Abstract
Christ and Bertsch 1 raised some thoughtful concerns regarding the need for not only diagnosis but also risk stratification in patients presenting to the emergency department with possible acute coronary syndrome (ACS). It is agreed that the overall goal in the management of patients is to improve outcomes in the short and long term. High-sensitivity troponin assays identify more patients with acute myocardial infarction (MI) as well as more patients with troponin elevations from other causes. 2,3 We also know that more patients at risk of future adverse events are identified, 4,5 and this is likely irrespective of the cause of the troponin elevation. Therefore, troponin in itself is a good risk stratification tool. However, troponin does not identify all patients at risk and therefore other risk stratification tools are also important.
There have been no randomized controlled studies to date proving that the use of high-sensitivity assays would improve outcomes compared with conventional assays. Studies have only shown that lowering the decision cut-off point, now that improved precision allows us to do so, improves outcomes. However, it would seem logical to hypothesize that as high-sensitivity troponins identify more patients at risk, more patients would be investigated and treated (for the underlying cause of the troponin elevation) which should, in turn, improve outcomes. In patients presenting with symptoms suggestive of ACS, the most likely cause of troponin elevation is acute MI, even when high-sensitivity assays are used. 3 Nevertheless, in addition to clinical evaluation, patients without significant dynamic changes in troponin over time may alert physicians to explore alternative causes of troponin elevation. Accurate diagnosis, by combining clinical assessment with investigation results, particularly troponin, is likely highly influential in patient outcome.
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