Cost Containment: Use of
Troponin testing in the
Inpatient Wards Setting
Neal Kaushal, R2
DSR2, May 2013
Troponin Assay
 Used to detect elevated levels of Troponin I and
Troponin T in the blood, in order to differentiate
between unstable angina and myocardial injury in
patients with chest pain or acute coronary syndrome
 A serum test, when ordered can be returned in a matter
of less than a few hours
Diagnosis of Myocardial Infarction
 Detection of a rise and/or fall of cardiac biomarker
values (preferably cTn with at least one value above the
99th percentile upper reference limit) and with at least
one of the following:
 Symptoms of ischemia
 Development of pathologic Q waves in the ECG
 New or presumed new significant ST-segment-T wave (STT) changes or new left bundle branch block (LBBB)
 Identification of an intracoronary thrombus by angiography
or autopsy
 Imaging evidence of new loss of viable myocardium or a
new regional wall motion abnormality.
Other Conditions Which Can
Cause Elevated Troponin
 Critical illness, such as sepsis
 Severe GI bleed (mismatch between O2 supply and
myocardial demand)
 Chemotherapy agents (e.g. anthracyclines)
 Toxins and venoms
 Carbon Monoxide or Cynanide poisoning
Examining How Troponin is
Ordered at UCI on Presentation
 Study population: n=27 charts of patients admitted to
the inpatient ward service by the Emergency
Department
 Inclusion criteria: Patients admitted to the ward
services with any presenting complaint
 Exclusion criteria: Patients discharged from the ED after
initial labs and workup were obtained
Examining How Troponin is Ordered at UCI
on Presentation of Chest Pain
N=3
Chest pain,
test (+)
N=13
Chest pain,
test (-)
N=11
No Chest Pain
n=27
The Non-Chest Pain Admissions
 N=2: POSS NEW HEART FAILURE
 N=1: CELLULITIS
 N=2: ALTERED MENTAL STATUS
 N=3: SOB POSS PNA
 N=1: LOWER EXTREMITY SWELLING
 N=2: ACUTE KIDNEY INJURY
Cost of Troponin Testing
 Cost of a single Troponin Assay:
 $11.08
 In patients who were admitted with a chief complaint of
chest pain, all of these patients underwent “serial”
troponin assays, i.e. every 6-8 hours to rule out ACT
 Multiply this by every patient admitted for chest pain,
over the course of months or a year will be quite costly
Take Home Points
 Every test we run in the hospital costs money
 Many are easy to run. But we should always keep in
mind the indication and pre-test probability of the tests
that we order
 What may seem like an innocent test on one patient,
when multiplied over many patients can add up to a
costly sum!