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The use of delta troponin in the emergency department
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Pathology (2011), 43(S1)
PATHOLOGY 2011 ABSTRACT SUPPLEMENT
predictors of diabetes, diabetic retinopathy and CVD, whilst greater complexity of the retinal vasculature branching patterns were associated with diabetes. At a public health level, recent AusDiab analyses have been used to develop a simple non-invasive questionnaire to assess risk for developing diabetes and have estimated the annual costs of obesity in Australia to be $14.5 billion. ELEVATED TROPONIN IN THE ABSENCE OF ACUTE CORONARY SYNDROME – IMPACT OF TROPONIN ASSAY Hans G. Schneider Alfred Pathology Service, Melbourne, and Monash University, Melbourne, Vic, Australia Troponin is the main marker for the diagnosis of acute coronary syndrome (ACS). Increased use of the troponin assay in other settings shows many clinical situations with elevated levels. These elevations can be seen both inside and outside the emergency department. A difficult group of patients present with typical chest pain to the emergency department and have elevated troponin levels that are not caused by ACS. In this group belong the takotsubo cardiomyopathy, aortic dissection and inflammatory cardiac conditions such as pericarditis, myocarditis and endocarditis. Patients that present with shortness of breath frequently have elevation of troponin levels. Pulmonary embolism is well recognised as a cause of elevation of troponin as are acute respiratory distress syndrome and pulmonary hypertension. However, troponin elevation has been described in patients with exacerbation of chronic obstructive pulmonary disease. Other causes are heart failure, critical illness, sepsis and stroke. End stage renal disease patients frequently have elevated troponin but now we see troponin elevations also with exercise and rapid heart rate. Therefore, one has to be very careful when assessing patients with troponin levels and take into account history, examination and coexisting illness. With new high sensitivity troponin assays we can expect increased percentages of ill patients to have troponin elevations.
the use of delta troponin in the ED, where the focus of both rapid identification of patients with an AMI and exclusion of serious pathology is required in a heterogenous population. The presentation will focus on the evidence of use of delta troponin in the ED for the diagnosis of AMI and other conditions. Results from ED-based research will be presented. GP-INITIATED PATHOLOGY TESTING: DATA FROM THE BEACH PROGRAM Clare Bayram, Helena Britt, Graeme Miller, Lisa Valenti Family Medicine Research Centre, University of Sydney, Sydney, NSW, Australia The BEACH study is a continuous national study of general practice activity. Each year approximately 1000 randomly sampled GPs provide data about 100 000 encounters. It contains data about pathology ordered at these encounters. In 2009–2010, GPs ordered 45.0 pathology tests/batteries per 100 encounters or 29.3 per 100 problems. At least one pathology test order was recorded at 17.7% of encounters (for 13.2% of problems managed), chemistry tests accounting for more than half of all pathology tests. Since 2000, rises in the number of tested problems and the number of problems managed at GP encounters contributed to overall increases in the proportion of encounters involving a pathology test, and the number of tests ordered by GPs. BEACH pathology data have been used to investigate: the problems responsible for the highest volume and growth of testing in primary care and how GPs’ testing behaviour in the management of these problems has changed; the extent to which GP-ordered pathology for type 2 diabetes, hypertension, lipid disorders, weakness/tiredness, ‘health checks’ and overweight/obesity aligned with testing recommended in inter/national guidance; expected volume of GP-ordered testing in 2020 using patient age-sex-specific test rates, extrapolated using GP-attendance rates and national population projections. PATHOLOGY: THE CONUNDRUM OF CHANGING DEMAND AND APPROPRIATE FUNDING
THE USE OF DELTA TROPONIN IN THE EMERGENCY DEPARTMENT
Ed Wilson EW Consulting, Kettering, Tas, Australia
Louise Cullen Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, and University of Queensland, Brisbane, Qld, Australia
It is more than 25 years since movement in rebates for pathology have been adjusted by negotiations based on the movement of the costs of provision of services. The pathology industry has relied on growth in demand and industry restructuring to deliver an efficiency dividend to the community and profit to providers. The industry faces decreasing opportunity for efficiency gains and continued growth in demand is not guaranteed. The public sector suffers collateral damage as those services provided by them to private or community based patients are delivered without the opportunity to achieve the efficiencies of the private industry. With an increasing range of tests and an increased emphasis on preventative medicine, the challenge is to provide sufficient funds to underwrite the current and future appropriate use of pathology. The Commonwealth, as the major underwriter of health services, needs our input to decide how to get best value out of the available funds and be confident that the money spent delivers necessary services of an acceptable quality and that they are affordable and
Acute chest pain is a common diagnostic and management problem that places a considerable burden on emergency departments (EDs). Amongst a large group of patients with a good prognosis exists a small number of individuals harbouring a high risk of potentially fatal recurrent ischaemic events in the short to medium term. Rapid identification of these high risk patients with acute coronary syndrome (ACS) remains a challenge. The detection of a raised cardiac troponin (cTn) is an integral part of the diagnosis of acute myocardial infarction (AMI). However there are numerous causes for a raised troponin in patients presenting to the ED. The diagnosis of AMI requires evidence of a rise and/or fall of cTn in association with clinical evidence of myocardial ischaemia. Few studies have addressed the implications of
