A pilot study of high sensitivity troponin-T testing to facilitate safe early disposition decisions in patients presenting to the Emergency Department with chest pain
Background: Many patients present to emergency departments with chest pain but little is known about this population and the safest, most efficient testing strategies.
Aims: We assessed clinical risk stratification of all patients with chest pain and, on a subset, utility of high sensitivity troponin at 4 and 6 hours after pain onset in aiding disposition decisions.
Methods: Patients with intermediate or high risk chest pain presenting within 6 hours of onset were eligible for detailed study of troponin testing and outcome. Confusion, inability to speak English, or need for urgent angiography were exclusions. Troponin levels were performed on arrival and at 4, 6 and 10-24 hours from chest pain onset. Thirty day follow-up assessed compliance with, and results of, further investigation.
Results: Chest pain accounted for 627 presentations over 112 days. Of 282 intermediate or high risk presentations 144 (51%) presented more than 6 hours after onset. The detailed study enrolled 52 patients with a troponin rise observed in 26%. In no cases did troponin increase between 6 and 10 hours and, in five cases, fell. Follow-up was achieved in 96%. Eight high risk patients (40%) and 4 intermediate risk patients (13%) had positive stress tests. For discharged patients with outpatient investigations booked in ED 92% attended whilst those with letters recommending investigations did not obtain testing.
Conclusions: This preliminary data suggests that high sensitivity troponin six hours after chest pain onset may be diagnostically useful. Marked differences in outpatient testing attendance suggest bookings should be made before discharge.