Abstract
Patients presenting to the Emergency Department with symptoms consistent with possible acute cardiac ischaemia, particularly chest pain, are one of the most common patient groups presenting to Emergency Departments in the developed world. These patients account for approximately 10 % of Emergency Department presentations and up to 25 % of hospital admissions (Goodacre et al., Heart 91:229–230, 2005). Up to 90 % of these patients do not have a final diagnosis of an acute coronary syndrome (ACS). This large group of patients consumes considerable hospital resources with extensive investigations being common practice. Cardiac troponin is very important in this assessment process because traditionally, the large number of hospital admissions has been driven by a need to measure circulating cardiac troponin on arrival at hospital and then again at a delayed period afterwards. Historically, the second blood sample has been approximately 6 h or later after arrival or symptom onset. This timeframe has been used because early research on cardiac troponins suggested that troponin rises due to myocardial necrosis from acute myocardial infarction (AMI) were not reliably detectable until 6–12 h after symptom onset (Cooper et al., Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London: National Clinical Guideline Centre for Acute and Chronic Conditions. http://publications.nice.org.uk/chest-pain-of-recent-onset-cg95. Accessed 15 Mar 2011, 2010).
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Goodacre S, Cross E, Arnold J, Angelini K, Capewell S, Nicholl J. The health care burden of acute chest pain. Heart. 2005;91:229–30.
Cooper A, Calvert N, Skinner J, et al. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London: National Clinical Guideline Centre for Acute and Chronic Conditions. 2010. http://publications.nice.org.uk/chest-pain-of-recent-onset-cg95. Accessed 15 Mar 2011.
Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1–10.
Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213–6.
Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208–12.
Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust [Comparative Study]. 2006;184(5):213–6.
Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust [Comparative Study Research Support, Non-U.S. Gov’t]. 2006;184(5):208–12.
Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ [Research Support, Non-U.S. Gov’t]. 2011;342:d2983.
Hollander JE, Robey JL, Chase MR, Brown AM, Zogby KE, Shofer FS. Relationship between a clear-cut alternative noncardiac diagnosis and 30-day outcome in emergency department patients with chest pain. Acad Emerg Med. 2007;14(3):210–5.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, Harvey D. White third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60(16):1581–98.
Diamond G, Kaul S. How would the Reverend Bayes interpret high-sensitivity troponin? Circulation. 2010;121:1172–5.
Goodacre SW, Angelini K, Arnold SR, Morris F. Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. QJM. 2003;96(12):893–8.
Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med. 2002;9(3):203–8.
Body R, McDowell G, Carley S, Mackway-Jones K. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the emergency department? Resuscitation. 2008;79:41–5.
Body R, Carley S, Wibberley C, McDowell G, Ferguson J, Mackway-Jones K. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81:281–6.
Han JH, Lindsell CJ, Luber S, Hoekstra KW, Hollander JE, Peacock WF, Pollack CV, Gibler WB. The role of cardiac risk factor burden in diagnosing acute coronary syndromes in the emergency department setting. Ann Emerg Med. 2007;49(2):145–52.
Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA. 2000;284:835–42.
Than M, Cullen L, Aldous S, Parsonage WA, Reid CM, Greenslade J, Flaws D, Hammett CJ, Beam DM, Ardagh MW, Troughton R, Brown AF, George P, Florkowski CM, Kline JA, Peacock WF, Maisel AS, Lim SH, Lamanna A, Richards AM. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol. 2012;5(59):2091–8.
Aldous SJ, Florkowski CM, Crozier IG, et al. High sensitivity troponin outperforms contemporary assays in predicting major adverse cardiac events up to two years in patients with chest pain. Ann Clin Biochem. 2011;48(Pt3):249–55. Epub 2011 Mar 25.
Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009;361:858–67.
National Institute of Health Care Excellence (NICE). Myocardial infarction (acute): early rule out using high-sensitivity troponin tests (Elecsys Troponin T high-sensitive, ARCHITECT STAT High Sensitive Troponin-I and AccuTnI + 3 assays)(DG15). 2015. http://nice.org.uk/guidance/dg15.
Pickering JW, Young JM, George P, Aldous S. The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department. Clin Biochem. 2015. pii: S0009-9120(15)00313-6. doi:10.1016/j.clinbiochem.2015.07.033.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2016 Springer International Publishing Switzerland
About this chapter
Cite this chapter
Than, M.P., Cullen, L. (2016). Evaluation of Patients Presenting with Chest Pain in the Emergency Department: Where Do Troponins Fit In?. In: Maisel, A., Jaffe, A. (eds) Cardiac Biomarkers. Springer, Cham. https://doi.org/10.1007/978-3-319-42982-3_4
Download citation
DOI: https://doi.org/10.1007/978-3-319-42982-3_4
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-42980-9
Online ISBN: 978-3-319-42982-3
eBook Packages: MedicineMedicine (R0)