Point of Care Troponin

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Nurses Edition Commentary

Mizuho Morrison, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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cameron b. -

I'm sorry that I miscategorized troponin as an enzyme. It is not. I stand corrected.

C. Berg

David H., M.D. (@BritFltDoc) -

Drs Berg & Ashoo,
Much of the recent discussion about ADPs, with the decision to discharge if the HEART score is low and troponin negative, have centered around the newer generation ultra-sensitive troponins. The low likelihood of a MACE (major adverse cardiac event) over the ensuing 6 weeks has been suggested to be in part due to the negative predictive power of serially negative ultra-sensitive troponins. As such, rule-out times have shortened from the tradition 6-8 hours in prior years, to 2 hours now, with the newer generation US troponins. It is still unclear to me though, whether the POC-troponin is sensitive enough to extrapolate to be used in this way. Is there actual data to support "rapid 2-hour rule outs" and discharge, using POC-troponin and not the ultra sensitive lab based assays ?
Thanks, David

cameron b. -

Great question, David.

The ADP that I've been advocating (for the last few years) was derived and validated utilizing our current troponin assay, which is not 'ultra-sensitive'. More recently, authors have advocated a single troponin (regardless of symptom onset) or 1hr delta strategy utilizing the newer generation of assays.

The short answer, check the performance characteristics of your own lab, but I do not think ultra-sensitive troponins are necessary for accelerated rule outs.

C Berg

Patrick B. -

Unconcerning EKG, Unconcerning patient appearance, LAB troponin is sent from triage (since who gets to these types of patients within 12 minutes anyway?). Clinician scans board or gets to patient, notifies RN that this will be a patient likely appropriate for discharge/outpatient management and hints that delta 2hr troponin strategy is likely. This way I can easily avoid using POC troponin routinely which almost never helps me immediately this type of patient. Certainly an argument for using a single troponin for DC with the HEART score but since it's rare to get face to face with this type of patient we can easily use HEART + 2hr delta troponin to send the majority for outpatient follow up. I suspect we are close to that 80% when you survey the more engaged clinicians in my community group.

A. Anderson, MD -

Hi, Berg,
My ED is (finally!) developing a chest pain ADP using the heart score. Can I possibly email you a specific question that is probably too long for this blog?
Dr. Anderson

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