VIDEO: High sensitivity cardiac troponin use based on the NCDR Chest Pain-MI Registry 

 

Cian McCarthy, MD, cardiovascular fellow, Massachusetts General Hospital, and a member of the National Cardiovascular Data Registry (NCDR) Chest Pain-MI registry steering committee, explains a study of the NCDR data showing only 33% of hospitals are using high-sensitivity troponin. However, he expects that to rise because high sensitivity troponin (hs-cTn) was included in recent guidelines as a front-line test. 

McCarthy presented the study at the American Heart Association (AHA) 2022 scientific sessions.[1] The study found Among 550 participating hospitals (including 251,000 patients), implementation of hs-cTn assays increased from 3.3% in the beginning of 2019 to 32.6% in the third quarter of 2021. 

"The majority of hospitals in the U.S. are not using high sensitivity troponin," McCarthy said. "We dod look to see if there was any characteristic difference in the hospitals that did or did not use high sensitivity troponin, and really we found no difference in terms of profit type, hospital size, or cath lab facilities, and that was a very interesting finding for us." 

The primary takeaway was implementation of hs-cTn among U.S. hospitals is increasing, but most hospitals continue to use less-sensitive assays. High sensitivity troponin use was associated with modestly shorter length of stay (LOS), greater use of echocardiography for non-ST-elevation acute coronary syndromes (NSTE-ACS) (82.4% vs. 75%), and less use of invasive angiography among low-risk patients (3.7% vs. 4.5%), but similar use for NSTE-ACS..

There was no association between hs-cTn use and noninvasive stress/CT coronary angiography testing. Among NSTE-ACS individuals, hs-cTn use was not associated with revascularization or in-hospital mortality. 

"I think implementation is only going too increase, and some of the manufactures of these assays are considering not even making traditional troponin tests anymore," McCarthy said. "And I think the data for high sensitivity troponin is reassuring.

High sensitivity Troponin has ben a hot topic of discussion in recent years, and interest has increased since last fall with it being included as a Class 1A front-line recommendation in 2021 AHA/ACC Chest Pain Evaluation Guidelines. McCarthy said traditional tropic testing requires up to six hours of serial testing on the hour. But, high sensitivity troponin tests can yield actionable data in the first test or by the second hour test. 

"The main benefit I see with high sensitivity troponin is a more efficient rule-out of MI, and we know the vast majority of patients coming to the ED with chest pain don't have an acute coronary syndrome, only one in 20 do," McCarthy explained. 

With the current levels of ED overcrowding, he said it would make sense for more hospitals to adopt high sensitivity troponin testing to speed patient discharge for those who do not need to be there. 

One reason why there might be low adoption is because there are several assays available that use different test algorithms and have different cut offs. "This can be very confusing for clinicians and hospitals looking to implement this which can be confusing for clinicians who ask how do I interpret all these different cut offs," McCarthy said. "So, the ACC just released an expert consensus document discussing the evaluation of chest pain in the ED. And in that document we outlined the strengths and differences between these algorithms and gave recommendations on which ones should be preferred, and the biomarker cut offs that can be used with each one."
 

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