Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Clin Cardiol. 2020 Dec;43(12):1573-1578. doi: 10.1002/clc.23482. Epub 2020 Oct 22.
High-sensitivity troponin assays (hs-Tn) detect lower serum concentrations than prior-generation assays and help guide acute coronary syndrome (ACS) evaluation in emergency departments. Outpatient hs-Tn utilization is not well described.
Outpatient providers use hs-TnT to triage patients with suspected ACS.
We compared the volume of outpatient prior-generation troponin tests in the pre-hsTn implementation period (January 2015-March 2018) with outpatient hs-TnT volume in the post-implementation period (April 2018-January 2020). Triage patterns were compared between patients with hs-TnT≥99th vs <99th percentile, using two-sample t tests. In patients triaged home, adverse events were compared between patients with hs-TnT≥99th vs <99th percentile, using log-rank tests.
Across a large tertiary healthcare system, a mean of 80 prior-generation tests/month were ordered during the pre-hsTn implementation period compared with 12 hs-TnT tests/month in the post-implementation period. Prior-generation orders rose by 1.72 tests/month during pre-implementation, vs a decline of 2.74 hs-TnT tests/month during post-implementation (P < .001). Among 129 hs-TnT orders, most were placed by cardiologists (54%) and primary care providers (32%). Patient symptoms at the time of troponin ordering included dyspnea (34%) and chest pain (33%), although 25% were asymptomatic. Among symptomatic patients (n = 74), those with hs-TnT > 99th percentile were more likely to be sent to the ED (RR, 3.36; 95% CI, 1.22-9.25; P = .002). Among patients sent home (n = 66), those with hs-TnT > 99th percentile had more adverse events by 6 months (3.3% vs 22.2% RR, 6.67; 95% CI, 1.04-42.9; P = .026).
In this healthcare system, outpatient troponin utilization significantly declined since hs-TnT implementation. Some providers use hs-TnT to triage patients with suspected ACS to the ED; others test asymptomatic patients and some send patients home despite high hs-TnT values.
高敏肌钙蛋白检测（hs-Tn）检测到的血清浓度低于前一代检测方法，有助于指导急诊科急性冠状动脉综合征（ACS）的评估。门诊 hs-Tn 的使用情况尚未得到很好的描述。
门诊医生使用 hs-TnT 对疑似 ACS 患者进行分诊。
我们比较了 hs-TnT 实施前（2015 年 1 月至 2018 年 3 月）和实施后（2018 年 4 月至 2020 年 1 月）门诊前一代肌钙蛋白检测的检测量。使用两样本 t 检验比较 hs-TnT≥99 百分位与＜99 百分位患者的分诊模式。使用对数秩检验比较 hs-TnT≥99 百分位与＜99 百分位患者分诊回家后 6 个月内的不良事件。
在一家大型三级医疗机构中，hs-TnT 实施前的平均每月检测量为 80 次，实施后的平均每月检测量为 12 次。在实施前，hs-TnT 检测量每月增加 1.72 次，而在实施后，hs-TnT 检测量每月减少 2.74 次（P<0.001）。在 129 例 hs-TnT 检测中，大部分由心脏病专家（54%）和初级保健医生（32%）开单。肌钙蛋白检测时患者的症状包括呼吸困难（34%）和胸痛（33%），但 25%的患者无症状。在有症状的患者中（n=74），hs-TnT>99 百分位的患者更有可能被送往急诊科（RR，3.36；95%CI，1.22-9.25；P=0.002）。在分诊回家的患者中（n=66），hs-TnT>99 百分位的患者在 6 个月内的不良事件发生率更高（3.3%比 22.2%；RR，6.67；95%CI，1.04-42.9；P=0.026）。
在这个医疗体系中，自 hs-TnT 实施以来，门诊肌钙蛋白检测量显著下降。一些医生使用 hs-TnT 对疑似 ACS 的患者进行分诊至急诊科；另一些医生检测无症状患者，而一些医生尽管 hs-TnT 值较高，仍将患者分诊回家。
