Chest pain accounts for more than 6.5 million Emergency Department (ED) visits annually (1). Yet, most of these patients are not experiencing acute myocardial infarctions (AMI). The ED clinicians’ ability to quickly risk stratify these cases and rule-in/rule-out AMI is essential to fast, effective treatment and optimal ED resource management.
Clinical use of cardiac troponin as biomarker–highly sensitive does not mean high sensitivity
A paradigm shift is underway with troponin testing. High-sensitivity troponin assays have enabled rapid rule-in and rule-out of acute and chronic myocardial injury, which can improve risk assessment in the ED. As laboratory departments consider how best to support referring physicians and their patients, it is essential that decision-makers consider both the analytical sensitivity and clinical specificity of true high-sensitivity troponin assays.
Time matters in the ED. The faster clinicians can deliver accurate results, the faster the ED can assess risk and appropriately triage patients. An assay that has precise results across more than 90% of the low end of detection, for example, may reveal small amounts of necrosis in a patient. With this information, the care team may be able to detect cardiac injury before an AMI occurs—which could enable earlier interventions and treatment.
Combined with clinical specificity, a true high-sensitivity troponin assay can provide additional clinical information beyond a simple rule-in or rule-out. For example, in troponin testing, male and female 99th percentile values can vary significantly. In one study, women who presented with chest pain were less likely than men to be triaged as emergent and were less likely to be admitted (2). More accurate testing with sex-specific cutoffs can provide the insights clinicians need to know—such as who to treat, who to admit, and who to discharge. Sex-specific cutoffs are another way true high-sensitivity troponin testing can support a more precise clinical assessment.
How troponin testing impacts ED costs
The millions of patients presenting with chest pain in the ED cost the U.S. an estimated $5 billion each year. Yet only 5.5% of these patients typically have an acute life-threatening condition. In fact, most of them are low risk (3).
The challenge is two-fold: discharging high risk patients has significant costs. AMI patients mistakenly discharged have almost twice the mortality risk as those who are hospitalized (3). Long assessments of every patient who presents with chest pain in the ED can lead to overcrowding and add costs.
The goal, then, is rapid, accurate diagnosis and risk stratification, which can limit readmissions and high-cost critical interventions. True high-sensitivity troponin can be effective in helping providers meet this objective. Conventional diagnostic protocols can take longer, increasing wait times and accumulating costs. In addition, poor low-end troponin sensitivity can increase the risk of missing early AMI presenters. Based on the average cost per bed-hour and a shorter serial testing interval (), providers could save approximately $232,800 for every 1,000 ED chest pain visits (4).
Accurately triaging chest pain patients in the ED is essential both to improved clinical care and cost containment. Implementing a true high sensitivity troponin assay can aid in early detection and can prevent readmissions and high-cost critical interventions.
- Women and black adults waited longer in the ER for chest pain evaluation. Journal of the American Heart Association; 2022 May 4 [cited 2022 Aug]. Available from: https://newsroom.heart.org/news/women-and-black-adults-waited-longer-in-er-for-chest-pain-evaluation
- Banco D, Chang J, Talmor N, et al. Sex and race differences in the evaluation and treatment of young adults presenting to the emergency department with chest pain. 2022 May 4 [cited 2022 Aug]. Available from: https://www.ahajournals.org/doi/10.1161/JAHA.121.024199
- Centers for Disease Control and Prevention, Ambulatory and Hospital Care Statistics Branch. National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. [cited 2022 Aug]. Available from: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf.
- Schreyer KE, Martin R. The Economics of an Admissions Holding Unit. West J Emerg Med. 2017 Jun;18(4):553-558. doi: 10.5811/westjem.2017.4.32740. Epub 2017 May 1. PMID: 28611873; PMCID: PMC5468058.