Department of Clinical Biochemistry

CARDIAC CHEST PAIN - GUIDELINES FOR BIOCHEMICAL INVESTIGATION

Background and purpose

The Clinical Policy Board approved the original version of this protocol for the biochemical
investigation of cardiac chest pain on 27th July 2001 (CPB/45/01/EL). The policy was introduced
w.e.f. 1st October 2001. In April 2008 troponin I measurement replaced troponin T within the Trust.
The original protocol was revised in September 2008.

In East Kent diagnostic testing for acute coronary syndrome is available using serum measurement
of the troponin I component of the cardiac contractile apparatus. Troponin I is a sensitive and
specific marker of cardiac muscle damage and is useful in risk stratification of patients with acute
coronary syndromes (Figure 1): in particular, it is used in establishing the diagnosis of non ST-
segment elevation myocardial infarction.

Figure 1. Pathological classification of acute coronary syndromes. NSTEMI = non ST-

segment elevation myocardial infarction; NQMI = non Q-wave myocardial infarction; QwMI = q-
wave myocardial infarction. Taken from Alpert et al. 2000.

The purpose of this protocol is to describe the use of the clinical biochemistry diagnostic service in
the evaluation of patients with cardiac chest pain. It outlines the appropriate times at which
troponin should be measured, the patients in whom it should be measured, and the situations in
which its measurement is not appropriate. The protocol is informed by national policy documents
supporting the use of troponin measurements. These include the National Service Framework for
Coronary Heart Disease which states that in the assessment of patients with suspected myocardial
infarction (MI) or other acute myocardial syndromes there should be an initial assessment of risk
on admission and a further assessment at 12 hours after onset of chest pain, on both occasions
using measurement of a troponin. Further, the National Institute for Health and Clinical Excellence
have stated that raised serum troponin concentrations should be used to identify patients with

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unstable angina who are at high risk of progression to MI or death and that such patients should
receive treatment with glycoprotein IIa/IIIb inhibitors.

This protocol should be used in conjunction with the clinical protocols for the management of MI
and acute coronary syndromes that have been developed and agreed by the cardiologists. It
assumes that all patients with suspected cardiac chest pain have an electrocardiogram (ECG)
performed on admission and that the results of this test are used to influence subsequent decision
making and test requesting.

Sources
1. National Service Framework for Coronary Heart Disease, March 2000.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida
nce/DH_4094275 (accessed 29th September 2008).

2. National Institute for Health and Clinical Excellence (NICE) guidance on the use of
glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes.
http://www.nice.org.uk/Guidance/TA47 (accessed 29th Sept 2008).

3. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined – a

consensus document of the Joint European Society of Cardiology/American College of
Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol
2000;36:959-969.

4. Wu AHB, Jaffe AS, Apple FS, Jesse RL, Francis GL, Morrow DA, et al. National Academy
of Clinical Biochemistry laboratory medicine practice guidelines: use of cardiac troponin and
B-type natriuretic peptide or N-terminal proB-type natriuretic peptide for etiologies other
than acute coronary syndromes and heart failure. Clin Chem 2007;53:2086-2096.

When to measure troponin I

1. Troponin I should be measured on admission in patients presenting with a suspected acute
coronary syndrome (i.e. unstable angina or non-Q wave MI). In practice, on average the
admission sample will probably be taken approximately 4 h after onset of chest pain.

2. If the troponin I measurement taken on admission in such patients is normal, then a second
sample for troponin I measurement should be taken 12 h after onset of chest pain. Note:
the second sample will not be analysed if the admission sample is increased (see note 1 ).

3. Troponin I should also be measured in patients with a suspected late presentation of MI,
(although it should not be requested when the delay between suspected episode and
presentation exceeds 7 days).

1
Patients with established renal failure, and sometimes patients with lesser degrees of kidney disease, will
often demonstrate increased concentrations of cardiac troponin in the absence of an acute coronary
syndrome. In such situations a second troponin I measurement taken 12 h after admission is indicated. A
dynamic change in the troponin I concentration of 20% or more may be used to define those with an acute
myocardial infarction.

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When not to measure troponin I
1. Troponin I should not be measured in patients with acute MI as demonstrated by new onset
ST segment elevation or new left bundle branch block (LBBB) on ECG testing. These
patients should be managed in accordance with the Trust guidelines on acute MI. Troponin
measurement does not influence practice in this setting and should not be requested.

2. Troponin I should not be measured in patients with chest pain that is clearly non-cardiac
(e.g. musculoskeletal, pleuritic) or in medical admissions when the diagnosis is clearly non-
cardiac (e.g. pneumonia).

3. A second troponin I measurement at 12 h is unnecessary, and will not be analysed, if the

initial troponin I measurement on admission is increased (see note 1).

4. Due to its persistence in the circulation, troponin I measurement should not be undertaken
to diagnose a re-infarction in an in-patient known to have had an acute MI.

Interpretation
1. Patients demonstrating raised troponin concentration (>0.05 ug/L, see note 2 ) on the
admission sample or 12 h post-onset of chest pain should be managed according to Trust
guidelines on acute coronary syndrome.

2. Patients who have normal serum troponin concentrations on admission and at 12 h post-
onset of chest pain and who have no demonstrable ECG changes are at low risk and
should be considered for early discharge and exercise testing.

Test availability
1. Troponin I measurement will be provided by the clinical biochemistry laboratories at the three
acute Trust sites on a 24 h per day basis with a 1 h turnaround time from receipt of the sample
in the laboratory.

2. Troponin I measurement will not be undertaken until, and unless, an ECG has been carried out
on the patient.

3. Requests will only be accepted providing the request form clearly states both the sample time
and time of onset of chest pain and the ECG findings.

4. The measurement of CK, CK-MB, AST and LDH will play no part in the management of
patients with cardiac chest pain and these tests will not be available in this setting.

2
The European Society of Cardiology/American College of Cardiology (ESC/ACC) recommend a single
decision cut-off point for cardiac troponin based on the 99th percentile of a reference population for the
diagnosis of patients presenting with myocardial infarction and that imprecision (coefficient of variation [CV])
at this point should be <10%.Whilst the 99th percentile value for the Abbott cTnI assay is quoted as 0.012
ug/L (manufacturer’s product information), under evaluation conditions we were only able to achieve a 10%
CV at a concentration of 0.04 ug/L (method evaluation report March 2008). To provide a robust and
consistent decision threshold with an allowance for fluctuations in analyser performance a decision threshold
of >0.05 ug/L was chosen.

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AUTHOR: Dr Edmund Lamb

DATE: 15 October 2008
VERSION: 2.0
REPLACES: Version 1.0, dated 5 October 2001
REVIEW DATE: 15 October 2011

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 Department of Clinical Biochemistry

FLOW CHART: BIOCHEMICAL INVESTIGATION OF CARDIAC CHEST PAIN

Suspicious cardiac chest pain

Suggestive history

New onset  Manage patient

ECG ST segment according to Trust
elevation or guidelines for acute
new LBBB MI.

Non-diagnostic
ECG changes

 Manage patient
Measure troponin on Troponin according to Trust
admission increased guidelines for
(see note 1) acute coronary
syndromes

Troponin normal

 Manage patient
according to Trust
Repeat troponin guidelines for acute
Troponin
12 h after onset of coronary
increased
chest pain syndromes

 Consider early
Troponin discharge and
normal arrange exercise
test

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