This brief article is well written and I agree the diagnostic label of 'troponin negative chest pain' is unhelpful. However the article repeats some common misconceptions which require correction.
Firstly, the article implies that the majority of patients attending hospital with chest pain have an acute coronary syndrome. This is absolutely not the case - in fact most patients with suspected acute coronary syndrome do not have it. (1) Often patients receive a label of acute coronary syndrome and this is later corrected by the cardiology registrar or consultant on call - although by then it may be too late to change the patient's perception that they have 'had a heart attack'.
Secondly, there appears to be a misunderstanding of the value of troponin testing. Troponin assays are positive when there has been myocardial necrosis. They do not give any information about the mechanism of myocardial necrosis - a positive troponin can indicate acute coronary syndrome, but may also occur in heart failure, prolonged arrhythmia, sepsis, pulmonary embolism and many other situations. (2)
Similarly, a negative troponin does not absolutely exclude a cardiac cause for symptoms - nor does it mean the patient is necessarily in a low risk group. (3) Patients with unstable angina, dynamic ECG changes, but negative troponin should be considered as having a similar risk of mortality and morbidity to those with a normal ECG but a positive troponin.
Troponin assays should generally be considered a prognostic, not a diagnostic test, and should be used in conjunction with the patients history and ECG - never alone.
1) Ekelund U. et al. Patients with suspected acute coronary syndrome in a university hospital emergency department: an observational study. BMC Emergency Medicine 2002, 2:1 doi:10.1186/1471-227X-2-1
2) Korff S. et al. Differential diagnosis of elevated troponins. Heart 2006;92:7 987-993 doi:10.1136/hrt.2005.071282
3) Curzen N. Troponin in patients with chest pain BMJ 2004;329:1357-1358 (11 December), doi:10.1136/bmj.329.7479.1357
Competing interests:
No competing interests
08 September 2013
Michael D Sosin
Consultant Cardiologist
Nottingham University Hospitals NHS Trust
Trent Cardiac Centre, City Hospital, Nottingham NG51PB
Rapid Response:
Re: “Troponin-negative chest pain”—a diagnostic evasion?
This brief article is well written and I agree the diagnostic label of 'troponin negative chest pain' is unhelpful. However the article repeats some common misconceptions which require correction.
Firstly, the article implies that the majority of patients attending hospital with chest pain have an acute coronary syndrome. This is absolutely not the case - in fact most patients with suspected acute coronary syndrome do not have it. (1) Often patients receive a label of acute coronary syndrome and this is later corrected by the cardiology registrar or consultant on call - although by then it may be too late to change the patient's perception that they have 'had a heart attack'.
Secondly, there appears to be a misunderstanding of the value of troponin testing. Troponin assays are positive when there has been myocardial necrosis. They do not give any information about the mechanism of myocardial necrosis - a positive troponin can indicate acute coronary syndrome, but may also occur in heart failure, prolonged arrhythmia, sepsis, pulmonary embolism and many other situations. (2)
Similarly, a negative troponin does not absolutely exclude a cardiac cause for symptoms - nor does it mean the patient is necessarily in a low risk group. (3) Patients with unstable angina, dynamic ECG changes, but negative troponin should be considered as having a similar risk of mortality and morbidity to those with a normal ECG but a positive troponin.
Troponin assays should generally be considered a prognostic, not a diagnostic test, and should be used in conjunction with the patients history and ECG - never alone.
1) Ekelund U. et al. Patients with suspected acute coronary syndrome in a university hospital emergency department: an observational study. BMC Emergency Medicine 2002, 2:1 doi:10.1186/1471-227X-2-1
2) Korff S. et al. Differential diagnosis of elevated troponins. Heart 2006;92:7 987-993 doi:10.1136/hrt.2005.071282
3) Curzen N. Troponin in patients with chest pain BMJ 2004;329:1357-1358 (11 December), doi:10.1136/bmj.329.7479.1357
Competing interests: No competing interests