A Critical Analysis of Troponin Testing for Patients with Pulmonary Embolism

The use of high-sensitivity cardiac troponin I (hs-cTnI) testing in the emergency room for patients with hemodynamically stable pulmonary embolism (PE) has been called into question by an exploratory analysis of the PROTECT cohort study. According to this study, mild elevations in hs-cTnI did not show any prognostic value for patients with PE, unlike conventional cardiac troponin I (cTnI) elevations which were associated with poor outcomes. This raises concerns about the widespread use of hs-cTnI for risk stratification in patients with PE. It is crucial to critically analyze the implications of these findings to ensure accurate risk assessment and appropriate patient management.

Despite the lack of proven clinical benefit, health systems have shifted towards favoring high-sensitivity tests over conventional ones. This preference extends not only to coronary artery disease and chest pain but also to other noncoronary conditions such as PE. Nevertheless, the study by Jiménez et al. challenges this approach by highlighting the potential misclassification of patients’ actual risk when hs-cTnI is used instead of cTnI. The study suggests that the falsely elevated risk identified with hs-cTnI can lead to unnecessary diagnostic tests and treatments, resulting in excess costs and treatment-related complications.

The study also raises concerns regarding the appropriate cutoff for hs-cTnI testing in patients with PE. Currently, European guidelines recommend using cardiac troponin levels for risk stratification but do not specify which assay type is preferred. However, the exploratory analysis suggests that a higher cutoff may be necessary to consider hs-cTnI results as clinically relevant for risk stratification. This further emphasizes the need for future research to determine optimal cutoffs and establish standardized guidelines.

While the study provides valuable insights into the limitations of hs-cTnI testing for patients with PE, it is essential to acknowledge its limitations. The analysis was based on a small patient sample with a relatively low number of events, which may limit the generalizability of the findings. Furthermore, the study did not propose alternative cutoffs for hs-cTnI testing, leaving this area open for further investigation. Refining the cutoff values and considering other biomarkers, such as NT-proBNP, could provide a more comprehensive risk assessment for patients with PE.

The Role of Comprehensive Patient Evaluation

The findings from the PROTECT cohort study emphasize the importance of interpreting and using biomarker results within the broader context of a comprehensive patient evaluation. Biomarkers alone should not be the sole basis for clinical decisions but should complement other clinical and diagnostic information. Incorporating patient history, symptoms, imaging studies, and other relevant factors is crucial to ensure accurate risk stratification and appropriate management.

The implications of this study’s findings for clinical practice are significant. Clinicians must exercise caution when relying solely on hs-cTnI testing for risk stratification in patients with stable PE. The potential for overestimating risk may result in unnecessary interventions, prolonged hospital stays, and increased resource utilization without improving patient outcomes. Until further evidence emerges, it may be prudent to consider both conventional cTnI and hs-cTnI results when assessing patients with PE to avoid misclassification and ensure appropriate risk stratification.

While the use of hs-cTnI testing has gained popularity in various clinical settings, its application in patients with PE remains uncertain. The exploratory analysis of the PROTECT cohort study by Jiménez et al. underscores the limitations and potential risks associated with relying solely on hs-cTnI for risk stratification. Further research is needed to establish optimal cutoff values, evaluate the specificity and sensitivity of hs-cTnI, and determine its role in combination with other biomarkers for accurate risk assessment in patients with PE. Until then, a comprehensive patient evaluation that incorporates clinical, diagnostic, and biomarker information remains essential for effective management and improved patient outcomes.

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