In response to the current flurry on troponins:
The Royal Liverpool University Hospital has been using troponin T as its
single cardiac marker since August 1998. The only indication for CK-MB is a
patient with a known infarct (tropT>0.2) who has ?re-infarcted within 14
days, then a CK-MBmass is measured.
Troponin T is measured at 12 hours post-onset of chest pain or 12 hours
post-arrival if the onset time is uncertain. Time of onset of pain has to be
confirmed on the form and the lab won't measure it any earlier nor twice on
any one patient admission unless discussed with them (to try and minimize
the serial measurers!).
Patients with non-acute ECG (on admission and after 1 hour),
haemodynamically stable, no pulmonary oedema, etc who are then pain free can
be admitted to the Obs ward for observation until their tropT is due. At 12
hours they have a further ECG and review by A&E senior. If all is OK then
are then discharged to their GP with a pre-printed letter and some GTN spray
if necessary. No ETT are done in A&E.
All borderline trop T (0.1-0.2) are referred medically who then arrange
urgent out-patient ETT for appropriate patients (usually within a week).
When we set up this policy it was decided that the numbers of patients to be
sent home from A&E were too large and resources too limited for exercising
everyone before discharge.
We now have 15 months of experience with Troponin T in this way and have had
very few difficulties. We've also surprisingly enough made huge savings on
our lab expenses due to the vastly overused CK measurement prior to this.
Elspeth Worthington
SpR Mersey Region
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