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. 2023 Oct:72:64-71.
doi: 10.1016/j.ajem.2023.07.014. Epub 2023 Jul 13.

Frequency, compliance, and yield of cardiac testing after high-sensitivity troponin accelerated diagnostic protocol implementation

Christopher W Baugh  1 , Ron Blankstein  2 , Ishani Ganguli  3 , James L Januzzi  4 , David A Morrow  2 , Joshua W Joseph  5 , Claire Jordan  6 , Gabrielle Donohoe  7 , Jordyn Fofi  7 , Katie McKinley  7 , Mahyar Heydarpour  8 , Benjamin M Scirica  2 , Marcelo F DiCarli  2 , John T Nagurney  9
Affiliations

Frequency, compliance, and yield of cardiac testing after high-sensitivity troponin accelerated diagnostic protocol implementation

Christopher W Baugh et al. Am J Emerg Med. 2023 Oct.

Abstract

Background: Among persons presenting to the emergency department with suspected acute myocardial infarction (MI), cardiac troponin (cTn) testing is commonly used to detect acute myocardial injury. Accelerated diagnostic protocols (ADPs) guide clinicians to integrate cTn results with other clinical information to decide whether to order further diagnostic testing.

Objective: To determine the change in the rate and yield of stress test or coronary CT angiogram following cTn measurement in patients with chest pain presenting to the emergency department pre- and post-transition to a high-sensitivity (hs-cTn) assay in an updated ADP.

Methods: Using electronic health records, we examined visits for chest pain at five emergency departments affiliated with an integrated academic health system 1-year pre- and post-hs-cTn assay transition. Outcomes included stress test or coronary imaging frequency, ADP compliance among those with additional testing, and diagnostic yield (ratio of positive tests to total tests).

Results: There were 7564 patient-visits for chest pain, including 3665 in the pre- and 3899 in the post-period. Following the updated ADP using hs-cTn, 862 (23.5 per 100 patient visits) visits led to subsequent testing versus 1085 (27.8 per 100 patient visits) in the pre-hs-cTn period, (P < 0.001). Among those who were tested, the protocol-compliant rate fell from 80.9% to 46.5% (P < 0.001), but the yield of those tests rose from 24.5% to 29.2% (P = 0.07). Among tests that were noncompliant with ADP guidance, yield was similar pre- and post-updated hs-cTn ADP implementation (pre 13.0%, post 15.4% (P = 0.43).

Conclusion: Implementation of hs-cTn supported by an updated ADP was associated with a lower rate of stress testing and coronary CT angiogram.

Keywords: Accelerated diagnostic protocol; Acute myocardial infarction; Coronary CT angiogram; Emergency department; High-sensitivity troponin assay; Stress test.

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Conflict of interest statement

Declaration of Competing Interest C.W.B. is a paid speaker for Roche Diagnostics and has previously participated in a Roche Advisory Board and is an advisor to Lucia Health Guidelines. I.G. reports consulting fees from F-Prime Capital. B.M.S. reports research grants via Brigham and Women's Hospital from AstraZeneca, Eisai, Novartis, and Merck and consulting fees from AstraZeneca, Biogen Idec, Boehringer Ingelheim, Covance, Dr. Reddy's Laboratory, Eisai, Elsevier Practice Update Cardiology, GlaxoSmithKline, Lexicon, Merck, NovoNordisk, Sanofi, St. Jude's Medical, and equity in Health [at] Scale. J.L.J. is a Trustee of the American College of Cardiology; is a board member of Imbria Pharmaceuticals and a Director at Jana Care; has received research support from Abbott, Applied Therapeutics, Innolife, Novartis Pharmaceuticals, and Roche Diagnostics; has received consulting income from Abbott, Beckman, Bristol Myers, Boehringer-Ingelheim, Janssen, Novartis, Pfizer, Merck, Roche Diagnostics and Siemens; and participates in clinical endpoint committees/data safety monitoring boards for Abbott, AbbVie, Bayer, CVRx, Intercept, Janssen, and Takeda. D.A.M. reports research grants to Brigham and Women's Hospital from Abbott Laboratories, Amgen, AstraZeneca/MedImmune, Daiichi Sankyo, Eisai, GlaxoSmithKline, Medicines Company, Merck, Novartis, Roche Diagnostics, and Takeda. He has received consulting fees from Abbott Laboratories, Aralez, AstraZeneca, Bayer, InCarda, Merck, Peloton, Roche Diagnostics, and Verseon. J.T.N.'s institution has received research funding on his behalf to perform research for Alere/Biosite/Quidel, Roche/IMARC, and Thermo-Fisher.

Figures

Fig. 1.
Fig. 1.
Compliance with Accelerated Diagnostic Protocol (ADP). MIBI = Sestamibi nuclear perfusion stress test, ETT = exercise tolerance test, hs-cTn = high sensitivity troponin, MI = myocardial infarction, CI = confidence interval, CABG = coronary artery bypass graft, CT = computed tomography, MRI = magnetic resonance imaging, PCI = percutaneous coronary intervention, CCTA = coronary computed tomography angiogram.
Fig. 2.
Fig. 2.
Overall cardiac testing yield*. *Yield = ratio of positive tests to total tests, MIBI = Sestamibi nuclear perfusion stress test, ETT = exercise tolerance test, hs-cTn = high sensitivity troponin, MI = myocardial infarction, CI = confidence interval, CABG = coronary artery bypass graft, CT = computed tomography, MRI = magnetic resonance imaging, PCI = percutaneous coronary intervention, CCTA = coronary computed tomography angiogram. Note that some patients had more than one stress test (e.g., a positive ETT followed by a positive MBI or a positive CCTA followed by a negative MIBI) so the sum of tests by modality exceeds the total number of compliant/noncompliant classifications and number of patient visits; however, the sequence of positive test followed by another positive test occurred in only five cases and none of those were in a low-risk category by HEART score.
Fig. 3.
Fig. 3.
Compliant cardiac testing yield*P = 0.49. *Yield = ratio of positive tests to total tests, MIBI = Sestamibi nuclear perfusion stress test, ETT = exercise tolerance test, hs-cTn = high sensitivity troponin, MI = myocardial infarction, CI = confidence interval, CABG = coronary artery bypass graft, CT = computed tomography, MRI = magnetic resonance imaging, PCI = percutaneous coronary intervention, CCTA = coronary computed tomography angiogram. Note that some patients had more than one stress test (e.g., a positive ETT followed by a positive MBI or a positive CCTA followed by a negative MIBI) so the sum of tests by modality exceeds the total number of compliant/noncompliant classifications and number of patient visits; however, the sequence of positive test followed by another positive test occurred in only five cases and none of those were in a low-risk category by HEART score.
Fig. 4.
Fig. 4.
Noncompliant cardiac testing yield*. P = 0.35. *Yield = ratio of positive tests to total tests, MIBI = Sestamibi nuclear perfusion stress test, ETT = exercise tolerance test, hs-cTn = high sensitivity troponin, MI = myocardial infarction, CI = confidence interval, CABG = coronary artery bypass graft, CT = computed tomography, MRI = magnetic resonance imaging, PCI = percutaneous coronary intervention, CCTA = coronary computed tomography angiogram. Note that some patients had more than one stress test (e.g., a positive ETT followed by a positive MBI or a positive CCTA followed by a negative MIBI) so the sum of tests by modality exceeds the total number of compliant/noncompliant classifications and number of patient visits; however, the sequence of positive test followed by another positive test occurred in only five cases and none of those were in a low-risk category by HEART score.
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