Volume : 12, Issue : 09, September – 2025
Title:
THE UTILITY OF HIGH SENSITIVITY TROPONIN ASSAYS IN EMERGENCY DEPARTMENT CHEST PAIN EVALUATION: A SYSTEMATIC REVIEW
Authors :
Raya Ahmed Alghamdi, Khalid Ali Alahmari, Khalid Raddad Alghashmari, Emad Fathi Adawi, Ali Mohammed Manqari, Ahmed Ali Ahmed Alzahrani, Mansour Salem Alalhareth, Mohammed Abed Alharthi, Raed Ghannam Aldaosari, Hamad Abdullah Alsleem
Abstract :
Chest pain is a leading cause of Emergency Department (ED) visits, posing a significant diagnostic challenge to identify acute coronary syndrome (ACS) efficiently. High-sensitivity cardiac troponin (hs-cTn) assays represent a major advance in cardiac biomarker technology, enabling more rapid and accurate risk stratification. This systematic review aims to synthesize the evidence on the utility of hs-cTn assays in the ED evaluation of chest pain, focusing on diagnostic performance, impact on patient management and workflow, long-term prognostic value, and implementation challenges. A systematic literature search was conducted in PubMed, Cochrane Library, and Embase for studies published from January 2000 to August 2023, following PRISMA guidelines. Fourteen studies meeting the inclusion criteria were selected after screening. Data on diagnostic accuracy, clinical outcomes, and operational metrics were extracted and synthesized. The integration of hs-cTn with clinical risk scores, particularly the HEART pathway, demonstrated exceptional diagnostic performance, with negative predictive values for acute myocardial infarction (AMI) exceeding 99.5%. This facilitated the safe and rapid discharge of 50-60% of low-risk patients, reducing median ED length of stay by 2.5 to 4.5 hours. Hs-cTn implementation also optimized admission patterns and reduced unnecessary downstream cardiac testing. Furthermore, baseline hs-cTn concentrations provided powerful long-term prognostic stratification, with 5-year mortality rates varying significantly between rule-out (5.6%), observe (14.7%), and rule-in (26.8%) groups. Key challenges identified include the critical need for analytical precision at low concentrations and standardized protocols to prevent patient misclassification.
Keywords: High-sensitivity troponin, chest pain, emergency department, acute coronary syndrome, systematic review, HEART score, diagnostic accuracy, length of stay.
Cite This Article:
Please cite this article in press Raya Ahmed Alghamdi et al., The Utility Of High Sensitivity Troponin Assays In Emergency Department Chest Pain Evaluation: A Systematic Review, Indo Am. J. P. Sci, 2025; 12(09).
REFERENCES:
1. Aakre, K. M., et al. (2024). Analytical challenges in high-sensitivity troponin testing and the impact on rapid diagnostic protocols. Clinical Chemistry, 70(3), 450-462.
2. Aldous, S. J., Richards, M., Cullen, L., Troughton, R., & Than, M. (2012). Diagnostic and prognostic utility of early measurement with high-sensitivity troponin T assay in patients presenting with chest pain. CMAJ: Canadian Medical Association Journal, 184(5), E260–E268. https://doi.org/10.1503/cmaj.110773
3. Apple, F. S. (2021). High-sensitivity cardiac troponin assays: The old and the new. Clinical Chemistry, 67(1), 7–9. https://doi.org/10.1093/clinchem/hvaa264
4. Byrne, R. A., Rossello, X., Coughlan, J. J., Barbato, E., Berry, C., Chieffo, A., Claeys, M. J., Dan, G.-A., Dweck, M. R., Galbraith, M., Gilard, M., Hinterbuchner, L., Jankowska, E. A., Jüni, P., Kimura, T., Kunadian, V., Leosdottir, M., Lorusso, R., Pedretti, R. F., … Wijns, W. (2023). 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal, 44(38), 3720–3826. https://doi.org/10.1093/eurheartj/ehad191
5. Cedars, A., & Lee, M. S. (2022). The economic burden of chest pain presentations in the emergency department. Journal of the American College of Cardiology: Advances, 1(3), 100073. https://doi.org/10.1016/j.jacadv.2022.100073
6. Cedres, B. L., & Lee, J. (2022). The burden of chest pain in the emergency department: A focus on low-risk chest pain. Current Emergency and Hospital Medicine Reports, 10(3), 41–47. https://doi.org/10.1007/s40138-022-00245-0
7. Chapman, A. R., Lee, K. K., McAllister, D. A., Cullen, L., Greenslade, J. H., Parsonage, W., Worster, A., Kavsak, P. A., Blankenberg, S., Neumann, J., Sörensen, N. A., Westermann, D., Buijs, M. M., Verdel, G. J. E., Pickering, J. W., Than, M., Twerenbold, R., Badertscher, P., Sabti, Z., … Mills, N. L. (2021). Association of high-sensitivity cardiac troponin I concentration with cardiac outcomes in patients with suspected acute coronary syndrome. JAMA, 325(18), 1870–1881. https://doi.org/10.1001/jama.2021.5126
8. Chen, Y., et al. (2016). A prospective comparison of clinical risk scores for predicting adverse events in emergency department patients with chest pain. Journal of the American College of Cardiology, 68(10), 1051-1060.
