Implementation of High-Sensitivity Cardiac Troponin Assays in the United States
Key result
High-sensitivity troponin evaluation is linked to ~6% shorter length of stay and less angiography in low-risk patients.
- Ratio 0.94
- 95% CI 0.90-0.98
- n=251,000
Why the study?
Few data exist regarding the implementation of high-sensitivity cardiac troponin assays in the United States since their approval.
Does evaluation with high-sensitivity cardiac troponin assays improve in-hospital testing efficiency and outcomes in patients with suspected acute coronary syndrome?
Key Points
- To examine trends in high-sensitivity cardiac troponin assay implementation across U.S. hospitals and assess associations with in-hospital cardiac testing and clinical outcomes.
- Analyzed 251,000 patients across 550 participating U.S. hospitals in the NCDR Chest Pain-MI Registry from January 1, 2019, through September 30, 2021.
- Evaluated associations between hs-cTn implementation, diagnostic imaging, and outcomes using generalized estimating equation models with logistic or Gamma distributions.
- Implementation of hs-cTn assays increased from 3.3% in Q1 2019 to 32.6% in Q3 2021 (Ptrend<0.001).
- hs-cTn use was associated with higher echocardiography use in NSTE-ACS (82.4% vs. 75.0%; aOR: 1.43, 95% CI, 1.19–1.73) and lower invasive coronary angiography in low-risk chest pain (3.7% vs. 4.5%; aOR: 0.73, 95% CI, 0.58–0.92).
- hs-cTn evaluation was associated with shorter length of stay (median 47.6 vs. 48.0 hours; ratio: 0.94, 95% CI, 0.90–0.98), with no differences in revascularization or in-hospital mortality among NSTE-ACS patients (2.8% vs. 3.2%; aOR: 0.98, 95% CI, 0.87–1.11).
Study Design
Type
Cohort (n=251,000)
Multicenter
Yes
Structured PICO
Does evaluation with high-sensitivity cardiac troponin assays improve in-hospital testing efficiency and outcomes in patients with suspected acute coronary syndrome?
P
Population
251,000 patients with suspected acute coronary syndrome (NSTEMI, unstable angina, or low-risk chest pain) evaluated at 550 U.S. hospitals participating in the NCDR Chest Pain-MI Registry.
E
Exposure
Evaluation with high-sensitivity cardiac troponin (hs-cTn) assays
C
Comparator
Evaluation with conventional (less-sensitive) cardiac troponin assays
O
Outcome
In-hospital cardiac testing (echocardiography, invasive coronary angiography, stress/CTCA) and outcomes (length of stay, in-hospital mortality, revascularization)
Main Result
Effect estimate: Ratio 0.94 (95% CI 0.90-0.98)
Absolute Event Rate: 47.6% vs 48%
Limitations
- Selection bias due to optional entry of low-risk chest pain and unstable angina patients
- Possibility of unmeasured confounders
- Inability to confirm accuracy of diagnosis classifications at individual sites
- Lack of post-discharge outcomes such as 30-day mortality or recurrent MI
- Inability to assess post-discharge invasive or non-invasive testing
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“High-sensitivity cardiac troponin is the preferred biomarker for evaluating acute chest pain according to the 2021 American College of Cardiology/American Heart Association guideline for the evaluation and diagnosis of chest pain; providing a class 1 recommendation. We examined the implementation of high-sensitivity cardiac troponin assays among participating hospitals in the National Cardiovascular Data Registry (NCDR) Chest Pain-MI Registry in the United States. We found that, although implementation is increasing, only one-third of hospitals had implemented these assays by the third quarter of 2021. We found use of high-sensitivity cardiac troponin was associated with a slightly shorter length of hospital stay, more use of echocardiography for non-ST segment elevation ACS and less use of invasive angiography in low-risk chest pain patients.”
“So still, the majority of the hospitals by the end of the third quarter 2021 were not using these assays.”
“This is not an insignificant change. Going from a conventional troponin to a high-sensitivity assay really requires a substantial bit of education—understanding how to think about these tests, how to use them, how to interpret them, and how to manage patients when the tests are abnormal.”
Implication
Implementation of high-sensitivity cardiac troponin assays in U.S. hospitals is associated with more efficient resource utilization, including shorter length of stay and less invasive angiography in low-risk patients, without increasing adverse outcomes.
Abstract
Background: Few data exist regarding the implementation of high-sensitivity cardiac troponin (hs-cTn) assays in the United States since their approval. Objectives: To explore trends in hs-cTn assay implementation over time and assess the association of their use with in-hospital cardiac testing and outcomes. Methods: We examined trends in implementation of hs-cTn assays among participating hospitals in the NCDR® Chest Pain-MI Registry from 1/1/2019 through 9/30/2021. Associations between hs-cTn use, use of in-hospital diagnostic imaging, and patient outcomes were assessed using generalized estimating equation models with logistic or Gamma distributions. Results: Among 550 participating hospitals (251,000 patients), implementation of hs-cTn assays increased from 3.3% in Q1, 2019 to 32.6% in Q3, 2021 (Ptrend<0.001). hs-cTn use was associated with more echocardiography among persons with NSTE-ACS (82.4% vs. 75.0%; aOR: 1.43, 95% CI, 1.19–1.73) but not among low-risk chest pain individuals. hs-cTn use was associated with less invasive coronary angiography among low-risk patients (3.7% vs. 4.5%; aOR: 0.73, 95% CI, 0.58–0.92) but similar use for NSTE-ACS. There was no association between hs-cTn use and non-invasive stress/CTCA testing. Among NSTE-ACS individuals, hs-cTn use was not associated with revascularization or in-hospital mortality. Use of hs-cTn was associated with shorter length of stay (LOS; median 47.6 hours vs. 48.0 hours; ratio: 0.94, 95% CI, 0.90–0.98). Conclusions: Implementation of hs-cTn among U.S. hospitals is increasing but most U.S hospitals continue to use less-sensitive assays. hs-cTn use was associated with modestly shorter LOS, greater use of echocardiography for NSTE-ACS, and less use of invasive angiography among low-risk patients.
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Cite This Study
McCarthy et al. (2022) conducted a cohort in Suspected acute coronary syndrome (NSTEMI, unstable angina, or low-risk chest pain) (n=251,000). High-sensitivity cardiac troponin (hs-cTn) assay vs. Conventional troponin assay was evaluated on Length of stay (LOS) in hours (Ratio 0.94, 95% CI 0.90-0.98). Evaluation with high-sensitivity cardiac troponin assays was associated with a modestly shorter length of stay, greater use of echocardiography for NSTE-ACS, and less use of invasive angiography among low-risk patients.