Clinical Considerations of High Sensitivity Troponins and CVD (original) (raw)

2018, American Society for Clinical Laboratory Science

Cardiovascular disease (CVD) remains the number one cause of death in the United States (US). According to the American Heart Association, it causes roughly 2300 deaths per day, and one death about every 38 seconds. The introduction and generalized use of high sensitivity cardiac troponins (hs-cTn) has the potential to improve diagnosis, which would allow for shorter times to reperfusion and better patient outcomes. Emergency departments in the US have established evidence-based protocols that aide providers to rule out acute coronary syndrome or acute myocardial infarction. These protocols currently utilize traditional troponin assay but are being validated using high-sensitivity troponin assays. With the advent of high-sensitivity troponin assays, however, clinicians must have care in their interpretation. The myonecrosis that leads to elevations in serum troponins is not a disease specific phenomena, but rather organ specific. As such, several diseases exist other than acute myocardial infarction (AMI) that can lead to troponin elevations. It is important for providers to use these biomarkers as an adjunct to the clinical picture to determine diagnosis, management, and treatment. High sensitivity troponin assays are also being studied to evaluate risk stratification and prognosis for CVD diseases such as procedural outcomes, transplant recipients, and chronic stable angina. The data shows mixed results in terms of applicability for risk stratification and prognosis but likely will evolve over time. Finally, the 2015 European Society of Cardiology (ESC) guidelines include an algorithm for managing acute coronary syndrome (ACS) using a-0/-1 hour hs-cTn testing based on studies that demonstrating a 97% sensitivity for a one hour testing protocol. The guidelines included two methods of ruling out AMI, a) a single sample with hs-cTn levels that were undetectable and b) a change of 6ng/L between zero and one hour or absolute threshold concentration >52ng/L. In 2017, the FDA cleared high sensitivity assays for use in the US. Continued studies are needed in the US to determine if protocols using hs-cTn lead to early diagnosis and, subsequently, improved patient outcomes. Studies are needed to incorporate the use of hs-cTn as a better prognostic indicator for various cardiac diseases and interventions.