High-sensitivity blood troponin (hs-cTn) assays in the initial evaluation of patients with chest pain, while initially more laborious, are associated with long-term reductions in hospital admissions, stress tests and high-cost invasive services, according to new real-world data.
The findings were published online Monday in the Journal of the American College of Cardiology (JACC), led by Ishani Ganguli MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital, Boston.
High-sensitivity assays have been successfully used in Europe and Australia for more than a decade. Since the U.S. Food and Drug Administration’s 2017 approval, hs-cTn tests have been “increasingly used across the country,” the researchers noted. Relative to the conventional assay, the high-sensitivity test both lowers the limit of detection and increases the speed of the assays, they said.
However, while hs-cTn testing provides “faster and more sensitive detection of myocardial injury,” the researchers highlighted concerns about negative effects on the U.S. healthcare ecosystem “due to cascades slowed adoption of these assays.”
Therefore, the researchers examined patient visits to five emergency departments between April 2017 and April 2019 using electronic health record and billing data to compare diagnoses and resource utilization in patients undergoing conventional troponin assays (cTn) versus hs-cTn.
The team concluded that hs-cTn implementation is associated with higher upfront emergency room costs for troponin and electrocardiogram (EKG) testing but lower rates of hospitalizations and downstream consultation, in addition to less use of advanced cardiac imaging and fewer high-cost invasive tests when compared to the use of conventional cTn assays, “suggesting a potential benefit of this approach.”
After hs-cTn introduction, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72 to 4.93) relative increase for any cascade event compared to patients with other symptoms.
Specifically, patients with chest pain undergoing hs-cTn were more likely to have two or more troponin tests (10.5%; 95% CI: 9.0, 12.0) and EKGs (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4).
However, these patients received net fewer computed tomography (CT) scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient visits; 95% CI: -6.5 to -5.3), and cardiac catheterizations (-0.65 per 100 patient visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5 to 2.6), or be hospitalized (-5.8%; 95% CI: -7.7 to -3.8).
“These results suggest that an initial hs-cTn followed by some additional upfront evaluation (for example, a second hs-cTn test ordered just an hour after the first test, rather than 3-6 hours as for the contemporary Tn assay) may have afforded emergency physicians greater confidence that the presentation was not an acute MI and allowed them to forego additional evaluation,” Ganguli and colleagues said, adding that the findings mirror those of a recent study in two Texas hospitals showing fewer admissions after hs-cTn introduction.
They concluded that sensible adoption of high-sensitivity blood troponin assays for initial evaluation of patients with chest pain is associated with greater use of repeated troponin testing and EKGs but less use of advanced cardiac imaging, hospitalization and invasive procedures – suggesting potential benefits to the approach.
Ganguli and colleagues said additional studies are now needed to assess the overall cost and value of integrating hs-cTn assays with education and revised patient care protocols for evaluation of patients with chest pain.
An accompanying editorial led by Christian Mueller, MD, of University Hospital Basel, Switzerland, notes that more than 12 million people every year present at an emergency department in North America and Europe with chest pains and suspected acute myocardial infarction (AMI), requiring substantial resource use and contributing to emergency room crowding.
Mueller and colleagues added that continuous interdisciplinary medical education is required “to maximize the medical and economic value of hs-cTnT” to both patients and hospitals. Such efforts will help reduce overcrowding, reduce patient anxiety and uncertainty, improve patient care and could significantly reduce health care costs, they suggested.
The editorialists went on to cite a 2017 economic study suggesting widespread implementation of the European Society of Cardiology hs-cTnT/I 0/1h-algorithm might help save more than $12 billion in U.S. health care spending per year.
Ganguli I, Cui J, Thakore N, et al. Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation. J Am Coll Cardiol 2021 May 3 (Article in press).
Mueller C, Boeddinghaus J, Nestelberger T. Downstream consequences of implementing high-sensitivity cardiac troponin: why indication and education matter. J Am Coll Cardiol 2021 May 3 (Article in press).