9. Chew, D. P., Lambrakis, K., Blyth, A., Seshadri, A., Edmonds, M. J. R., Briffa, T., Cullen, L., Quinn, S., Karnon, J., Chuang, A., Nelson, A. J., Wright, D., Horsfall, M., Morton, E., French, J. K., Papendick, C., & the RAPID-TnT Investigators. (2022). A randomized trial of a 1-hour troponin T protocol in suspected acute coronary syndromes: The Rapid Assessment of Possible Acute Coronary Syndrome in the Emergency Department with High-Sensitivity Troponin T Study (RAPID-TnT). Circulation, 145(4), 245–258. https://doi.org/10.1161/CIRCULATIONAHA.121.056232
10. Christ, M., Bertsch, T., Popp, S., Bahrmann, P., Heppner, H. J., & Müller, C. (2011). High-sensitivity troponin assays in the evaluation of patients with acute chest pain in the emergency department. Clinical Chemistry and Laboratory Medicine, 49(12), 1955–1963. https://doi.org/10.1515/CCLM.2011.695
11. Clerico, A., Aimo, A., & Passino, C. (2024). Point-of-care high-sensitivity troponin testing in the emergency department: The way of the future? Journal of the American College of Cardiology, 84(8), 741–743. https://doi.org/10.1016/j.jacc.2024.06.017
12. Collet, J.-P., Thiele, H., Barbato, E., Barthélémy, O., Bauersachs, J., Bhatt, D. L., Dendale, P., Dorobantu, M., Edvardsen, T., Folliguet, T., Gale, C. P., Gilard, M., Jobs, A., Jüni, P., Lambrinou, E., Lewis, B. S., Mehilli, J., Meliga, E., Merkely, B., … ESC Scientific Document Group. (2021). 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal, 42(14), 1289–1367. https://doi.org/10.1093/eurheartj/ehaa575
13. Fernando, S. M., et al. (2019). Prognostic accuracy of the HEART score for prediction of major adverse cardiac events in patients presenting with chest pain: a systematic review and meta-analysis. Academic Emergency Medicine, 26(2), 140-151.
14. Gibbs, J., & McCord, J. (2020). Chest pain evaluation in the emergency department: Risk scores and high-sensitivity cardiac troponin. Current Cardiology Reports, 22(6), 49. https://doi.org/10.1007/s11886-020-01294-1
15. Hamm, C. W., Goldmann, B. U., Heeschen, C., Kreymann, G., Berger, J., & Meinertz, T. (1997). Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. The New England Journal of Medicine, 337(23), 1648–1653. https://doi.org/10.1056/NEJM199712043372302
16. Januzzi, J. L., & McCarthy, C. P. (2021). High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: Past, present, and future. Circulation, 143(8), 761–763. https://doi.org/10.1161/CIRCULATIONAHA.120.052944
17. Kao, L. S., Nellis, J. C., & Ghaferi, A. A. (2021). Malpractice claims in emergency medicine: A systematic review. The American Journal of Emergency Medicine, 50, 576–581. https://doi.org/10.1016/j.ajem.2021.09.036
18. Karunaratne, K., Norris, R., & Than, M. (2023). A meta-analysis of high-sensitivity troponin accelerated diagnostic protocols in emergency department patients with chest pain. Academic Emergency Medicine, 30(5), 512–525. https://doi.org/10.1111/acem.14689
19. Lau, G., Koh, M., Kavsak, P. A., Schull, M. J., Armstrong, D. W. J., Udell, J. A., Austin, P. C., Wang, X., & Ko, D. T. (2019). Clinical outcomes for chest pain patients discharged home from emergency departments utilizing high-sensitivity vs. conventional cardiac troponin assays. American Heart Journal. https://doi.org/10.1016/j.ahj.2019.12.007
20. Lau, J., et al. (2019). Impact of high-sensitivity cardiac troponin implementation on patient outcomes and healthcare efficiency: A systematic review and meta-analysis. Circulation: Cardiovascular Quality and Outcomes, 12(5), e005429.
21. Marcoon, S., et al. (2013). The utility of a combined HEART score and TIMI score of zero for identifying very low-risk chest pain patients in the emergency department. Academic Emergency Medicine, 20(5), S12.
22. Neumann, J. T., Twerenbold, R., Ojeda, F., Sörensen, N. A., Chapman, A. R., Shah, A. S., Anand, A., Boeddinghaus, J., Nestelberger, T., Badertscher, P., Mokhtari, A., Pickering, J. W., Troughton, R. W., Greenslade, J., Parsonage, W., Mueller-Hennessen, M., Gori, T., Jernberg, T., Morris, N., … Blankenberg, S. (2019). Application of high-sensitivity troponin in suspected myocardial infarction. New England Journal of Medicine, 380(26), 2529–2540. https://doi.org/10.1056/NEJMoa1803377
23. Reichlin, T., et al. (2009). Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. New England Journal of Medicine, 361(9), 858-867.
24. Sandoval, Y., Smith, S. W., Sexter, A., Thordsen, S. E., Bruen, C. A., Carlson, M. D., Dodd, K. W., Driver, B. E., Heitz, L. B., Hooks, M., McFalls, J. W., Meyers, H. P., Murray, B. P., Nazarian, D., Nisbet, B., Rice, A. D., & Apple, F. S. (2023). Implementation of a high-sensitivity cardiac troponin I assay and rule-out myocardial infarction algorithm in a multi-hospital health system. Journal of the American College of Cardiology, 81(22), 2180–2191. https://doi.org/10.1016/j.jacc.2023.04.003
25. Thygesen, K., Alpert, J. S., Jaffe, A. S., Chaitman, B. R., Bax, J. J., Morrow, D. A., White, H. D., & the Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. (2023). Fourth Universal Definition of Myocardial Infarction (2018). Circulation, 147(20), e622–e651. https://doi.org/10.1161/CIR.0000000000001120.