High Sensitivity Troponins are RNG, prove me wrong.
Started by RustedFox
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Careful. Your post will cause your hsTrop to be high.
I would add the nuance that HS trop isnt fully random, but it takes a proper result like 0.1 and then adds to random numbers to it, and I’m not entirely sure these digits are significant.
0.1 —> 0.1 cool
0.128 —> 0.141 is this just the same thing or actual delta???
One of our sister hospitals was moving to Hs trop and asked a couple of us what we do with the mid-tier values that fall out of the “so low it’s not cardiac” zone but don’t enter “ oh this is ACS” zone. And they were disappointed to hear my answer which was it’s all vibes based! But it’s the honest truth. Pray they have an old trop that’s similar. Pray they have ckd you can blame it on. Get that delta and show it’s flat. 🤷♂️
0.1 —> 0.1 cool
0.128 —> 0.141 is this just the same thing or actual delta???
One of our sister hospitals was moving to Hs trop and asked a couple of us what we do with the mid-tier values that fall out of the “so low it’s not cardiac” zone but don’t enter “ oh this is ACS” zone. And they were disappointed to hear my answer which was it’s all vibes based! But it’s the honest truth. Pray they have an old trop that’s similar. Pray they have ckd you can blame it on. Get that delta and show it’s flat. 🤷♂️
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Our high-sensitivity troponin comes out in ng/L, and doesn't give us numbers after a decimal point. i.e. <6 is the lowest possible reading, and from there 7, 8, 9, 40, you get the idea.
We have an algorithm we generally adhere to with the expectation that we generally do at least one repeat unless HPI dictates otherwise. On the second troponin, a delta of <4 is considered insignificant, and you can stop there. Delta of 4 - 9 warrants a third troponin. 10 or greater and it's generally admit, call cardiology time.
Cardiac biomarkers of acute coronary syndrome: from history to high-sensitivity cardiac troponin - PubMed
This is the paper referenced to justify the algorithm.
We have an algorithm we generally adhere to with the expectation that we generally do at least one repeat unless HPI dictates otherwise. On the second troponin, a delta of <4 is considered insignificant, and you can stop there. Delta of 4 - 9 warrants a third troponin. 10 or greater and it's generally admit, call cardiology time.
Cardiac biomarkers of acute coronary syndrome: from history to high-sensitivity cardiac troponin - PubMed
This is the paper referenced to justify the algorithm.
now if only I could communicate with such succinct wisdom 😭
I love the "midwit meme" format so much. Bravo.
"Six-seven".
It becomes infinitely worse when 90+% of your patients are 900 years old and they all roll hsTnIs in the 30s and 40s all the damn time.
Meaningless numbers.
I get the same numbers every shift. Most people have priors to compare to. It’s really not a big deal. If you’re stuck, well there’s always obs.
I think BP is more of a RNG (I had to look that up because you're a gamer) than hsTrop.
Do you know how many lives would be saved, each year, if the BP machines in the ED randomly gave a BP between 110 and 150? Every single time?
About 28,310.
How much money would be saved?
$37,490,838.
STOP IT.
Yeah but even that sucks, especially when you have to use Meditech to look at anything that's older than a few weeks.
You know what IS helpful? Seeing a result that says: "Trop < 0.05" and being done with it.
Yesterday guy with every cardiac risk factor, classic crescendoing excertional angina story, doesn’t come in for 8hr and now feels fine.
Trop 65
Delta in one hour is 50
It’s grossly positive. Normal renal function. Prior result of 12 last year different visit. The delta (while negative) is also grossly positive.
Treated, admitted.
Admission note is “troponin grossly flat 62–>50”
🤯
Trop 65
Delta in one hour is 50
It’s grossly positive. Normal renal function. Prior result of 12 last year different visit. The delta (while negative) is also grossly positive.
Treated, admitted.
Admission note is “troponin grossly flat 62–>50”
🤯
Make Numbers Meaningful Again.
2+2=5
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Too late for the "good" Radiohead list.
It's not sensitive enough. I still have 50 year old ankle sprains that have negative hsTrops. More sensitive until we can get admit every 18 year old sore throat for an obs admission for NSTEMI and add minimum two hours to every visit. Probably easier than fixing our broken system about never missing a MI.
I find the inpatient people dont understand that a delta troponin goes both ways. A rapidly improving troponin is also (probably) bad.
Something I've blindly accepted by following the algorithm, but I don't think I've ever really understood why a falling troponin is that bad (i.e. from say 20 to 13).
It means whatever they just complained about was enough stress to the heart to cause a transient troponin rise, but the ischemic moment is over now and you're catching the downtrend back to whatever their real baseline value is. It's a case of "actual" ACS, the vague non-specific "it's not a heart attack but this dude does have pain from critically bad coronary arteries".
like when your toilet won't flush but then you wait a few min and then flush it later with great success?
