High-sensitivity troponin tests for the early rule out of NSTEMI

NICE's guideline on chest pain of recent onset

Section 1.2.5: Use of biochemical markers for diagnosis of an acute coronary syndrome. National guidance provides assurance of the evidence base supporting the change in practice.

NICE's diagnostics guidance on high-sensitivity troponin tests for the early rule out of NSTEMI

National guidance provides assurance of the evidence base supporting the change in practice.

European Society of Cardiology guidelines on acute coronary syndromes in patients presenting without persistent ST-segment elevation (2015)

International guidance provides assurance of the evidence base supporting the change in practice.

The association for clinical biochemistry and laboratory medicine national audit (2019)

Indicates current practice and allows benchmarking.

International Federation of Clinical Chemistry and Laboratory Medicine's resources from the committee on clinical applications of cardiac biomarkers

Online resources and publications to support adoption of high-quality testing locally.

Hospital episodes statistics (HES) data for accident and emergency activity

Provides high-level data including the number of patients admitted for cardiac conditions. More detailed data would need HES data extraction.

NHS England's A&E attendances and emergency admissions

Includes data on the number of patients discharged, admitted or transferred within 4 hours of arrival. Could be used locally to identify a need to reduce emergency department waiting times.

Januzzi JL et al. (2019) Recommendations for Institutions Transitioning to High-Sensitivity Troponin Testing. Journal of the American College of Cardiology 73 (9): 1059–77

Provides prompts for sites to consider when planning adoption of an early rule-out protocol.

AHSN/Peninsula Collaboration for Health Operational Research and Development (PenCHORD) project – Cardiac troponin: diagnosing heart attacks in A&E

This project and associated report explores the potential impact on heart attack care pathways in the South West, if high-sensitivity troponin assays are implemented consistently. The content could be used for developing business cases locally and planning adoption.

Ambavane A et al. (2017) Economic evaluation of the one-hour rule-out and rule-in algorithm for acute myocardial infarction using the high-sensitivity cardiac troponin T assay in the emergency department. PLOS ONE 12(11): e0187662

May help support the development of a business case locally.

Thygesen K, Alpert JS, Jaffe AS et al. (2019) Fourth universal definition of myocardial infarction (2018) European Heart Journal 40 (3): 237–269

Provides information and details about diagnosing myocardial infarction, which will be useful to teams developing clinical protocols.

Wu AHB, Christenson RH, Greene DN et al. (2018) Clinical Laboratory Practice Recommendations for the Use of Cardiac Troponin in Acute Coronary Syndrome: Expert Opinion from the Academy of the American Association for Clinical Chemistry and the Task Force on Clinical Applications of Cardiac Bio-Markers of the International Federation of Clinical Chemistry and Laboratory Medicine. Clinical Chemistry 64 (4): 645–655

Focuses on clinical laboratory practice recommendations for high-sensitivity troponin assays.

Risk scores:

Emergency Department Assessment of Chest Pain score (EDACS)

GRACE score

GRACE 2

HEART score

TIMI risk score

T-MACS

These are not being presented as validated or approved tools. These are scoring systems contributors referred to during the development of this resource. Users should be aware of the risks and benefits of each tool as a prognostic stratification tool, to understand how the result can be used in clinical practice. The choice of tool should be considered in the context of the high-sensitivity troponin assay in use.