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Cover of High-Sensitivity Cardiac Troponin for the Rapid Diagnosis of Acute Coronary Syndrome in the Emergency Department: A Clinical and Cost-Effectiveness Evaluation

High-Sensitivity Cardiac Troponin for the Rapid Diagnosis of Acute Coronary Syndrome in the Emergency Department: A Clinical and Cost-Effectiveness Evaluation

CADTH Optimal Use Report, No. 2.1

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When patients with chest pain (or other symptoms suggestive of acute coronary syndrome [ACS]) present at an emergency department (ED), investigations are rapidly conducted to rule out ACS. ACS represents a spectrum of clinical presentations of myocardial ischemia ranging from ST-segment elevation myocardial infarction (STEMI) to non-STEMI (NSTEMI) and unstable angina (UA).1–3 STEMI is diagnosed by specific electrocardiogram (ECG) findings and portends a high risk of cardiac death. NSTEMI and UA are typically caused by myocardial ischemia, but of differing severity depending on the presence of myocardial infarction (MI), and are often clinically indistinguishable because of the similarity in symptoms and transient or non-specific ECG findings of ischemia at presentation. In 2000, the European Society of Cardiology and the American College of Cardiology (ESC/ACC) jointly redefined myocardial necrosis to incorporate cardiac troponin (cTn) assays as a diagnostic determinant. In 2007, the ESC/ACC/American Heart Association (AHA) updated the definition of MI and advocated a “rise and/or fall” of cTn during a six to nine-hour time period using the 99th percentile in a reference population as the cut-off for classifying an acute and evolving MI.3 The time frame for the assessment of cTn, after the first measurement, has been reduced to three to six hours in the third universal of MI (2012).4 Therefore, in patients with suspected MI, but without ECG STEMI criteria, the cTn level is the discriminating criterion between NSTEMI and UA.

In Canada, there are two cTn tests available: cardiac troponin T (cTnT) and cardiac troponin I (cTnI). As of 2012, the manufacturer of the cTnT reagent started to remove the conventional reagent and replace it with a high-sensitivity cTnT (hs-cTnT) reagent. High-sensitivity cTnI (hs-cTnI) is not yet available, but its introduction to the market is expected within the next year. In the emergency medicine community, such a change is generating concern. A higher sensitivity assay will potentially result in earlier identification of those individuals experiencing an MI (as well as possibly those who can be safely discharged from the ED with no further investigations). However, the use of high-sensitivity assays may also be associated with lower clinical specificity. Such lower specificity could potentially result in higher rates of false-positive tests; that is, situations where patients are incorrectly identified as having NSTEMI. Therefore, the use of hs-cTn assays could lead to conducting additional investigations and undertaking more vascular interventions (e.g., angiogram). These additional investigations and interventions carry the potential to increase the pressure on EDs, cardiology referrals, and possibly cardiac catheterization suites. These could result in additional costs to the health care system and cause increased anxiety to patients.


This report is prepared by the Canadian Agency for Drugs and Technologies in Health (CADTH). The report contains a comprehensive review of the existing public literature, studies, materials, and other information and documentation (collectively the “source documentation”) available to CADTH at the time of report preparation.

The information in this report, when finalized, is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. The information in this report should not be used as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process, nor is it intended to replace professional medical advice. While CADTH has taken care in the preparation of this document to ensure that its contents are accurate, complete, and up to date as of the date of publication, CADTH does not make any guarantee to that effect. CADTH is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in the source documentation. CADTH is not responsible for any errors or omissions or injury, loss, or damage arising from or relating to the use (or misuse) of any information, statements, or conclusions contained in or implied by the information in this document or in any of the source documentation.

This document and the information provided are prepared and intended for use in the context of the Canadian health care system. Other health care systems are different; the issues and information related to the subject matter of this document may be different in other jurisdictions and, if used outside of Canada, it is at the user’s risk. This disclaimer and any questions or matters of any nature arising from or relating to the content or use (or misuse) of this document will be governed by and interpreted in accordance with the laws of the Province of Ontario and the laws of Canada applicable therein, and all proceedings shall be subject to the exclusive jurisdiction of the courts of the Province of Ontario, Canada.

CADTH takes sole responsibility for the final form and content of this document, subject to the limitations noted above. The statements and conclusions in this document are those of CADTH and not of its advisory committees and reviewers. The statements, conclusions, and views expressed herein do not necessarily represent the views of Health Canada or any Canadian provincial or territorial government. Production of this document is made possible by financial contributions from Health Canada and the governments of Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Northwest Territories, Nova Scotia, Nunavut, Prince Edward Island, Saskatchewan, and Yukon.

Please contact CADTH’s Vice-President of Corporate Services at ac.htdac@secivresetaroproc with any inquiries about this notice or other legal matters relating to CADTH’s services.

Copyright © 2013 Canadian Agency for Drugs and Technologies in Health.

PMID: 24175356

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