From the Research
A low-risk workup for acute coronary syndrome (ACS) can be safely initiated with a single troponin test for patients deemed low risk, as it has been shown to have no significant difference in 30-day cardiac mortality and acute myocardial infarction rates compared to serial troponin testing. This approach is supported by a recent study published in the JAMA Network Open in 2021 1, which found that patients discharged after a single negative troponin test result had similar outcomes to those who underwent serial troponin tests. The study included 27,918 adult ED encounters and found no statistically significant difference in the primary outcome of acute myocardial infarction or cardiac mortality within 30 days between the two groups.
When evaluating patients with suspected ACS, it is essential to consider their individual risk factors and clinical presentation. The HEART score, which includes history, electrocardiogram, age, risk factors, and troponin, can be a useful tool in assessing a patient's risk level 1. For patients with a low HEART score and a single negative troponin test result, a low-risk workup can be initiated, which may include:
- A comprehensive history and physical examination
- Laboratory tests, such as complete blood count, comprehensive metabolic panel, and urinalysis
- Electrocardiogram (ECG) to evaluate for signs of ischemia or infarction
- Risk factor assessment, including family history, hypertension, diabetes, and hyperlipidemia
Additional testing, such as serial troponin tests, echocardiogram, or stress test, may be considered for patients with a higher HEART score or those who are deemed high risk. However, for low-risk patients, a single troponin test can be a safe and effective way to rule out ACS, allowing for earlier discharge and reducing the need for further testing and treatment. It is also important to note that the management of ACS involves a comprehensive approach, including the use of antiplatelet and anticoagulation therapy, as well as other medical therapies, such as statins, angiotensin-converting enzyme inhibitors, and beta blockers, as recommended by the FP essentials guidelines 2.