This document discusses diagnosing and treating acute coronary syndrome (ACS). It provides guidance on using troponin tests to evaluate patients with possible ACS, noting that troponin levels should not be interpreted alone and that even small increases above the cutoff can indicate heart issues. Symptom characteristics are unreliable indicators of ACS, and both the presence and absence of risk factors neither rule ACS in or out. Proper use and interpretation of troponin tests can help effectively diagnose and treat ACS.

1. THE HEART UNDER STRESS
# SMACCGOLD R ICK BODY IMAGE AT HT T P : / / FAV.ME /D4NZ 8 7 I B Y E THE LANI T E

2. HOW TO TREAT A BADLY STRESSED HEART
GOING TOO FAST? SHOCK IT!
GOING TOO SLOW? PACE IT!
INFARCTING? CATH IT!

3. IMAGE BY
PANTHERA-ME AT
HTTP://FAV.ME/
D3ELDZP
THE AIM OF THIS TALK IS TO DISCUSS..
THE LATEST EVIDENCE THAT WILL HELP YOU TO
MANAGE SUSPECTED ACS BETTER IN YOUR PRACTICE

4. QUESTION 1
WHEN SHOULD I SUSPECT ACS?

5. 45 YEAR OLD MAN
WITH 'INDIGESTION'

6. CHARACTER OF CHEST PAIN
IS A USELESS DIAGNOSTIC TEST
BASED ON BODY ET AL. RESUSCITA T I O N 2 0 1 0 ; 8 1 ( 3 ) : 2 8 1 - 6

7. THE PATTERN OF RADIAT I O N I S
USELESS TOO
BODY ET AL. RESUSCITA T I O N 2 0 1 0 ; 8 1 ( 3 ) : 2 8 1 - 6

8. IF YOUR PATIENT'S
SYMPTOMS ARE ATYPICAL...
ACS IS JUST AS
LIKELY A S I F T H E
SYMPTOMS WERE
TYPICAL!
GREENSLADE ET AL, ANN EMERG MED 2012; 60(6): 777-85

9. Excluding ACS because a patient has no risk factors is roughly as
clever as inserting a left sided chest drain with a trochar
SIMILARLY, HAVING 'LOTS OF RISK FACTORS' DOES *NOT*
RULE IN ACS!
% with AMI
26
19.5
13
6.5
0
0 1 2 3 4 or 5
Number of risk factors
21.3
13.6
19
24.1
12.2
BODY ET AL, RESUSCITA T I O N 2 0 0 8 ; 7 9 ( 1 ) : 4 1 - 5

10. SURE, SURE.
BUT WE'RE ALL GREAT
DIAGNOSTICIANS AT
SMACC GOLD!
IMAGE BY NELSON SANTOS, HTTP://
UPLOAD.WIKIMEDIA.ORG/WIKIPEDIA/COMMONS/
C/C8/DR._HOUSE_CARICATURE.JPG

11. IF YOU THINK HS-TROPONIN IS BAD, YOU SHOULD
SEE HOW NON-SPECIFIC *DOCTORS* ARE!
% with MACE
60
45
30
15
0
Def not Prob not Could be Prob is Def is
"Is this ACS?"
52.8
35.5
16.4
9.1 5.4
BODY ET AL (MEMC VII, 2013)

12. WITH PRASUGREL PRE-TREATMENT, 2.6% OF PATIENTS
HAD A MAJOR BLEED WITHIN A WEEK
OVER TREATMENT IS DANGEROUS
MONTALESCOT ET AL, NEJM 2013; 369(11): 999-1010

13. “One must be a professional
Ulysses in craft and wisdom not to
sometimes err in estimating the
nature of an attack of severe heart
pain”
–WILLIAM OSLER

14. HOW TO CURE 'TROPONINITIS'

15. YOU ONLY GET A 'NORMAL' TROPONIN IF THE
PATIENT'S CONDITION IS ALSO 'NORMAL '
Troponin T (ng/L)
40
30
20
10
0
'Normals' All comers
99th percentile subgroup
27.7
37.2
29.9
14.4
99th% Males Females
COLLINSON ET AL, CLIN CHEM 2012; 58(1): 219-25

16. IN CKD THE 'NORMAL RANGE' FOR HS-TROP T IS
UP TO 139NG/L
Troponin T (ng/L)
300
225
150
75
0
139
297
136
95TH
PERCENTILES
PLOTTED
52
CKD 3 CKD 4 CKD 5 All
CHOTIVANAWAN ET AL, J MED ASSOC THAI 2012; 95: SUPPL 2: S127-32

17. BUT. . .
THERE'S A GOOD
REASON WHY THE
CUT-OFF IS SO LOW!
<0.05
0.05-0.19
>0.2
Validation Implementation
21
24
0 10 20 30 40
% with death or AMI after a year
5
24
39
7
USED PROPERLY,
TROPONIN CAN SAVE LIVES
MILLS ET AL, JAMA 2011; 305(12): 1210-6

18. THE RISE AND FALL
OF TROPONIN

19. EVIDENCE-BASED PEARL:
NEVER RELY ON A
20% DELTA T O
RULE IN OR RULE OUT
AMI

20. WHICH PATIENT HAS A
MYOCARDIAL INFARCTION?
• Central chest pain
• No prior history
• Trop 1: 10ng/L
• Trop 2: 15ng/L
• Delta 50%
• ECG normal
• Nothing else going on
• Trop 1: 2000ng/L
• Trop 2: 2200ng/L
• Delta 10%

21. SO WHAT SHALL
WE DO?
• Keep it simple, silly!
• Trop 2 - Trop 1 = 'Absolute
delta'
• For trop T, a change >10ng/L
is significant

22. 70
45 YEAR OLD MAN
WITH 'INDIGESTION'
CKD 2 (eGFR 60)
LATERAL ST
DEPRESSION AND A
TROPONIN OF 55NG/L
(CUT-OFF 14NG/L)

23. "Police arrested two kids yesterday, one was drinking battery acid,
the other eating fireworks.
They charged one and let the other off”
–TOMMY COOPER, 1921 - 1984