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The effect of cardiac troponin testing on clinical care in a veterans population

A randomized controlled trial

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Abstract

BACKGROUND: Cardiac troponin is more accurate than creatine kinase (CK) testing for detecting myocardial injury in patients with acute coronary syndromes (ACS), but its effects on clinical care compared with CK testing alone is open to question.

OBJECTIVE: To test the effects of troponin I on medical decisions for patients undergoing cardiac enzyme testing.

DESIGN: Randomized, controlled trial.

SETTING: Urban academic Veterans Affairs medical center.

PATIENTS: Three hundred ninety-two patients presenting to the emergency department (ED) and outpatient settings with symptoms and/or electrocardiograms suggestive but not diagnostic of ACS.

INTERVENTION: Random assignment to linked CK-troponin I (CKTnI) testing or CK testing alone.

MEASUREMENTS: ED discharge and cardiac catheterization incidence (primary); ED medication use, inpatient noninvasive testing, revascularization procedures, discharge medications, and 8-week ED visits, hospitalizations, and procedures (secondary).

RESULTS: Groups were similar in all variables except history of heart failure (CK 26.8% vs CKTnI 17.0%). ACS comprised 12.2% of the cohort. ED discharge incidence was greater in the CKTnI arm (18% vs 9.6%; relative risk [RR], 1.83; 95% CI, 1.08 to 3.31; P=.02; number needed to test=12.6; 95% CI, 4.5 to 130). Troponin testing had no significant effect on catheterization incidence (18.2% vs 14.5%; RR, 1.19; 95% CI, 0.72 to 1.92; P>.20) or other outcomes except follow-up echocardiography (13.4% vs 7.4%; RR, 2.24; 95% CI, 1.11 to 4.69; P=.02).

CONCLUSIONS: In a veterans population undergoing cardiac enzyme testing, CKTnI testing led to more ED discharges than CK testing alone but had no effect on inpatient care and was associated with more echocardiograms in a follow-up period.

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Authors and Affiliations

  1. Philadelphia VA Medical Center and the Division of General Internal Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA

    Michael Berkwits MD, MSCE

  2. Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA

    A. Russell Localio JD, MS & Stephen E. Kimmel MD, MSCE

  3. Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

    Stephen E. Kimmel MD, MSCE

Authors
  1. Michael Berkwits MD, MSCE
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  2. A. Russell Localio JD, MS
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  3. Stephen E. Kimmel MD, MSCE
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Corresponding author

Correspondence to Michael Berkwits MD, MSCE.

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The authors report no conflicts of interest that could have affected the conduct of the trial, or that compromise the reporting or interpretation of its results.

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Berkwits, M., Localio, A.R. & Kimmel, S.E. The effect of cardiac troponin testing on clinical care in a veterans population. J GEN INTERN MED 20, 584–592 (2005). https://doi.org/10.1111/j.1525-1497.2005.0111.x

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  • DOI: https://doi.org/10.1111/j.1525-1497.2005.0111.x

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