PointofCareTestingforCardiacbiomarkerinEDaRomanianExperience

DianaCarmenCimpoeuPreotu.UniversityofMedicineandPharmacyGr.T.PopaIai,Romania
In the Emergency Department, the ideal cardiac biomarker will allow early detection of
patients with acute coronary syndromes, acute heart failure and pulmonary embolism and will
indicate the optimal disposition and treatment. But in the real medical practice, for economical
reasons, the biomarker are often used only for differential diagnosis when the clinical and others
paraclinictools,likeECGorechocardiographyareinsufficienttodecidetheadmissionandinhospital
management.Itisestimatedthatbetween2%and5%ofpatientswithMIaremissedanddischarged,
patientspresentingwithnonspecificchestdiscomforttotheemergencydepartment,wholackother
confounding risks of ACS, still require risk stratification.These patients are often triaged to a chest
pain unit where serial cardiac markers (eg, myoglobin, troponins, and CKMB) are evaluated, and
noninvasivetestinghelpsruleoutACS.Still,some4%to14%ofthesepatientswithnegativestudies
goontohaveseriousfutureoutcomes.
For Romania, the period between 2007 2009 ment a new period for emergency
departmentswithnewequipments,personneltrainingandmodernlegislationincludingguidelines
for emergency care. For 54 Emergency Hospitals in whole country, the Ministry oh Health bought
completnewequipmentsincluding devicesforbiomarkersquantitativeassesment: TroponinI,D
dimer,NTproBNP,Myoglobin,CKMB.Thebiomarkersareusedmoreandmore,butnotforallthe
patientswithchestpainordyspnea,yet.TheproportionofusingNTproBNPincreasedwith23,1%
in2009comparedwiththesameperiodof2008,andth3euseoftroponinIincreasedwith17,3%in
all the Romanian EDs in 2009 compared with 2008, and for CKMB with 11,2 %. In this time the
cardiovascular diseases rate remained at the same high level, but the ED presentation increased
with5%(during2009comparedwith2008).Whatisnew?TheconceptofPointofCareDiagnostic
whichofferthepossibilitytoobtainthebiomarkervalueinlessthat15minutestocorrelatethe
resultswithclinicalandothersnoninvasivetestsandtotaketheimportantdecisionsforadmission
ordischargethepatientorforstartatreatmentstrategy.
In a retrospective study with the objectives to asses the role in medical practice, in ED of cardiac
biomarkersandtoevaluatetheaccuracyofdifferentialdiagnosismadeusingthebiomarkersandits
potentialprognostic;wehaveincluded1599patientswithchestpain.Forthepatientspresentedin
one Emergency Department of Clinical Emergency Sf. Spiridon Hospital Iasi the inclusion criteria
waschestpainwithorwithoutdyspneaneedingdifferentialdiagnosisafterclinic,ECGandchestX
rayevaluation.Theperiodforthestudywasthe30thofSeptember2008the30thofMay2009.In
EDwehaveperformthedeterminationofcardiacbiomarkersusingaPathfastDeviceforTroponinI,
Ddimer,NTproBNP,CKMBandCardiacReaderforTroponinT.StatisticalanalysisusingSPSS13.0
wasdone.Results:Basedoncardiacbiomarkers46,7%ofpatientswasadmittedinhospital,(39,3%
incardiologyand7.4%inothersclinics).Theadmissiondispositionwascorrelatewiththehighlevel
ofNTproBNPandDdimers.Inhospitalmortalitywas0.06%andthebetterpredictorofmortality
wasNTproBNP(r=0,275,p<0.001).NopatientsentathomediedordevelopedanAMIinthefirst7
day. In our study troponin I has better correlation with positive diagnosis for AMI (p<0,001) than
troponinT.
Conclusions: A panel of cardiac biomarkers may provide for both a rapid rule out and a rapid
identificationofpatientswithhighrisk.InRomaniathenewtechnologycouldimprovethepracticein
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Emergency Department and the data from the daily practice proved a real increased of cardiac
biomarkersuse.NTproBNPappearlikethebestindicatorofnecessityofadmissionandpredictorof
mortality for the patient with chest pain presented in ED. The differential diagnostic using the
cardiacbiomarkersbecamemorecomfortableforthephysiciansandsaferforthepatients.