title: Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department.
abstract: The evaluation of patients presenting to the emergency department with suspected acute coronary syndrome (ACS) remains a clinical challenge. The traditional assessment includes clinical risk assessment based on cardiovascular risk factors with serial electrocardiograms and cardiac troponin measurements, often followed by advanced cardiac testing as inpatient or outpatient (i.e. stress testing, imaging). Despite this costly and lengthy work-up, there is a non-negligible rate of missed ACS with an increased risk of death. There is a clinical need for diagnostic strategies that will lead to rapid and reliable triage of patients with suspected ACS. We provide an overview of the evidence for the role of highly sensitive troponin (hsTn) in the rapid and efficient evaluation of suspected ACS. Results of recent research studies have led to the introduction of hsTn with rapid rule-in and rule-out protocols into the guidelines. Highly sensitive troponin increases the sensitivity for the detection of myocardial infarction and decreases time to diagnosis; however, it may decrease the specificity, especially when used as a dichotomous variable, rather than continuous variable as recommended by guidelines; this may increase clinician uncertainty. We summarize the evidence for the use of coronary computed tomography angiography (CTA) as the rapid diagnostic tool in this population when used with conventional troponin assays. Coronary CTA significantly decreases time to diagnosis and discharge in patients with suspected ACS, while being safe. However, it may lead to increase in invasive procedures and includes radiation exposure. Finally, we outline the opportunities for the combined use of hsTn and coronary CTA that may result in increased efficiency, decreased need for imaging, lower cost, and decreased radiation dose.
authors: Knight Cardiovascular Institute, Oregon Health and Science University, 3180 SW Sam Jackson Park Road, Mail Code UHN62, Portland, OR 97239, USA Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA ferencik@ohsu.edu.
authors: Maros
authors: M
authors: Ferencik
authors: Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
authors: Udo
authors: U
authors: Hoffmann
authors: Department of Radiology, University of Tuebingen, Tuebingen, Germany.
authors: Fabian
authors: F
authors: Bamberg
authors: Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
authors: James L
authors: JL
authors: Januzzi
mesh_terms: D054058:Acute Coronary Syndrome; D000072226:Computed Tomography Angiography; D004636:Emergency Service, Hospital; D006801:Humans; D012307:Risk Factors; D014336:Troponin
chemical_list: D014336:Troponin
keywords: Acute chest pain; Acute coronary syndrome; Coronary computed tomography angiography; Highly sensitive troponin