Use of Cardiac Biomarker Testing in the Emergency Department | Journal Scan

Makam AN, Nguyen OK.
JAMA Intern Med 2015;175:67-75.
The following are 12 points to remember about cardiac biomarker testing in the emergency department (ED):

1. Acute coronary syndrome (ACS) is a leading cause of death in the United States and accounts for 625,000 hospital discharges annually.

2. Cardiac biomarkers have emerged as a powerful tool to rapidly detect myocardial necrosis, which is a hallmark of ACS, but can also occur in various other illnesses.

3. Increasingly sensitive assays for cardiac biomarkers have enabled their use in the ED for early diagnosis of ACS, critical to the timely initiation of potentially life-saving evidence-based therapies.

4. A national study, however, identified high rates of cardiac biomarker testing even among individuals without clinical presentations suggestive of ACS.

5. Furthermore, biomarker testing was highly prevalent during visits with a high volume of other tests or services rendered during the visit independent of the clinical presentation.

6. There are a multitude of potential reasons for high-volume testing, including diagnostic uncertainty, defensive medicine, fee-for-service payment models, time pressure, perceived patient reassurance, and practice culture.

7. The high rate of testing among individuals with low suspicion of ACS is concerning because of the potential increase in health care costs and downstream harms owing to false-positive results.

8. Potential consequences of unwarranted biomarker testing include patient anxiety, diagnostic red herrings, unnecessary cardiology consultations, and inappropriate subsequent testing and treatment.

9. These potential harms owing to false-positive results are more likely to affect subsequently hospitalized patients because individuals with abnormal biomarker test results are more likely to be hospitalized.

10. More attention is needed to better characterize these harms and to develop strategies for targeted and appropriate use of cardiac biomarkers in the ED setting.

11. The high rates of testing in a population without suspicion of ACS are even more concerning in the context of the impending adoption of highly sensitive cardiac biomarker assays in the United States, which yield more false-positive test results.

12. Further research is needed to examine the false-positive testing burden and subsequent testing, consultations, and treatment that may follow.
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