Abstract
Introduction
The purpose of this study was to determine the effect of recommendations to limit
troponin testing to patients with either chest pain or ischemic electrocardiographic
changes.
Methods
We included all adult patients hospitalized in a regional hospital in internal medicine,
cardiology, and intensive care departments in 2014-2016 and in 2019 after recommending
limiting troponin testing to patients with either chest pain or ischemic electrocardiographic
changes.
Results
After the intervention, testing decreased from 51.5% (11,634/22,581) to 34.6% (3417/9882).
However, if only those with ischemia or chest pain were tested, the frequency would
be 9.4% (924/9882) with a 95% confidence interval of 8.8%-9.9%. Variables increasing
the odds of ordering a troponin test were older age, male sex, a discharge diagnosis
of tachyarrhythmia, congestive heart failure, and dizziness or syncope as well as
lower albumin and higher glucose, uric acid, and blood urea nitrogen test results.
There were lower odds in those with nonspecific symptoms and infections of the skin,
soft tissues, and the urinary tract. Auditing increased the effectiveness of the intervention
in 1 internal medicine department (odds ratio 0.70, 95% confidence limit 0.60-0.82)
after adjustment for other significant independent variables. The area under the curve
was 0.713.
Conclusion
We found that an educational program with clear recommendations decreased the proportion
of patients with troponin testing in hospitalized internal medicine departments, but
the intervention was only partially effective and did not include patients with congestive
heart failure and other conditions in which expert recommendations for testing are
discordant.
Keywords
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References
- Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study.BMJ. 2017; 359: j4788https://doi.org/10.1136/bmj.j4788
- Overuse of troponin? A comprehensive evaluation of testing in a large hospital system.J Hosp Med. 2017; 12: 329‐331https://doi.org/10.12788/jhm.273
- 2018 Update on medical overuse.JAMA Intern Med. 2019; 179: 240‐246https://doi.org/10.1001/jamainternmed.2018.5748
- Troponin testing in patients without chest pain or electrocardiographic ischemic changes.Am J Med. 2017; 130: 1205‐1210https://doi.org/10.1016/j.amjmed.2017.03.032
- Impact of the cardiac troponin testing algorithm on excessive and inappropriate troponin test requests.Am J Clin Pathol. 2006; 126: 195-199https://doi.org/10.1309/GK9B-FAB1-Y5LN-BWU1
- Reducing excess cardiac biomarker testing at an academic medical center.J Gen Intern Med. 2014; 29: 1468-1474https://doi.org/10.1007/s11606-014-2919-5
- Fourth Universal Definition of Myocardial Infarction (2018).J Am Coll Cardiol. 2018; 72: 2231‐2264https://doi.org/10.1016/j.jacc.2018.08.1038
- Clinical interpretation of high-sensitivity troponin testing.JAMA Intern Med. 2019; 179: 725-726https://doi.org/10.1001/jamainternmed.2019.0371
- Clinical interpretation of high-sensitivity troponin testing—reply.JAMA Intern Med. 2019; 179: 726https://doi.org/10.1001/jamainternmed.2019.0374
- Prevalence, determinants, and clinical associations of high-sensitivity cardiac troponin in patients attending emergency departments.Am J Med. 2019; 132 (110.e8‐110.e21)https://doi.org/10.1016/j.amjmed.2018.10.002
- Frequency of troponin testing in inpatient versus outpatient settings.Am J Cardiol. 2017; 119: 1153‐1155https://doi.org/10.1016/j.amjcard.2016.12.030
- Use of cardiac biomarker testing in the emergency department.JAMA Intern Med. 2015; 175: 67-75https://doi.org/10.1001/jamainternmed.2014.5830
- Hazards with ordering troponin in patients with low pretest probability of acute coronary syndrome.Am J Emerg Med. 2015; 33: 1258‐1260https://doi.org/10.1016/j.ajem.2015.06.00
Article Info
Publication History
Published online: July 15, 2020
Footnotes
Funding: None.
Conflicts of Interest: None.
Authorship: Both authors had access to the data and a role in writing this manuscript.
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
