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Strategies to improve the assessment of patients with suspected acute coronary syndrome continue to evolve, in recognition that fewer than 20% of those attending the Emergency Department with chest pain receive a diagnosis of myocardial infarction. Identifying patients without myocardial infarction at an earlier stage has the potential to reduce hospital admissions for serial cardiac biomarker testing, and facilitate appropriate investigation for alternative causes. However, such strategies are only helpful if it can be demonstrated that they do not compromise patient safety.
In 2016, the National Institute for Health and Care Excellence (NICE) updated their guidance on the evaluation of patients with suspected acute coronary syndrome. For the first time, they recommended clinicians consider ruling out myocardial infarction if a patient has very low concentrations of cardiac troponin at presentation when measured using a high-sensitivity assay.1 This guidance could lead to a significant reduction in the proportion of patients who require serial testing, and may tempt clinicians to consider upgrading their infrastructure to facilitate implementation. In the UK, two high-sensitivity assays are recommended by NICE for use in clinical practice, the Roche Elecsys high-sensitivity cardiac troponin T assay (hs-cTnT) and the Abbott ARCHITECTSTAT high-sensitivity cardiac troponin I assay (hs-cTnI). These assays measure different subtypes of cardiac troponin, and there are important differences in the normal reference range, diagnostic thresholds, levels of imprecision and in the lowest absolute concentrations which can be reliably detected, also known as the limit of detection (LoD) (Table 1).
NICE recommend clinicians apply the LoD as a threshold below which myocardial infarction can be safely ruled out at presentation. Such a strategy is only recommended for patients deemed to be at low risk of myocardial infarction ‘as indicated by a validated tool’. During …
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