A shortcut review of the literature was carried out to establish whether prehospital point of care (POC) troponin tests are reliable and accurate enough to detect acute coronary syndrome (ACS) in adult patients.
Nine papers were found to be relevant to the clinical question following the below-described search strategies. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of those best papers are tabulated. It is concluded that based on the currently available evidence, POC troponin assays are insufficiently sensitive to ‘rule out’ ACS in the prehospital environment.
- cardiac care
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Three part question
In (patients with suspected cardiac chest pain), can (paramedics use troponin point of care test) (safely ‘rule out’ Acute Coronary Syndromes in the prehospital emergency settings)?
An ambulance is called in the middle of the night by a 56-year-old female patient complaining of chest pain. On paramedics’ arrival, the woman is alert and orientated and reports that the chest pain had self-resolved 5 min ago. The ECG recorded on the scene shows benign early repolarisation with no other abnormalities. There are no other pertinent clinical findings. You are aware that the history, physical examination and ECG cannot be used to ‘rule out’ an acute coronary syndrome (ACS) alone. You wonder whether a point of care (POC) troponin test could help you to ‘rule out’ ACS without requiring transfer to hospital.
MEDLINE (Ovid) 1946 to March week 3, 2018
EMBASE (Ovid) 1974 to March week 4, 2018
(Emergency Medical Services/or paramedic*.mp. or Emergency Medical Technicians/OR Ambulance*.mp. OR (pre-hospital.mp. OR prehospital.mp.) OR (out of hospital.mp. OR out-of-hospital.mp.)) AND (Acute Coronary Syndrome/OR Myocardial Infarction/OR Chest pain/) AND (Troponin I/OR Troponin T/)
CINAHL Plus (EBSCOhost) 2000 to March week 4, 2018
(troponin I OR troponin T OR ctni OR cTnI) AND (Emergency Medical Services OR Emergency Medical Technicians OR paramedic* OR pre-hospital OR prehospital OR ambulance* OR out of hospital OR out-of-hospital) AND (acute coronary syndrome OR Myocardial Infarction OR Chest Pain)
The above-described search strategy yielded a total of 187 papers of which 9 papers were relevant to the three-part question. Irrelevant papers or papers of insufficient quality of evidence, those not written in English and those which were published before the year 2000 (the first year when cardiac troponin was cited as the reference standard biomarker for diagnosing acute myocardial infarction (AMI)) were excluded from review (see table 1).
Diagnosing ACS in patients with chest pain in the prehospital settings is one of most challenging tasks. As cardiac biomarker testing is central to the diagnosis of AMI, there are incredible potential advantages to using cardiac biomarker POC assays but current evidence is limited in the prehospital setting. The evidence that is available suggests that POC troponin assays alone are insufficiently sensitive to ‘rule out’ ACS in the prehospital settings. Future research should focus on the use of POC troponin assays in conjunction with validated decision aids. The development of POC troponin assays with greater analytical sensitivity and precision is likely to improve diagnostic performance.
Clinical bottom line
Based on the currently available evidence, POC troponin assays are insufficiently sensitive to ‘rule out’ ACS in the prehospital environment.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.