Admitting patients with isolated troponin elevation under the care of a cardiology team has been an issue widely debated amongst cardiologists, medical registrars and emergency department doctors. Many an occasion we have encountered patients at a very low level of coronary risk admitted to a monitored bed simply due to a “small troponin leak”. I would like to hear what my colleagues have to say on this issue.
Analysing the data from the Platelet IIb/IIIa Antagonism for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network (PARAGON) B troponin substudy, the Global Utilization of Strategies To Open Occluded Coronary Arteries (GUSTO) IIa troponin substudy, and the Chest Pain Evaluation by Creatine Kinase-MB, Myoglobin, and Troponin I (CHECKMATE) study , Rao et al. concluded that “for patients with high- and low-risk chest pain, baseline troponin elevation without CK-MB elevation was associated with increased risk for early and short-term adverse outcomes”. They suggested that these patients should be admitted to the hospital and monitored in either an coronary care or step-down unit.(Am J Cardiol. 2003 Apr 15;91(8):936-40).
How about the patients with isolated tropinin elevation without chest pain? This scenario makes the conundrum even more complex. In a retrospective comparative analysis of 183 patients (92 study group patients had troponin T >0.04 microg/L) Carlson et.al reported that “thirty-day (13.0% vs 4.4%; p = 0.032) and 1-year (33% vs 4.6%; p <0.001) mortality rates were significantly higher in the study group, whereas myocardial infarction, unstable angina, and revascularization were infrequent”. They concluded that patients with raised troponin even without associated chest pain fared worse with higher mortality rates. Thus they recommended “careful follow up” (Am J Cardiol. 2008 Sep 15;102(6):668-71. Epub 2008 Jun 26).
What ever the circumstance is a troponin elevation should not be ignored!
