Accelerated Diagnostic Protocols Using High-sensitivity Troponin Assays to “Rule In” or “Rule Out” Myocardial Infarction in the Emergency Department: A Systematic Review

Jutkowitz E, Hsiao J, Celedon M, Erqou S, Konnyu K, Rudolph J, Baig M, Trikalinos T, Ngamdu K, Kanaan G, Tran TP, Rickard T, Cui S, Balk E. Accelerated Diagnostic Protocols Using High-sensitivity Troponin Assays to “Rule In” or “Rule Out” Myocardial Infarction in the Emergency Department: A Systematic Review. VA Evidence-based Synthesis Program Reports. Washington (DC): Department of Veterans Affairs (US); 2023 Mar 1.

In the United States (US), 7 million people annually visit the emergency department (ED) for chest pain, but only 4% of these patients are diagnosed with myocardial infarction (MI). Rapid rule-out and rule-in of MI should reduce time to correct patient diagnosis and reduce clinician, staff, and other hospital resource needs, along with ED overcrowding, unnecessary testing, and unnecessary hospitalizations. However, the clinical implications of missing an MI can be severe and may include mortality as well as medicolegal risk. In addition, incorrectly diagnosing an MI may put patients through unnecessary testing and treatment. Newer high-sensitivity cardiac troponin (hs-cTn) assays entered the global market in 2010 and are now the preferred troponin biomarker for diagnosing MI, as per the 2021 ACC/AHA Joint Committee on Clinical Practice Guidelines. Multiple accelerated diagnostic protocols (ADPs) have been devised to help ED providers quickly rule out MI. ADPs can incorporate hs-cTn, risk scores, and other clinical criteria (eg, patient history or electrocardiogram findings) to stratify patients into categories that inform clinical management. Most ADPs that incorporate hs-cTn were initially evaluated in observational studies that computationally derived and validated the decision rules and concluded that they are likely safe and effective. Health systems, including the VA, now aim to implement ADPs with hs-cTn into clinical practice. The VA Evidence Synthesis Program (ESP) was asked by the VA Office of Emergency Medicine for an evidence review on ADPs that use hs-cTn to rule in or rule out MI.