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The publication authored by Macdonald, et al. focused on the accuracy
of a 2 hour serial multiple biomarker protocol for exclusion of
myocardial infarction in the Emergency Department1. Correct use of
biomarkers to exclude MI is essential.
I recently observed a case in the emergency department which
demonstrated improper use of
the troponin assay.
The patient, a man in his 60's with history of diabete...
The patient, a man in his 60's with history of diabetes mellitus,
hyperlipidemia, presented to the emergency department with complaints of 5
days of upper
abdominal burning radiating to the chest. EKG revealed a STEMI.
Despite the clinical picture and positive electrocardiogram, the
physician incorrectly delayed
consulting cardiology until the point of care troponin results were
Evidence of STEMI in a patient with multiple risk factors and
correlating clinical picture should
prompt immediate cardiac intervention. About 5% of patients with acute
chest pain present with
The newest generation of highly-sensitive cardiac troponins holds
great promise for early
identification of myocardial infarction (MI), better risk stratification
and rapid effective coronary
interventions2. The challenge remains for doctors to accurately diagnose
those presenting with
non-specific ECG changes and without a straightforward clinical picture.
The cardiac troponin
values play a significant role in identifying patients with non-STEMI and
acute coronary syndrome at high risk, thus enabling rapid non-invasive and
Elevation of troponin may occur in multiple conditions other than
acute myocardial infarction. It
may occur in patients with temporary coronary artery vasospasm, severe but
heart failure, mechanical trauma of the heart, pulmonary embolism, post-
cardiac surgery and in
patients with pericarditis/myocarditis. Other causes of increased troponin
levels include sepsis,
end stage renal disease, tachyarrythmias and acute cerbrovascular events2-
4. Patients with
carbon monoxide toxicity and adriamycin cardiotoxicity may also exhibit
Patients with elevated levels will include those with myocardial
infarctions as well as those with
myocardial injury from other causes. It is therefore important to consider
the clinical picture, the absolute level and change of cTn early after
1. Macdonald SP, et al. Serial multiple biomarkers in the assessment
of suspected acute coronary syndrome: multiple infarct markers in chest
pain (MIMIC) study Emerg Med J emermed-2011-200667Published Online First:
21 March 2012 doi:10.1136/emermed-2011-200667
2. Twerenbold R, Jaffe A, Reichlin T, et al. High-sensitive troponin
T measurements: what
do we gain and what are the challenges? Eur Heart J.2012;33(5): 579-586.
3. Giannitsis E, Katus HA. Current Recommendations for Interpretation
of the Highly Sensitive Troponin T Assay for Diagnostic, Therapeutic and
Prognostic Purposes in Patients with a Non-ST-elevation Acute Coronary
Syndrome. Eur Cardiology Journal.2009;33:44-47.
4. Inbar R, Shoenfeld Y. Elevated Cardiac Troponins: the Ultimate
Marker for Myocardial Necrosis, but Not Without a differential diagnosis.
Isr Med Assoc J. 2009;11:50-53.