Appropriateness of high-sensitivity troponin testing and adherence to chest pain pathways across emergency and acute care units at a UK teaching hospital

High-sensitivity troponin (hs-troponin) testing has enabled the rapid identification and management of acute coronary syndrome (ACS). However, inappropriate troponin testing in patients can lead to increased costs through prolonged waiting times and unnecessary further investigations and interventions.

To assess the appropriateness of hs-troponin requests and compliance with the new 0h/1h troponin and chest pain pathways, developed in line with ESC and NICE guidance, across the Emergency Department (ED), Same Day Emergency Care (SDEC), and Acute Medical Unit (AMU) at our teaching hospital.

A retrospective audit was conducted by randomly selecting 100 cases with a troponin request between 24 October and 24 November 2023. Patient hospital records were searched and reviewed for clinical presentation, ECG findings, timing and frequency of troponin requests, and subsequent cardiology involvement. Chest pain was categorised as cardiac, possibly cardiac, or non-cardiac, and ECGs were assessed for ischaemic changes.

Mean age was 63 ± 18 years (range 20–102); 56% were female. Most troponin requests (96%) originated in ED. Among patients with negative troponin results, 23% were referred to AMU and 27% to SDEC for further care. Chest pain was reported in 62% of cases, of which 42% were non-cardiac; 6% had ischaemic ECG changes. Among non-chest-pain presentations (38%), only 11% showed ischaemic changes. Common alternative presentations included dyspnoea (21%), palpitations (18%), and falls/syncope (18%).

Overall, 56% of initial troponin requests were deemed inappropriate, and 78% were made before physician review. The troponin pathway was correctly followed in 45% of cases. Serial testing occurred in 52%, with 10% of initial repeats unnecessary. Median time to repeat testing was 3 h 25 min (IQR 2 h 30 min–5 h); only 8% met the 1–2 h target. 31% of serial cases had more than one repeat, 88% of which were unnecessary.

An initial ECG was performed within 10 min of presentation in 22% (median 40 min, IQR 20 min–1 h 30 min), and 57% had a repeat ECG. Troponin testing led to cardiology referral in 27% and further investigations in 21%. ACS management was initiated in 10% of cases, while confirmed ACS occurred in 2%.

A large proportion of troponin requests were inappropriate, contributing to unnecessary further investigations and management. Compliance with the new troponin pathway and ECG performance was suboptimal, potentially delaying ACS diagnosis or discharge. Educational interventions, electronic decision-support tools, and revised order sets could improve adherence and efficiency. These findings highlight a broader challenge in the acute care setting and support implementation of guideline-aligned decision tools to optimise troponin testing. A re-audit is planned following pathway optimisation.