3%). Conclusion: A high sensitivity troponin T result below the LoB (<3 ng/L) is highly sensitive for excluding AMI and identifies patients at low risk of 30-day MACE. A result below the LoB (<5 ng/L) will identify a larger population of patients as low risk but has a greater risk of missed AMI and MACE.

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