Eliminating CK-MB Testing in Suspected ACS

Alvin MD, Jaffe AS, Ziegelstein RC, Trost JC.
Eliminating Creatine Kinase–Myocardial Band Testing in Suspected Acute Coronary Syndrome: A Value-Based Quality Improvement. JAMA Intern Med 2017;Aug 14:[Epub ahead of print].

The following are key points to remember about eliminating creatine kinase–myocardial band (CK-MB) testing in suspected acute coronary syndrome (ACS):

  1. Cardiac biomarker testing occurs in nearly 30 million emergency department visits nationwide each year in the United States.
  2. The American College of Cardiology/European Society of Cardiology indicate that cardiac troponin (cTn) is the biomarker of choice owing to its nearly absolute myocardial tissue specificity and high clinical sensitivity for myocardial injury.
  3. Multiple academic medical centers have implemented interventions to eliminate the routine ordering of CK-MB tests, with published patient safety outcomes data; however, CK-MB testing is still ordered in many hospitals and emergency departments.
  4. Although seemingly straightforward to articulate, there are significant barriers to implementation, and the biggest hurdle has been convincing physicians who have ordered CK-MB for years to change their practice.
  5. Hospital leadership should present the evidence supporting elimination of CK-MB and exclusive use of cTn to diagnose acute myocardial infarction, identify reinfarction, and estimate infarct size.
  6. Education may be provided through various venues, including lectures, pocket cards, online modules, social media demonstrations, and simulations.
  7. In addition, academic institutions must engage the house staff as members of the quality improvement team for an effective initiative.
  8. It is also important to inform physicians that CK-MB adds to the health care system financial burden without adding value to patient care.
  9. Hospital leaders need to partner with information technology and/or laboratory medicine staff to remove CK-MB from standardized ACS routine order sets. Doing this simple step alone has been shown to significantly reduce CK-MB ordering.
  10. Eliminating a simple laboratory test that provides no incremental value to patient care can lead to millions of health care dollars saved without adversely affecting patient care quality, and in this case potentially improving patient care.

Keywords: Academic Medical Centers, Acute Coronary Syndrome, Biomarkers, Creatine Kinase, MB Form, Emergency Service, Hospital, Myocardium, Myocardial Infarction, Patient Care, Patient Safety, Quality Improvement, Secondary Prevention, Troponin

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