Saturday, November 18, 2017

Appropriate and inappropriate use of troponin assays

The article offers a useful perspective on troponin testing but, if I’m not mistaken (correct me if I’m wrong) starts out with an error:

Troponin is a protein in striated muscle that regulates excitation and contraction, and consists of 3 molecules: C, I, and T. Troponin I and T are specific to cardiac tissue…

I’m pretty sure skeletal muscle has troponin I and T.

At any rate, the key point of the article is that in the old days of the early generation troponins, any elevation meant the patient was having an acute MI, usually due to acute coronary syndrome. Several generations (and sensitivity improvements) later that is no longer the case. The problem is, too many of us apparently interpret troponins the way we did in those good old days. This, as the author points out, can lead to problems such as knee jerk anticoagulation.

The remedy for this, according to the author, is to do a history and physical before ordering a troponin. That’s easier said than done in the crazy environment of hospital medicine where time is of the essence and we often have to utilize a shotgun approach to very sick patients. The reality is that troponin positivity has now become much more complex and requires considerable skill in applying the result to the prevailing clinical context.

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