Guidance

1 Recommendations

1 Recommendations

1.1 The following high-sensitivity troponin tests are recommended as options for the early rule out of non-ST-segment elevation myocardial infarction (NSTEMI) in people presenting to an emergency department with chest pain and suspected acute coronary syndrome:

  • Access High-Sensitivity Troponin I Assay

  • ADVIA Centaur High-Sensitivity Cardiac Troponin‑I Assay

  • Alinity High Sensitive Troponin‑I assay

  • ARCHITECT STAT High Sensitive Troponin‑I assay

  • Atellica IM High-Sensitivity Cardiac Troponin I Assay

  • Dimension Vista High-Sensitivity Cardiac Troponin I Assay

  • Dimension EXL High-Sensitivity Cardiac Troponin I Assay

  • Elecsys Troponin T-high sensitive assay

  • Elecsys Troponin T-high sensitive STAT assay

  • VIDAS High sensitive Troponin I assay

  • VITROS High Sensitivity Troponin I Assay.

1.2 The tests are recommended for use with different early rule-out test strategies alongside clinical judgement, including:

  • A single sample on presentation using a threshold at or near the limit of detection, which will vary depending on the assay being used. If this sample is positive it should not be used to rule in NSTEMI.

  • Multiple sample strategies, which typically include a sample at initial assessment followed by a second sample taken at 30 minutes to 3 hours (if clinically appropriate) and use of 99th percentile thresholds or thresholds at or near the limit of detection of the assay.

    Healthcare professionals should consider the likely time since the onset of symptoms when interpreting test results.

1.3 When NSTEMI is not ruled out using early rule-out test strategies, use NICE's guideline on recent-onset chest pain of suspected cardiac origin to help diagnose myocardial infarction, and consider using sex-specific thresholds at the 99th percentile (see section 4.7 and section 5.2).

1.4 Further research is recommended on the diagnostic performance of the TriageTrue High Sensitivity Troponin I test when using samples at point of care (see section 5.1).

Why the committee made these recommendations

When someone comes to a hospital emergency department with chest pain, tests are needed to work out if they're having a myocardial infarction (heart attack), and if so, what type it is and what treatment they need. Standard troponin tests take 10 to 12 hours, so people need to be admitted to hospital while they wait for the results.

High-sensitivity troponin tests can help to quickly rule out a type of heart attack called an NSTEMI. Doing these tests can mean people with normal troponin levels do not need to be admitted to hospital, and those with a confirmed NSTEMI can get earlier treatment.

Evidence shows that, of the high-sensitivity troponin tests, 9 are similarly effective in terms of diagnostic performance. Of these, 8 are also similarly cost effective compared with standard troponin tests in different early rule-out test strategies and so are recommended for use in the NHS.

There is only 1 diagnostic accuracy study for Elecsys STAT, and no diagnostic accuracy evidence for Alinity and Dimension EXL. But they use the same methods, principles and reagents as alternative versions of the tests that do have diagnostic accuracy evidence and were included in the economic model. The main difference is that they are run on different analysers. They are therefore also recommended.

Although the TriageTrue test has the potential to be cost effective, its diagnostic accuracy when used on whole blood is uncertain.