Should an elderly woman with uncontrolled hypertension, a three‑month lapse in antihypertensive and levothyroxine therapy, and remote anterior and inferior Q‑wave myocardial infarctions but no chest pain or other acute cardiac symptoms be taken to the emergency department solely for troponin testing?

Should She Be Seen in ED for Troponin Testing?

No, this elderly woman does not require emergency department evaluation solely for troponin testing in the absence of acute cardiac symptoms. 1

Clinical Context Assessment

This patient presents with:

• No chest pain or acute cardiac symptoms (the critical determining factor)
• Uncontrolled hypertension from medication non-adherence
• Remote (old) myocardial infarctions with Q-waves on ECG
• Three-month lapse in antihypertensive and thyroid therapy

The absence of acute ischemic symptoms is the key decision point. Current guidelines reserve troponin testing for patients with symptoms suggestive of acute coronary syndrome, not for asymptomatic screening even in high-risk patients. 1

Guideline-Based Decision Algorithm

When ED Troponin Testing IS Indicated:

• Active chest pain or anginal equivalent symptoms (dyspnea, diaphoresis, nausea with exertional pattern) 1
• Symptoms occurring within the preceding 24 hours 2
• Ischemic ECG changes (ST-segment depression ≥0.05 mV, transient ST elevation, new T-wave inversions) 1
• Hemodynamic instability (hypotension, tachycardia, new heart failure) 1
• New arrhythmias or syncope 1

When ED Troponin Testing IS NOT Indicated:

• Asymptomatic patients, regardless of cardiac risk factors 2, 3
• Remote symptoms that resolved >24 hours ago without high-risk features 1, 2
• Routine screening in patients with known coronary disease 1

Appropriate Management Strategy

For this asymptomatic patient, the correct approach is:

1. Urgent outpatient follow-up within 1-2 weeks to restart antihypertensive and levothyroxine therapy 1

2. Blood pressure control is the immediate priority, as uncontrolled hypertension poses ongoing cardiovascular risk 1

3. If outpatient follow-up cannot be arranged within 1-2 weeks, consider observation or further testing, but this is for medication management, not troponin assessment 1

4. A single troponin test in primary care could be considered only if symptoms occurred >12 hours ago and the patient remains asymptomatic with no high-risk features, but this requires systems for immediate result notification and action 2, 3

Critical Pitfalls to Avoid

Do not order troponin testing "just to be safe" in asymptomatic patients. This leads to:

• False-positive results requiring unnecessary hospitalization 4, 3
• Inappropriate resource utilization (23.4% of ED troponin tests are inappropriate) 4
• Delayed management of the actual problem (medication non-adherence) 2

Troponin elevation without acute symptoms often reflects chronic conditions (hypertensive heart disease, chronic kidney disease, old infarction) rather than acute coronary syndrome, and does not change management in asymptomatic patients. 1, 5

When to Reconsider ED Evaluation

Send this patient to the ED immediately if she develops:

• New chest pain, pressure, or anginal equivalent symptoms 1
• Severe hypertension with end-organ symptoms (headache, visual changes, dyspnea suggesting hypertensive emergency) 1
• Syncope or presyncope 1
• New dyspnea at rest 1

The presence of remote Q-wave infarctions and current medication non-adherence makes her high-risk for future events, but this warrants aggressive outpatient risk factor modification, not ED troponin screening. 1