Clinical Considerations of High Sensitivity Troponins and CVD

Abstract

Cardiovascular disease (CVD) remains the number one cause of death in the United States. According to the American Heart Association, it causes roughly 2300 deaths per day, and one death about every 38 seconds. The introduction and generalized use of high sensitivity cardiac troponins (hs-cTn) has the potential to improve diagnosis, which would allow for shorter times to reperfusion and better patient outcomes. Currently, emergency departments have established evidence-based protocols that aide providers to rule out acute coronary syndrome or acute myocardial infarction. The 2015 European Society of Cardiology (ESC) guidelines included an algorithm for managing ACS using a 0/1 hour hs-cTn testing based on studies that showed sensitivity for a 1 hour testing protocol at 97%. The guidelines included two methods of ruling out AMI, a) a single sample with hs-cTn levels that were undetectable and b) a change of 6ng/L between 0 and 1 hour or absolute threshold concentration >52ng/L. In 2017, the FDA cleared high sensitivity assays for use in the US. However, validation studies are needed in the US as a 3% missed acute MI rate would likely be unacceptable given our medical-legal environment. High-sensitivity troponins are also being studied to evaluate risk stratification and prognosis for CVD diseases such as procedural outcomes, transplant recipients, and chronic stable angina. The data currently is mixed, and likely will evolve over time. With the advent of high-sensitivity troponin assays, however, clinicians must have care in their interpretation. The myonecrosis that leads to elevations in serum troponins is not a disease specific phenomena, but rather an organ specific one. As such, several diseases exist, other than acute MI that can lead to troponin elevations. It is important for providers to use these biomarkers as an adjunct to the clinical picture to determine diagnosis, management, and treatment.