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High-sensitivity cardiac troponin in the emergency department: The perfect storm?

2016; Elsevier BV; Volume: 234; Linguagem: Inglês

10.1016/j.ijcard.2016.12.034

1874-1754

Giuseppe Lippi, Gianfranco Cervellin,

Coronary Interventions and Diagnostics

We read with interest the article of Carlsson et al. [ [1] Carlsson A.C. Bandstein N. Roos A. et al. High-sensitivity cardiac troponin T levels in the emergency department in patients with chest pain but no myocardial infarction. Int. J. Cardiol. 2016; 228: 253-259 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar ], concluding that high-sensitivity cardiac troponins (HS-cTns) are frequently increased over the 99th percentile in emergency department (ED) patients with no evidence of myocardial ischemia. As soon as novel HS immunoassays will become commercially available, it is predictable that emergency physicians will be challenged with many non-ischemic increases of cTns. There are many clinical and demographical variables that may lead to increased cTns and these are associated with cardiac ischemia and mortality. Renal function impact troponin values, only partially due to decreased renal clearance, but mostly to ongoing cardiac damage [ [2] Fahie-Wilson M.N. Carmichael D.J. Delaney M.P. et al. Cardiac troponin T circulates in the free, intact form in patients with kidney failure. Clin. Chem. 2006; 52: 414-420 Crossref PubMed Scopus (61) Google Scholar ]. All these factors are important predictors of cardiovascular morbidity and mortality. However, their combination can be so variable in the ED patient that the use of predictive cut-offs may be unreliable and probably unsafe [ [3] Cervellin G. Lippi G. Of MIs and men–a historical perspective on the diagnostics of acute myocardial infarction. Semin. Thromb. Hemost. 2014; 40: 535-543 Crossref PubMed Scopus (2) Google Scholar ]. Notably, the medium and long-term cardiovascular risk is highly dependent upon cTns values [ [4] Ahmed A.N. Blonde K. Hackam D. et al. Prognostic significance of elevated troponin in non-cardiac hospitalized patients: a systematic review and meta-analysis. Ann. Med. 2014; 46: 653-663 Crossref PubMed Scopus (38) Google Scholar ], but no evidence exists that patients with increased cTn would need urgent management for ischemic disease, since they can be managed in an out-of-hospital setting.