Acute chest pain in the high-sensitivity cardiac troponin era: A changing role for noninvasive imaging?

Am Heart J. 2016 Jul:177:102-11. doi: 10.1016/j.ahj.2016.03.025. Epub 2016 Apr 30.

Abstract

Management of patients with acute chest pain remains challenging. Cardiac biomarker testing reduces the likelihood of erroneously discharging patients with acute myocardial infarction (AMI). Despite normal contemporary troponins, physicians have still been reluctant to discharge patients without additional testing. Nowadays, the extremely high negative predictive value of current high-sensitivity cardiac troponin (hs-cTn) assays challenges this need. However, the decreased specificity of hs-cTn assays to diagnose AMI poses a new problem as noncoronary diseases (eg, pulmonary embolism, myocarditis, cardiomyopathies, hypertension, renal failure, etc) may also cause elevated hs-cTn levels. Subjecting patients with noncoronary diseases to unnecessary pharmacological therapy or invasive procedures must be prevented. Attempts to improve the positive predictive value to diagnose AMI by defining higher initial cutoff values or dynamic changes over time inherently lower the sensitivity of troponin assays. In this review, we anticipate a potential changing role of noninvasive imaging from ruling out myocardial disease when troponin values are normal toward characterizing myocardial disease when hs-cTn values are (mildly) abnormal.

Publication types

  • Review
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cardiomyopathies / blood
  • Cardiomyopathies / complications
  • Cardiomyopathies / diagnostic imaging
  • Chest Pain / blood
  • Chest Pain / diagnostic imaging*
  • Chest Pain / etiology
  • Computed Tomography Angiography
  • Coronary Angiography
  • Coronary Artery Disease / blood
  • Coronary Artery Disease / complications
  • Coronary Artery Disease / diagnostic imaging*
  • Diagnosis, Differential
  • Echocardiography, Stress
  • Exercise Test
  • Humans
  • Magnetic Resonance Imaging
  • Myocardial Infarction / blood
  • Myocardial Infarction / complications
  • Myocardial Infarction / diagnostic imaging*
  • Myocardial Perfusion Imaging
  • Myocarditis / blood
  • Myocarditis / complications
  • Myocarditis / diagnostic imaging
  • Pulmonary Embolism / blood
  • Pulmonary Embolism / complications
  • Pulmonary Embolism / diagnostic imaging
  • Sensitivity and Specificity
  • Tomography, Emission-Computed, Single-Photon
  • Troponin / blood*

Substances

  • Troponin