High Sensitivity Troponin

WHY: McLaren Health Care is implementing a 5th generation, high sensitivity cardiac troponin T (hs-cTn) assay to improve the management of chest pain patients with suspected ACS. By definition, a hs-cTn assay is characterized by a lower limit of detection and an increased precision. Adoption outside of the US has been driven by clinical studies demonstrating that use of hs-cTn in ED patients undergoing evaluation for possible AMI permits more rapid and accurate rule-in and rule-out decisions compared with use of current Troponin I assays. Algorithms incorporating a change (delta) in troponin also help to distinguish patients with cTn elevations from other causes such as advanced age, CHF, sepsis or CKD.

The advantages of hs-cTn for McLaren patients are several. Low-risk patients can be more efficiently identified and discharged from the ED without need for excessive resource utilization, and more high-risk ACS patients can be identified with the opportunity for improved outcomes through application of more aggressive therapies. Published studies have shown implementation of hs-cTn assays along with evidence based algorithms can lead to faster rule out of patients with less time in the ED and less invasive testing, with no increase in overdiagnosis as indicated by stable cardiac catheterization rates.

WHAT: Implement hs-cTn assays across McLaren using an evidence-based algorithm to improve the care of patients with suspected ACS. Successful implementation of hs-cTn across McLaren will depend on provider education regarding appropriate ordering, use of 99th percentile thresholds, serial testing, changes in cTn, and risk assessment using validated clinical risk scores and/or ECGs. Providers also need to note the hs-cTn assay results in whole numbers (i.e. the Upper Reference Limit is 19 ng/L) compared to the present Troponin I assay which results in decimals (i.e. the URL is 0.056 ng/ml).

HOW: A multidisciplinary group involving cardiology, emergency medicine, internal medicine and laboratory medicine has reviewed and recommended an evidence based algorithm, and educational strategies and support are being distributed through the High Value Care program at the System and Subsidiary levels. Adding Computerized Decision Support in the EHR and LIS will hardwire changes, and the protocol will be monitored and adjusted as feedback and evidence dictates.

Selected References

Baugh, C. W., Scirica, B. M., Januzzi, J. L., Morrow, D. A., Lewandrowski, K. B., Jarolim, P., … Nagurney, J. T. (2019). Implementation of an Emergency Department High-Sensitivity Troponin Chest Pain Pathway in the United States. Critical Pathways in Cardiology, 18(1), 1–4. https://doi.org/10.1097/HPC.0000000000000164

Januzzi, J. L., Mahler, S. A., Christenson, R. H., Rymer, J., Newby, L. K., Body, R., … Jaffe, A. S. (2019). Recommendations for Institutions Transitioning to High-Sensitivity Troponin Testing: JACC Scientific Expert Panel. Journal of the American College of Cardiology, 73(9), 1059–1077. https://doi.org/10.1016/j.jacc.2018.12.046

Mayeux, B. P. (2017). A Troponin Assay Conversion: What Success Looks Like. The Journal of Applied Laboratory Medicine, 1(5), 585–589. https://doi.org/10.1373/jalm.2016.022129

Peacock, W. F., Baumann, B. M., Bruton, D., Davis, T. E., Handy, B., Jones, C. W., … Dinkel, C. (2017). Efficacy of High-Sensitivity Troponin T in Identifying Very-Low-Risk Patients With Possible Acute Coronary Syndrome. JAMA Cardiology, 77030. https://doi.org/10.1001/jamacardio.2017.4625

Sandoval, Y., & Jaffe, A. S. (2017). Using High-Sensitivity Cardiac Troponin T for Acute Cardiac Care. American Journal of Medicine, 130(12), 1358-1365.e1. https://doi.org/10.1016/j.amjmed.2017.07.033