Acute Cardiac Biomarker Testing

Preferred Biomarker Testing

Patients frequently seek medical care for chest pain; the evaluation includes biomarker testing to assist in ruling out acute coronary syndromes (ACS), such as acute myocardial infarction (AMI). Creatine kinase muscle/brain (CK-MB) tests are sometimes performed when troponin testing is more appropriate due to its greater sensitivity and specificity. The American Society for Clinical Pathology, through the Choosing Wisely initiative of the American Board of Internal Medicine (ABIM) Foundation, the European Society of Cardiology, American College of Cardiology Foundation, American Heart Association, and the World Heart Federation, recommends troponin testing over CK-MB testing to evaluate for myocardial injury and suggest CK-MB testing only as an alternative when a troponin assay is not available. Given advances in troponin testing, CK-MB has limited additional clinical utility, and some hospitals and health systems are removing this test from their menus. High-sensitivity troponin testing is preferred and may potentially reduce analytic time, contributing to decreased length of stay in the emergency department. High-sensitivity cardiac troponins T and I have similar diagnostic accuracy; however, high-sensitivity troponin T has greater prognostic accuracy.  

Appropriate Troponin Retest Interval

Troponin testing should be performed initially upon patient presentation. Follow-up testing is for standard troponin testing is recommended 3 hours later; follow-up testing for high-sensitivity troponin testing is recommended 1-3 hours later.  The length of time between blood draws for troponin testing is important in identifying a rise or fall pattern. Repeating the troponin test at the appropriate interval may improve patient care by preventing unnecessary treatment delays that may result in increased cardiac muscle damage and may also reduce lengths of stay and costs associated with those stays.

Recommendations

Preorder

Provider Education

Educate ordering providers on the appropriate retest interval for follow-up troponin testing. Such training can include the potential effects on quality and care efficiency when performing this test outside recommended retest intervals.

Order Set and Provider Preferences Review

Review the active configured ordering options in the Computerized Physician Order Entry (CPOE), including protocols, order sets, and/or preference lists. Evaluate the appropriateness of the various options and aim to eliminate any conflicting mechanisms.

Ordering Protocol Standardization

Identify standard uses and contexts for troponin testing and establish ordering protocols to improve the efficiency and standardization of order placement.

Interval Guidance

Repeat the serum troponin test approximately 3 hours after the initial test. Repeat the high-sensitivity troponin test approximately 1-3 hours after the initial test.