But what’s the clinical significance of a minimally elevated troponin in this situation?
to massively oversimplify this (but still get it correct): HS Trop comes in four kinds
1) negative and its been enough time (usually more than 2 hours since onset, but its test specific)
2) negative and it hasnt been enough time so you have to repeat it in 1-2 hours (test specific)
3) oh **** thats clearly positive
4) anything thats abnormal but not "oh **** thats postive" CANNOT be interpreted by one troponin alone. It can't. It can only be understood in the context of the delta trop. Steady trop is often but not always a send home vs CT coronary arteries if you can do that, bad stories/high HEARTs stay. Rising trop is straight to the hospital. Dropping trop is also straight to the hospital unless you have a clear explanation like 6 hours of SVT that you converted in the ED.
edit: there is a secondary conversation that most of the ED docs I interact with are doing the H part of the HEART score totally wrong and it annoys me because its not really 'history' its 'associated classic-type symptoms' but the AEART score doesnt work as an acronym. But I see tons of people argue that H is subjective or that "everyone gets at least a 1 otherwise why would you even do it" and it just drives me nuts that they clearly havent read the heart score because its spelled out how to score that H value and its basically 'how many of these things do they have'. /rant
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would be cool to study. 30 day outcomes of those who *had* chest pain in the ED and have falling troponins. What is their 30 day outcome
You’re admitting troponins that start off minimally elevated but fall like in the example of going from 20 > 13? Seems like an unnecessary admission to the hospital. If they’ve got a good story then they’re already admitted before the 2nd troponin is back. If they don’t have a good story then they’re going home.
If they have a good story you're admitting them with just HEAR and not needing the T. So you're right here.
no no no my friend. The official stance of hsTrop (and who knows if we will agree that it is right 10 years from now) is that you are sending high risk people home who have inducible ischemia and would benefit from seeing a cardiology asap (though not emergently) if they had a 20 and dropped to a 13.
edit: I should add that I am the local cowboy who sends everyone home and isnt admitting nonsense... but I'm not on here defending when *I* break the rules. Which is a lot. I'm saying what the current literature says on this.
What do you do with people who go from <7 to 7?
My questioning isn’t necessarily directed at you because we send home “high risk” people all day with minimally elevated troponins because they’ve got previous troponins. My guess is that probably 80% of patients we see have previous troponins to compare it to.
So in that case <7 and 7 (assuming your numbers are like mine) are still all negative.
Delta troponin has no relevance of the numbers are in the normal range, even if the delta is big. Negative is negative (as long as it's more than 2 hours out from onset) and 7 remains negative even if it's a rise from 0. Unless the argument is the guy had the cardiac event IN the ER around the time the first test was drawn.
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Duuude .
I'm going to respond in long form to the HEART score item because you've absolutely bullseye'd it.
Respond later. I'm tired.
So many times I've had that discussion. In deliberately colorful terms .
I'm doing like five things at once so I can't confirm the quality of this next thing I'm going to write, so take it as what it is...
Open evidence says that a falling troponin in a person with a moderately or significantly high-risk story actually leads to a significantly higher 30-day mortality of about 12% as opposed to a rising Delta troponin with a 30-day mortality of 5%. They say that the difference in short-term mortality is not clinically significant, but suggests that a rising Delta trip out in has a trend towards a higher short-term mortality, but that a falling Delta troponin has a unambiguous and statistically significant trend towards increased 30-day mortality. They suggest that it's because, like I said earlier, a cardiac event that already occurred and the patient survived, but is likely in a a critical enough State that it will just occur again in the next 30 days and they may not survive the next episode.
They say that they primarily pulled this from a 2021 Aurora study and two other studies specifically about falling Delta troponin, but they didn't spell out what those two other studies were
IMO, a minimally falling delta (say 5 points) is underwhelming.
But I’ve had at least two 10-15 points falling deltas in patients with concerning stories (pain hours before coming in) that had real lesions that got a stent.
I just worry when someone sees 45–>31 and immediately says “ruled out! Done!”
Not so fast my friend.
But I’ve had at least two 10-15 points falling deltas in patients with concerning stories (pain hours before coming in) that had real lesions that got a stent.
I just worry when someone sees 45–>31 and immediately says “ruled out! Done!”
Not so fast my friend.
We enjoy the added clarity of POC Hs-Trops so we have BS like ADHF admitted to floor and then immediately transferred to CCU because the nurses saw the POC trop was 900 and the lab trop was 630 (run twenty minutes apart but drawn from same stick) so the patient was clearly having an NSTEMI.
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