Learn to Love High Sensitivity Troponins by Jim Ducharme, MD
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KEY POINTS AND RECOMMENDATIONS
1. Even the most accurate troponin assay should not reassure you when the story and/or the ECG are high risk. Nothing has changed for those patients, even with an undetectable high-sensitivity troponin. Unstable angina is still a thing!
2. High sensitivity troponins are not negative or positive – they will be undetectable (below the limit of detection), measureable but below the 99th percentile (grey or “observe” zone), or measurable and above the 99th percentile (abnormal). The delta (or rate of rise) over 1-3 hours is important in interpreting detectable troponins. Rapidly rising (delta) troponins are indicative of myocardial injury even if below the 99th percentile threshold.
3. Higher troponin levels are associated with worsening prognosis, even if stable (not rising).
4. Consider non-ischemic cardiac and non-cardiac causes for presentation for all patients with detectable hs troponin.
5. Low-risk patients presenting after 3 hours with non-ischemic ECGs may be “ruled-out” with a single hs troponin result below the level of detection. These patients are at very low risk (less than 1%) of MACE (Major Adverse Cardiac Events).
6. Early presenters (less than 3 hours of symptoms) with undetectable troponin will require a delta troponin of between 1 and 3 hours before they can be confidently “ruled out.”
7. Patients with non-ischemic ECGs and detectable troponins below the 99th percentile at presentation will require a repeat sample. Patients with stable levels (unchanging) may not have acute myocardial ischemia, but they are at higher risk for both MACE and mortality than patients with undetectable troponins. These patients are in the “observe zone” – neither “rule-in” nor “rule-out.” There are no clear guidelines on the best management of these patients.
8. A combination of a clinical assessment and a second sample between 1 and 3 hours after the first is the recommended approach for serial sampling with hs troponin.
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