Keywords
emergency department
acute coronary syndrome
myocardial infarction
point-of-care testing
serial measurement
chronic kidney disease
How to Cite
Abstract
Recent advances in emergency department (ED) assessment of suspected acute coronary syndrome (ACS) have been driven by the use of high-sensitivity cardiac troponin (hs-cTn) assays, which allow detection of myocardial injury at levels below the analytical detection limit of traditional cardiac troponin assays, and facilitate rapid diagnostic pathways. The value of these is, however, not to be judged based on the concentration of the biomarkers alone, but integrated with symptoms, electrocardiography (ECG), time of presentation, assay-specific thresholds, and serial change. This narrative review brings together literature provided by the authors regarding the evolution of hs-cTn assays, single-sample vs serial testing, point-of-care testing, sex-related differences, chronic kidney disease (CKD), hemodialysis, coronary CT angiography (CCTA), and risk stratification. We propose a pragmatic conceptual model in which hs-cTn helps with the rule-out, rule-in and observation decision-making process, but is not used as a standalone diagnosis of type 1 myocardial infarction (MI). Specific focus is placed on analytical and clinical constraints such as non-ACS elevations, inter-assay non-interchangeability, and uncertain generalizability of pathways to populations. Future directions include, but are not limited to, personalized interpretations, evidence-based incorporation of biomarker and anatomical imaging (with the support of artificial intelligence (AI) tools). Overall, it is concluded that when used as part of a structured clinical pathway, hs-cTn enhances the efficiency and sensitivity of diagnosis and should not be used in place of clinical reasoning or evidence of myocardial ischemia.
References
1. Apple FS, Smith SW, Greenslade JH, Sandoval Y, Parsonage W, Ranasinghe I, et al; SAMIE Investigators. Single high-sensitivity point-of-care whole-blood cardiac troponin I measurement to rule out acute myocardial infarction at low risk. Circulation. 2022;146(25):1918-29. doi:10.1161/CIRCULATIONAHA.122.061148.
2. Kavsak PA, Hewitt MK, Mondoux SE, Cerasuolo JO, Ma J, Clayton N, et al. Diagnostic performance of serial high-sensitivity cardiac troponin measurements in the emergency setting. J Cardiovasc Dev Dis. 2021;8(8):97. doi:10.3390/jcdd8080097.
3. Chapman AR, Lee KK, McAllister DA, Cullen L, Greenslade JH, Parsonage W, et al. Association of high-sensitivity cardiac troponin I concentration with cardiac outcomes in patients with suspected acute coronary syndrome. JAMA. 2017;318(19):1913-24. doi:10.1001/jama.2017.17488.
4. Fabre-Estremera B, Smith SW, Sandoval Y, Schulz K, Okeson B, Cullen L, Apple FS. Rapid rule-out of myocardial infarction using a single high-sensitivity cardiac troponin I measurement strategy at presentation to the emergency department: the SAFETY study. Clin Chem. 2023;69(6):627-36. doi:10.1093/clinchem/hvad033.
5. Chuang AM, Nguyen MT, Kung WM, Lehman S, Chew DP. High-sensitivity troponin in chronic kidney disease: considerations in myocardial infarction and beyond. Rev Cardiovasc Med. 2020;21(2):191-203. doi:10.31083/j.rcm.2020.02.17.
6. Dalal JJ, Ponde CK, Pinto B, Srinivas CN, Thomas J, Modi SK, et al. Time to shift from contemporary to high-sensitivity cardiac troponin in diagnosis of acute coronary syndromes. Indian Heart J. 2016;68(6):851-5. doi:10.1016/j.ihj.2016.03.013.
7. Ramos HR, López LE, Quiroga Castro W, Serra CMJ. High-sensitivity cardiac troponins: sex-specific values in clinical practice. Precision or confusion? Hellenic J Cardiol. 2019;60(3):171-7. doi:10.1016/j.hjc.2019.02.005.
8. Yang S, Manjunath L, Willemink MJ, Nieman K. The role of coronary CT angiography for acute chest pain in the era of high-sensitivity troponins. J Cardiovasc Comput Tomogr. 2019;13(5):267-73. doi:10.1016/j.jcct.2019.05.007.
9. Perrone MA, Storti S, Salvadori S, Pecori A, Bernardini S, Romeo F, et al. Cardiac troponins: are there any differences between T and I? J Cardiovasc Med (Hagerstown). 2021;22(11):797-805. doi:10.2459/JCM.0000000000001155.
10. Hunderup MM, Kampmann JD, Kristensen FB, Hafsund M. The short-term effect of hemodialysis on the level of high-sensitive cardiac troponin T: a systematic review. Semin Dial. 2024;37(2):110-1. doi:10.1111/sdi.13178.
11. Chaulin AM. False-positive causes in serum cardiac troponin levels. J Clin Med Res. 2022;14(2):80-7. doi:10.14740/jocmr4664.
12. Geladari EV, Vallianou NG, Evangelopoulos A, Koufopoulos P, Panagopoulos F, Margellou E, et al. Cardiac troponin levels in patients with chronic kidney disease: markers of high risk or just noise? Diagnostics (Basel). 2024;14(20):2316. doi:10.3390/diagnostics14202316.
13. Lee MMY, Masri A. Differentiating cardiac troponin levels during cardiac myosin inhibition or cardiac myosin activation treatments: drug effect or the canary in the coal mine? Curr Heart Fail Rep. 2023;20(6):504-18. doi:10.1007/s11897-023-00620-2.
14. Garg P, Morris P, Fazlanie AL, Vijayan S, Dancso B, Dastidar AG, et al. Cardiac biomarkers of acute coronary syndrome: from history to high-sensitivity cardiac troponin. Intern Emerg Med. 2017;12(2):147-55. doi:10.1007/s11739-017-1612-1.
15. Blanc L, Vaissaire A, Renard N, Vargmo C, Størvold GL, Bouhadef A, Claret PG. Analytical and clinical performance of high-sensitivity cardiac troponin point-of-care assays as an aid in the diagnosis of myocardial infarction: a narrative review. Emerg Med Int. 2025;2025:5717892. doi:10.1155/emmi/5717892.
16. McDermott M, Kimenai DM, Anand A, Huang Z, Houston A, Williams S, et al; HDRUK Regional Linked Data Driven Evidence Network. Adoption of high-sensitivity cardiac troponin for risk stratification of patients with suspected myocardial infarction: a multicentre cohort study. Lancet Reg Health Eur. 2024;43:100960. doi:10.1016/j.lanepe.2024.100960.
17. Westwood ME, Armstrong N, Worthy G, Fayter D, Ramaekers BLT, Grimm S, et al. Optimizing the use of high-sensitivity troponin assays for the early rule-out of myocardial infarction in patients presenting with chest pain: a systematic review. Clin Chem. 2021;67(1):237-44. doi:10.1093/clinchem/hvaa280.
18. Shah AS, Griffiths M, Lee KK, McAllister DA, Hunter AL, Ferry AV, et al. High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study. BMJ. 2015;350:g7873. doi:10.1136/bmj.g7873.
19. Maayah M, Grubman S, Allen S, Ye Z, Park DY, Vemmou E, et al. Clinical interpretation of serum troponin in the era of high-sensitivity testing. Diagnostics (Basel). 2024;14(5):503. doi:10.3390/diagnostics14050503.
20. Capodifoglio S, De Iuliis V. Diagnostic accuracy of point-of-care high-sensitivity troponin algorithms for emergency department rule-out and rule-in of acute myocardial infarction: a systematic review and meta-analysis. Emerg Med J. 2026. doi:10.1136/emermed-2026-215922.