From the Guidelines
For a patient presenting with chest pain and an elevated troponin of 92, a stress test is not the appropriate initial management. Instead, this patient should be treated as having an acute coronary syndrome (ACS) based on the elevated troponin level, which indicates myocardial injury has already occurred 1. The immediate steps should include:
- Obtaining an ECG to assess for any ischemic changes or arrhythmias
- Starting dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as ticagrelor, to reduce further clot formation
- Anticoagulation with heparin or enoxaparin to prevent further thrombosis
- Arranging for urgent cardiac catheterization to determine if there is an occlusive coronary lesion requiring intervention Additional medications should include:
- High-intensity statin therapy to reduce cholesterol levels and inflammation
- Beta-blockers if the patient is hemodynamically stable, to reduce myocardial oxygen demand
- Nitroglycerin for ongoing chest pain, to help reduce myocardial oxygen demand and improve blood flow Stress testing is contraindicated in the setting of an elevated troponin as it may precipitate further myocardial damage 1. Only after the acute event has resolved and if the patient has non-obstructive coronary disease might stress testing be considered for risk stratification, typically several weeks later, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. Key considerations in managing this patient include:
- The elevated troponin level indicates myocardial injury, and the goal is to prevent further damage through revascularization if indicated
- Cardiac catheterization will determine the need for intervention, such as angioplasty or stenting
- The patient should be closely monitored for any signs of further ischemia or complications, such as arrhythmias or heart failure.
From the Research
Elevated Troponin and Chest Pain
- Elevated troponin levels are highly specific for myocardial damage, but not every patient with elevated troponin levels has acute myocardial infarction (AMI) 2
- The clinical presentation and electrocardiogram of each patient must be taken into account when evaluating elevated troponin levels 2
- Elevated troponin levels can be found in numerous diseases, and a diagnostic dilemma can ensue in patients with persistently elevated troponin levels but normal ischemic work-up 3
Diagnostic Approach
- A practical approach to the diagnosis of myocardial infarction is discussed in the context of updated definitions of MI 4
- The measurement of serum troponin levels is a great diagnostic advance, but highly sensitive troponin assays can detect elevated troponin levels in the absence of MI 4
- Consideration of alternative diagnoses, such as Churg-Strauss syndrome, is important in patients with elevated troponin levels and eosinophilia 3
Treatment and Management
- The benefits and risks of adding clopidogrel to different doses of aspirin in the treatment of patients with acute coronary syndrome (ACS) are studied 5
- The optimal daily dose of aspirin may be between 75 and 100 mg, with or without clopidogrel, as bleeding risks increase with increasing aspirin dose without any increase in efficacy 5
- Aspirin and clopidogrel resistance are major concerns in the treatment of ACS, and further studies are needed to establish the mechanisms and management of platelet hyperactivity or antiplatelet drug biological resistance 6
Stress Test
- There is no direct evidence in the provided studies to suggest that a stress test should be ordered for a patient with elevated troponin levels and chest pain
- However, the clinical presentation and electrocardiogram of each patient must be taken into account when evaluating the need for further diagnostic testing, such as a stress test 2