Critical Evaluation of patients sent home from the emergency department with elevated troponin T levels

Abstract

Critical evaluation of patients sent home from the emergency department with elevated troponin T levels Master thesis, Programme in Medicine, 2017 Soza Zangana Supervisor: Ola Hammarsten Department of Clinical Chemistry and Transfusion medicine, Institute of biomedicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden Background The diagnostics of acute myocardial infarction (AMI) is often based on symptoms such as chest pain and dyspnea in combination with an electrocardiogram (ECG) and blood samples. When the ECG is inconclusive, the diagnostics of AMI is often dependent on significant short time change in levels of high sensitive cardiac troponin T (hs-cTnT), indicating acute myocardial injury. But, if the event of the AMI occurred a few days before attendance to the emergency department (ED), the short time dynamic often required for the diagnosis would not be present, and the patient would have a stable troponin elevation above the cut off limit 14 ng/L. The hypothesis in this trial is that a follow up sample at least 10 days later might reveal a long time troponin dynamic, indicating that the patient did in fact have an AMI. Aims The aim is to get an overview on the medical history of the patients that are sent home from the ED with a stable troponin elevation. The aim is also to investigate whether there is a long time troponin dynamic that we are missing at the ED. Methods Patients were enrolled from the emergency departments at Sahlgrenska University Hospital in Gothenburg. In total, 32 patients were included. Follow up samples of hs-cTnT were collected and a review of the patients’ medical records was done. A percental change in hs-cTnT more than +60% or -50% was considered pathological. Results The average age of these patients was 79 years. A percentage of 56.7% had a known ischemic cardiovascular disease, 28.1% had heart failure, 32.3% had an arrhythmia and 25.8% had chronic obstructive pulmonary disease (COPD). The patients had 2 or more severe diseases in 78.1% of the cases. The percental change in hs-cTnT in most of the patients were normal. Five patients had a pathological change, but they had other explanations for the acute troponin elevation at the ED, such as atrial flutter. Conclusions The results show that these patients are old and suffer from several co-morbidities. No long time troponin dynamic indicating a missed AMI was found. Even though this is a small study with few patients, it can still give the ED doctors a small insurance that they’re not missing myocardial infarctions at the ED with their current diagnostic routines.