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Letter
Letter in response to ‘High-sensitivity troponin T for early rule-out of myocardial infarction in recent onset chest pain’
  1. Edward Carlton1,
  2. Kim Greaves2
  1. 1Emergency Department, Poole Hospital, Poole, Dorset, UK
  2. 2Department of Cardiology, Poole Hospital, Poole, Dorset, UK
  1. Correspondence to Dr Edward Carlton, Emergency Medicine ST5, Emergency Department, Poole Hospital Longfleet Road Poole Dorset BH15 2JB, UK; edwardcarlton{at}hotmail.com

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We read with interest the study by Aldous et al.1 This study adds to the growing body of published evidence that points to the safe use of new high-sensitivity troponin assays earlier in the patient journey.2–4 The authors quite rightly point out that further prospective testing is required.

The current aim of emergency department research surrounding suspected cardiac chest pain is to allow identification of a patient group that can be safely discharged following rapid rule-out of myocardial infarction with very low (ideally 1%) major adverse cardiac event (MACE) rates. In the recently published ASPECT study, Than et al identified such a group using a combination of risk scoring using the thrombolysis in myocardial infarction (TIMI) score, ECG and negative point-of-care biomarkers for myocardial necrosis (CK-MB, myoglobin and ‘low-sensitivity’ troponin) tested at 0 and 2 h giving MACE rates of 0.08%.5 However, the cost effectiveness of point-of-care biomarker testing has recently been questioned,6 and therefore the focus has switched to new laboratory high-sensitivity troponin assays.

We note that the cohort of patients investigated by Aldous et al1 had a high prevalence of high-risk clinical features prior to troponin testing (52% had ischaemic heart disease and 33% had prior revascularisation). This may have contributed to the relatively higher MACE rates of 1.2% observed in this study, and highlights the Bayesian argument regarding pretest probability. We suggest that improved early risk stratification using a combination of history, risk factors and ECG may improve the accuracy of early high-sensitivity troponin. However, a risk score appropriate for this purpose has yet to be identified. One problem with current risk score systems, such as the thrombolysis in myocardial infarction and GRACE (Global Registry of Acute Coronary Events), is that they were developed to identify high rather than low risk individuals.7 ,8 Furthermore, they often require knowledge of troponin and angiography results. Further validation of risk scores is required.

At a time when there is increased focus on the new emergency department quality indictors, it is strongly recommended that patient satisfaction should be taken into account.9 We have found no published evidence that patients have increased satisfaction when discharged earlier following an episode of chest pain assessed by accelerated chest pain protocols. Rather, may patients actually prefer to be admitted to hospital for a longer period of observation following what is an undoubtedly a high-anxiety presentation? Qualitative research in this area is also required.

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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