Most US hospitals not using high-sensitivity cardiac troponin assays
National registry data show only one-third of U.S. hospitals are using high-sensitivity cardiac troponin assays as of September 2021, with most continuing to use less sensitive cardiac troponin assays despite guideline recommendations.
“High-sensitivity cardiac troponin is the preferred biomarker for evaluating acute chest pain according to the 2021 American College of Cardiology/American Heart Association guideline for the evaluation and diagnosis of chest pain; providing a class 1 recommendation,” Cian McCarthy, MD, cardiovascular disease fellow at Massachusetts General Hospital, told Healio. “We examined the implementation of high-sensitivity cardiac troponin assays among participating hospitals in the National Cardiovascular Data Registry (NCDR) Chest Pain-MI Registry in the United States. We found that, although implementation is increasing, only one-third of hospitals had implemented these assays by the third quarter of 2021. We found use of high-sensitivity cardiac troponin was associated with a slightly shorter length of hospital stay, more use of echocardiography for non-ST segment elevation ACS and less use of invasive angiography in low-risk chest pain patients.”
Assessing registry data
McCarthy and colleagues analyzed NCDR Chest Pain-MI Registry data for 550 participating hospitals from January 2019 to September 2021, examining trends in the implementation of high-sensitivity cardiac troponin, the use of in-hospital diagnostic imaging and patient outcomes (n = 251,000).
The findings were published in the Journal of the American College of Cardiology.
Data show implementation of high-sensitivity cardiac troponin assays increased from 3.3% in the first quarter of 2019 to 32.6% in the third quarter of 2021 (P for trend < .001). Use of high-sensitivity cardiac troponin assays was associated with more echocardiography among patients with non-ST segment elevation ACS (NSTEACS; 82.4% vs. 75%), for an adjusted OR of 1.43 (95% CI, 1.19-1.73). However, researchers did not observe the same association for patients with low-risk chest pain.
Additionally, among low-risk patients, the use of high-sensitivity cardiac troponin was associated with less invasive coronary angiography (3.7% vs 4.5%; adjusted OR = 0.73; 95% CI, 0.58-0.92), but among patients with NSTEACS, there was no relationship between use of high-sensitivity cardiac troponin and invasive coronary angiography. There was no association between high-sensitivity cardiac troponin use and noninvasive stress testing or coronary CT angiography testing.
Among patients with NSTEACS, high-sensitivity cardiac troponin use was not associated with revascularization or in-hospital mortality. Use of high-sensitivity cardiac troponin was associated with a shorter length of stay (median, 47.6 vs. 48 hours; ratio = 0.94; 95% CI, 0.9-0.98)
“These data highlight that further opportunities to implement high-sensitivity cardiac troponin assays exist and this may optimize care for patients with possible or definitive acute coronary syndrome,” McCarthy told Healio.
McCarthy said observational studies suggest high-sensitivity cardiac troponin may be helpful for CV risk stratification to guide the allocation of preventive therapies.
“The majority of randomized clinical trials that have examined the impact of high-sensitivity cardiac troponin assays occurred in Europe, New Zealand and Australia,” McCarthy told Healio. “As hospitals continue to implement these assays in the United States, implementation trials would provide further opportunity to examine the influence of these assays on patient testing and outcomes.”
US remains ‘significant outlier’ in assay utilization
In a related editorial, Martha Gulati, MD, MS, FACC, FAHA, FASPC, FESC, president of the American Society for Preventive Cardiology, professor of medicine at the Smidt Heart Institute at Cedars-Sinai, director of CVD prevention and associate director of the Barbra Streisand Women’s Heart Center and chair of the writing group of the ACC/AHA chest pain guideline, and David D. Berg, MD, MPH, associate physician in the cardiovascular division at Brigham and Women’s Hospital and an investigator in the TIMI study group, noted that in a global survey of 1,902 medical centers in 23 countries conducted in 2016, most respondents from Europe (60%) and Australia (55%) had already adopted high-sensitivity cardiac troponin assays.
“Thus, despite progress, the United States remains a significant outlier in high-sensitivity cardiac troponin utilization,” Gulati and Berg wrote.
The data show adoption of high-sensitivity cardiac troponin assays has not been associated with excess resource utilization and in some clinical scenarios may be having a favorable impact on cardiac testing, Gulati and Berg wrote.
“It is our hope that reports like this shine a spotlight on this issue and motivate quality improvement efforts to more effectively implement high-sensitivity cardiac troponin in U.S. hospitals,” Gulati and Berg wrote. “As report cards go, there is definite room for growth and improvement in implementation, but also the need for continued evaluation.”
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For more information:
Cian McCarthy, MD, can be reached at cmccarthy37@partners.org. Twitter: @cianpmccarthy.
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