High Sensitivity Troponin

[Backpack234]

Listening to this month's EMRAP and was pleasantly surprised to hear them discuss the new high sensitivity troponins. What are you doing with these patients who have elevated troponins but are either low risk or aren't slam dunk ACS?

With the previous method, a high troponin was >0.08, and anything above that was NSTEMI/STEMI type I or II and required admission for further eval. The new "elevated troponin", though, is 10-15 with Acute MI being >100. This 15-99 grey area that leads to a lot of discussion with inpatient docs. "Well, that patient doesn't have chest pain, so it can't be ACS, they don't need admission". What's your practice?

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[TooMuchResearch]

Who is ordering troponin on patients without chest pain (other than triage)?

 

[RustedFox]

Who is ordering troponin on patients without chest pain (other than triage)?

MLPs at my shop do this all the damn time. I have to chase "marginal" trops in old people with renal disease every damn shift.

 

[MechEDoc]

Who is ordering troponin on patients without chest pain (other than triage)?

Lots of people.

Right heart strain, myocarditis, weakness in an elderly patient, shortness of breath, acute onset nausea and vomiting with questionable inferior lead ST or T-wave changes.

 

[southerndoc]

Discharging someone with an elevated troponin is a recipe for successful litigation. Chances are you're going to be right most of the time, but someone even with a small increase in troponin without chest pain will have a family recover damages if you send them home and they have an untoward effect.

Word to the wise: address elevated troponins very well in your documentation. Repeat troponins that don't show an elevation are an absolute must if you are discharging someone with an elevated troponin.

 

[Backpack234]

Who is ordering troponin on patients without chest pain (other than triage)?

Acute Coronary Syndromes Risk Stratification | EM Cases

cardiac risk factors, the diagnostic utility of recent cardiac testing, which patients in the ED should have a cardiac work-up, Acute Coronary Syndromes Risk Stratification key points in ECG interpretation and how best to use and interpret cardiac biomarkers like troponin.

emergencymedicinecases.com

Discharging someone with an elevated troponin is a recipe for successful litigation. Chances are you're going to be right most of the time, but someone even with a small increase in troponin without chest pain will have a family recover damages if you send them home and they have an untoward effect.

Word to the wise: address elevated troponins very well in your documentation. Repeat troponins that don't show an elevation are an absolute must if you are discharging someone with an elevated troponin.

I feel this way as well. Since we started using this new troponin which is way more sensitive but less specific, I get tons of push back from hospitalists suggesting that a troponin of 53 is definitely not ACS. Wasn't sure if other docs run into similar situations

 

[southerndoc]

hsTrop is a double-edged sword. Studies show it increases unnecessary procedures.

 

[thegenius]

MLPs at my shop do this all the damn time. I have to chase "marginal" trops in old people with renal disease every damn shift.

I hear ya. At one hospital I work at we order Troponins as frequently as we order UA's for every damn medical complaint. Which is ridiculous!!!

At my other hospital our hospitalists constantly tell me "don't order that troponin for the <name just about any disease>, don't look under the hood in these old patients. Just admit them to me and I'll take care of it. Which I love!

 

[deleted547339]

I hear ya. At one hospital I work at we order Troponins as frequently as we order UA's for every damn medical complaint. Which is ridiculous!!!

At my other hospital our hospitalists constantly tell me "don't order that troponin for the <name just about any disease>, don't look under the hood in these old patients. Just admit them to me and I'll take care of it. Which I love!

But you actually can get serial trops before you can get a urine sample....

 

[Groove]

This is why I'm actually not in favor of hsTrops at my current shop. I don't need them any more sensitive than they are. I do order them though in a variety of patients when appropriate but I'm not afraid to address an indeterminate troponinemia. If they have a small rise, they get an obligatory 2h delta at the very least and sometimes I will buff the chart with a call to cards. Sometimes it's easier to get a POC trop on the ones with underlying dz where you suspect it will give a small rise but have a low pre-test prob for ACS. Our upper limit on POCs are 0.08 which gives you a black number and therefore everyone isn't freaking out. Our send down assays upper limit is 0.034 which will bling red all over the screen if they happen to be 0.035 and I've got a gazillion nurses alerting me.

I will say though that it's uncommon for me to send someone out with an elevated trop. It happens, but it's usually someone that's been worked up before with neg cath, etc.. and has chronic trop leaks due to underlying dz with clear trend of elevated trop for all their visits.

You gotta be careful with some of these people. As promising as HEART, GRACE, and all our other clinical decision rules are, they don't catch everyone. I had a guy not long ago with no medical problems at all but had what sounded to me like exertional angina. He downplayed it quite a bit. Neg EKG, neg work up. HEART was less than 3. I told him that I suspected he was downplaying his sx and was bothered by nothing more than his exertional component and thought he needed to come in for testing. He refused. I counseled him on risks of MI, death, etc.. and he left AMA. Back the next day with STEMI. Luckily, did fine but I try not to be too cavalier with these people in spite of mounting hospital pressures to discharge everyone unless they are having a STEMI in the ED.

 

[GonnaBeADoc2222]

MLPs at my shop do this all the damn time. I have to chase "marginal" trops in old people with renal disease every damn shift.

Ordering things like troponin, ddimer, IV antibiotics, imaging beyond plain film should require attending EMR login credentials.

 

[TooMuchResearch]

Lots of people.

Right heart strain, myocarditis, weakness in an elderly patient, shortness of breath, acute onset nausea and vomiting with questionable inferior lead ST or T-wave changes.

Sure, but of consider a lot of that to be a chest pain equivalent in the right setting. Chest pain equivalent with elevated troponin still is an admission where I work.