Kyle Fortman, PA-C, MBA: Troponin and Heart Injury Risk Screening Recommendations

A conglomeration of 7 leading cardiovascular and thoracic medical organizations, including the American College of Cardiology (ACC) and American Heart Association (AHA), published a new guideline for the clinical evaluation and diagnosis of chest pain in patients in October 2021.¹

Chief among the recommendations set by the guideline authors was the evidence-based support for the primary use of high sensitivity troponin for the as a biomarker diagnosis of acute myocardial infarction (MI). The guideline also put emphasis on tailoring chest pain diagnostics with consideration the patients’ key demographics, including the history of disparate treatment response based on patients’ skin color, and the need to prioritize language in care response.²

During the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston, TX, this week, a session reflected on the now 3-year old guideline, as well as more recent updates to the recommendations. In an interview with HCPLive at AAPA 2024, session presenter Kyle Fortman, PA-C, MBA, director of the Marcus Heart Valve Center at Piedmont Healthcare, reviewed the status of real-world application of the recommendations.

Regarding the utility of high sensitivity cardiac troponin, Fortman said he observes a greater embrace of it as a primary diagnostic tool for acute MI—though the rollout may be hinder by higher cost demand.

“So some facilities, smaller entities may not be there yet, but there is a push that across United States, you will be left behind if you're not utilizing high sensitivity troponin,” Fortman said. “The negative predictive value is so high, it's in the 95% range. So, if we stick to the 99% confidence interval, we will not miss any MIs and that's the big push for the sensitivity—it's just so high.”

Indeed, Fortman believes any US-based hindrance to cardiac troponin testing adoption is primarily a resourcing issue. However, he believes there may be some issues with the functionality contrasted to the utilization observed in Europe prior to the tool reaching regulation in the US.

“Most of the base research and studies were in Europe, where the population expects different things,” Fortman explained. “They don't expect to have an answer to their question of 'what's causing my chest pain' before they leave. They're more willing to be discharged and come back after ruling out. And so, the medical legality of it's a little bit different in European countries than here.”

Fortman and colleagues posited whether, when identifying a patient with elevated troponin, would there be comfort in their being sent home if possible, similar to the practice assessed in Europe. He noted that practices like his were told to anticipate an approximate 20% increase in cardiology consults due to the testing adoption; that prediction proved generous.

“I would take that to mean we're utilizing it correctly and it's not increasing the need for things, but that we're at a sweet spot where we're identifying the right people and putting them either in the bucket to go home or continuing in the bucket to come into the hospital to get treated,” he said.

Fortman additionally reviewed some of the finer details from the 2021 guideline, including the recommendations around low-risk chest pain and best practices to foster shared decision making with the patients, as well as shifts in acute cardiovascular event nomenclature.

References

1. ^{Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in Circulation. 2021 Nov 30;144(22):e455] [published correction appears in Circulation. 2023 Dec 12;148(24):e281]. Circulation. 2021;144(22):e368-e454. doi:10.1161/CIR.0000000000001029}
2. ^{Iapoce C. New Clinical Guideline Focuses Solely on Chest Pain Evaluation, Diagnosis. HCPLive. Published October 28, 2021. https://www.hcplive.com/view/new-clinical-guideline-focuses-solely-chest-pain-evaluation-diagnosis}