Emergency department triage of patients with acute chest pain:: definition of cardiac troponin I decisional value to manage patients without electrocardiographic evidence of ischemia

The aim of this study was to define the use of a new cardiac troponin I (cTnl) assay for emergency patients with chest pain and no specific electrocardiographic changes consistent with the presence of ischemia. Patients (n = 106) admitted in Emergency/Cardiology Departments for chest pain and suspicion of acute coronary syndrome (ACS) were randomized into two diagnosis groups (ACS or non-ACS) by two independent cardiologists. cTnl measurements were performed at admission, and 6 hours and 12 hours later with a new generation assay (Access AccuTnl, Beckman Coulter). Using an upper reference limit of 0.04 mug/l, 27 patients had a cTnl elevation not related to the final diagnosis of ischemia; the positive predictive value (PPV) was 67% with specificity 48%. The decisional value was re-defined and set at 0.16 mug/l, a concentration corresponding to the 99th percentile of the non-ACS patient group. Precision (coefficient of variation) was 8% at this level, PPV 97% and specificity 98%. This new decisional value is now used in our institution and could be included in standard care guidelines to improve the management of patients presenting chest pain in emergency departments.