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
Pathology (2011), 43(S1)
PATHOLOGY 2011 ABSTRACT SUPPLEMENT
predictors of diabetes, diabetic retinopathy and CVD, whilst greater complexity of the retinal vasculature branching patterns were associated with diabetes. At a public health level, recent AusDiab analyses have been used to develop a simple non-invasive questionnaire to assess risk for developing diabetes and have estimated the annual costs of obesity in Australia to be $14.5 billion. ELEVATED TROPONIN IN THE ABSENCE OF ACUTE CORONARY SYNDROME – IMPACT OF TROPONIN ASSAY Hans G. Schneider Alfred Pathology Service, Melbourne, and Monash University, Melbourne, Vic, Australia Troponin is the main marker for the diagnosis of acute coronary syndrome (ACS). Increased use of the troponin assay in other settings shows many clinical situations with elevated levels. These elevations can be seen both inside and outside the emergency department. A difficult group of patients present with typical chest pain to the emergency department and have elevated troponin levels that are not caused by ACS. In this group belong the takotsubo cardiomyopathy, aortic dissection and inflammatory cardiac conditions such as pericarditis, myocarditis and endocarditis. Patients that present with shortness of breath frequently have elevation of troponin levels. Pulmonary embolism is well recognised as a cause of elevation of troponin as are acute respiratory distress syndrome and pulmonary hypertension. However, troponin elevation has been described in patients with exacerbation of chronic obstructive pulmonary disease. Other causes are heart failure, critical illness, sepsis and stroke. End stage renal disease patients frequently have elevated troponin but now we see troponin elevations also with exercise and rapid heart rate. Therefore, one has to be very careful when assessing patients with troponin levels and take into account history, examination and coexisting illness. With new high sensitivity troponin assays we can expect increased percentages of ill patients to have troponin elevations.
the use of delta troponin in the ED, where the focus of both rapid identification of patients with an AMI and exclusion of serious pathology is required in a heterogenous population. The presentation will focus on the evidence of use of delta troponin in the ED for the diagnosis of AMI and other conditions. Results from ED-based research will be presented. GP-INITIATED PATHOLOGY TESTING: DATA FROM THE BEACH PROGRAM Clare Bayram, Helena Britt, Graeme Miller, Lisa Valenti Family Medicine Research Centre, University of Sydney, Sydney, NSW, Australia The BEACH study is a continuous national study of general practice activity. Each year approximately 1000 randomly sampled GPs provide data about 100 000 encounters. It contains data about pathology ordered at these encounters. In 2009–2010, GPs ordered 45.0 pathology tests/batteries per 100 encounters or 29.3 per 100 problems. At least one pathology test order was recorded at 17.7% of encounters (for 13.2% of problems managed), chemistry tests accounting for more than half of all pathology tests. Since 2000, rises in the number of tested problems and the number of problems managed at GP encounters contributed to overall increases in the proportion of encounters involving a pathology test, and the number of tests ordered by GPs. BEACH pathology data have been used to investigate: the problems responsible for the highest volume and growth of testing in primary care and how GPs’ testing behaviour in the management of these problems has changed; the extent to which GP-ordered pathology for type 2 diabetes, hypertension, lipid disorders, weakness/tiredness, ‘health checks’ and overweight/obesity aligned with testing recommended in inter/national guidance; expected volume of GP-ordered testing in 2020 using patient age-sex-specific test rates, extrapolated using GP-attendance rates and national population projections. PATHOLOGY: THE CONUNDRUM OF CHANGING DEMAND AND APPROPRIATE FUNDING
THE USE OF DELTA TROPONIN IN THE EMERGENCY DEPARTMENT
Ed Wilson EW Consulting, Kettering, Tas, Australia
Louise Cullen Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, and University of Queensland, Brisbane, Qld, Australia
It is more than 25 years since movement in rebates for pathology have been adjusted by negotiations based on the movement of the costs of provision of services. The pathology industry has relied on growth in demand and industry restructuring to deliver an efficiency dividend to the community and profit to providers. The industry faces decreasing opportunity for efficiency gains and continued growth in demand is not guaranteed. The public sector suffers collateral damage as those services provided by them to private or community based patients are delivered without the opportunity to achieve the efficiencies of the private industry. With an increasing range of tests and an increased emphasis on preventative medicine, the challenge is to provide sufficient funds to underwrite the current and future appropriate use of pathology. The Commonwealth, as the major underwriter of health services, needs our input to decide how to get best value out of the available funds and be confident that the money spent delivers necessary services of an acceptable quality and that they are affordable and
Acute chest pain is a common diagnostic and management problem that places a considerable burden on emergency departments (EDs). Amongst a large group of patients with a good prognosis exists a small number of individuals harbouring a high risk of potentially fatal recurrent ischaemic events in the short to medium term. Rapid identification of these high risk patients with acute coronary syndrome (ACS) remains a challenge. The detection of a raised cardiac troponin (cTn) is an integral part of the diagnosis of acute myocardial infarction (AMI). However there are numerous causes for a raised troponin in patients presenting to the ED. The diagnosis of AMI requires evidence of a rise and/or fall of cTn in association with clinical evidence of myocardial ischaemia. Few studies have addressed the implications of
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.