HOT OF THE PRESS

Hot Off the Press: Troponin Testing and

Coronary Syndrome in Geriatric Patients
With Nonspecific Complaints: Are We
Overtesting?
Justin Morgenstern, MD1 , Corey Heitz, MD2 , Chris Bond, MD3 , and
William K. Milne, MD4

BACKGROUND ARTICLE SUMMARY

onspecific complaints, such as “fatigue,” “dizzi-
N ness,” and “not feeling well” are relatively com-
mon among elderly patients presenting to the
emergency department (ED).1,2 The appropriate
workup of such complaints is not always evident.
When employed in populations with very low risk
of disease, our tests can result in many more false
positives than true positives, frustrating physicians
and potentially harming our patients. However, a
significant number of elderly patients presenting
with nonspecific symptoms are ultimately diagnosed
with serious or life-threatening conditions.3 Elderly
patients diagnosed with acute coronary syndrome
(ACS) are more likely than younger patients to pre-
sent without chest pain, including up to 20% who
present with weakness as their chief complaint.4,5
Therefore, the troponin presumably has some role
in the workup of elderly patients presenting with
nonspecific symptoms. This study by Wang and col-
leagues uses a chart review to explore the frequency
of ACS in elderly patients presenting with nonspeci-
fic complaints and the utility of troponin testing in
this population.
This is a chart review study that identified patients
aged 65 years and older presenting to the ED with a
nonspecific chief complaint in whom the treating
physician decided to order a troponin. Of 594 elderly
patients with nonspecific complaints, troponins were
ordered in 416 (69%), of whom 52 (12%) were posi-
tive. However, only five patients were determined to
have ACS. The ED troponin was 80% sensitive and
88% specific for ACS, with a negative predictive value
(NPV) of 99.7%, but a positive predictive value (PPV)
of only 7.7%.
QUALITY ASSESSMENT
Strategies to improve the accuracy of medical chart
reviews include training abstractors before starting the
study, explicitly defining inclusion and exclusion crite-
ria, precisely defining variables of interest, using a
standardized abstraction form, holding periodic meet-
ings to resolve disputes and review coding rules, moni-
toring the performance of the abstractors, blinding the
abstractors to the study hypothesis, and testing inter-
rater agreement between multiple abstractors.6

From the 1University of Toronto, Toronto, Ontario, Canada; the 2Virginia Tech Carilion School of Medicine, Roanoke, VA; the 3University of
Calgary, Calgary, Alberta, Canada; and the 4University of Western Ontario, Goderich, Ontario, Canada.
Received February 2, 2020; accepted February 3, 2020.
Discussing: Wang AZ, Schaffer JT, Holt DB, Morgan KL, Hunter BR. Troponin testing and coronary syndrome in geriatric patients with nonspeci-
fic complaints: are we overtesting? Acad Emerg Med 2020;27:6–14.
Associated podcast: https://thesgem.com/2020/01/sgem280-this-old-heart-of-mine-and-troponin-testing/
The authors have no relevant financial information or potential conflicts to disclose.
Supervising Editor: Jeffrey A. Kline, MD.
Address for correspondence and reprints: Justin Morgenstern, MD; e-mail: justin.morgenstern@gmail.com.
ACADEMIC EMERGENCY MEDICINE 2020;00:1–4.

© 2020 by the Society for Academic Emergency Medicine ISSN 1553-2712

doi: 10.1111/acem.13933 1
2 MORGENSTERN et al. • TROPONIN OVERTESTING AND CORONARY SYNDROME IN GERIATRIC PATIENTS WITH NONSPECIFIC COMPLAINTS

Impressively, this study utilized all of these recom- AUTHOR’S COMMENTS

mended methodologic techniques.
As a general rule, tests perform poorly in populations
However, there are inherent limitations to chart
with a very low prevalence of disease. ACS is relatively
review methodology that limit the reliability of the
rare in patients without chest pain or dyspnea, and
reported findings. Clinicians may have altered the
therefore we should expect the troponin to be a low
chief complaint after the troponin value was
value test in this population. However, ACS is more
reported. For example, in the context of a positive
common in elderly patients, and the elderly are also
troponin, the physician might decide to emphasize
more like to present with atypical symptoms, such as
the fact that the patient mentioned chest pain,
“weakness.”4,5 The limitations of chart review data pre-
despite an initial chief complaint of “fatigue” or
clude any definitive rules, so clinicians will have to
“multiple complaints,” resulting in the exclusion of
continue to use their clinical judgment to determine
patients in whom troponin testing was truly valu-
whether the nonspecific symptoms in the patient in
able. Furthermore, the retrospective look at these
front of them warrant testing for possible ACS.
data necessitated a dichotomous approach to tro-
ponin values (in which the test was considered
either positive or negative at a specific cutoff). How- TOP SOCIAL MEDIA COMMENTARY
ever, even before the introduction of high-sensitivity
Dr. Art Sanders on the SGEM blog: I am con-
troponins, the troponin result has always had to be
cerned about the 19% mortality of elder patients with
interpreted within the clinical context and often con-
no documented ACS (15 deaths of 77 patients). The
sidering the trend of multiple values. In a chart
authors note “There is a wide body of literature
review, we lose this crucial aspect of clinician judg-
demonstrating that troponin elevation predicts worse
ment and therefore do not know how these tro-
outcomes in a variety of noncardiac conditions.”
ponin results would have been interpreted in real
Patients died from a variety of other causes such as
practice. For these reasons, although we believe the
sepsis, dehydration, etc. Would these other conditions
general conclusion that troponin testing in this pop-
have been diagnosed and warrant admission if the tro-
ulation is low yield with many false positives, the
ponin had not been tested? The lesson might be that,
precise numbers reported should be interpreted cau-
especially with high sensitivity troponin, we may need
tiously.
to think differently about troponin testing – as an ED
doctor, I may not diagnose the patient as NSTEMI,
KEY RESULTS but admission to assess for the other serious condi-
tions is warranted. If we discourage troponin testing,
They initially identified 1,146 potentially eligible
we may not be aware of some of these serious condi-
patients. After excluding the patients who had a speci-
tions, especially with atypical presentations in elder
fic complaint listed and those with documented fever,
patients.
they were left with a total of 594 patients. Of those,
Dr. Wand responds: We did not specifically look
412 (69%) had troponins ordered. The average age of
into how troponin would perform as a prognostic fac-
the cohort was 78 years old, 58% were female, and
tor. However, I did go back into the original data set
75% were admitted to hospital. The most common
to look at the original presentations and reasons for
chief complaints were altered mental status (43%),
admission. . . None of these 16 patients who had an
weakness/fatigue (33%), and dizziness (21%).
initial troponin elevation and died within 30 days of
The troponin was positive in 52 patients (12.6%),
the index visit had just an elevated troponin as cause
but only five (1.2%) were adjudicated as having ACS
of admission. All of them had other reasons that were
at the index visit or within 30 days. Focusing specifi-
found during their ER visit that cause them to be
cally on the first troponin in the ED, this results in a
admitted.
sensitivity of 80%, a specificity of 88%, a NPV of
Again, I am unable to fully comment on whether
99.7%, and a PPV of 7.7%. Considering all tro-
the troponin added valuable prognostic information or
ponins, the sensitivity was 100% (95% confidence
risk stratification on top of the other tests that were
interval [CI] = 48% to 100%), the specificity was 81%
abnormal for these patients as that was not our
(95% CI = 77% to 85%), the NPV was 100%, and
paper’s intention. But I think your question is a
the PPV was 6.1%.
ACADEMIC EMERGENCY MEDICINE • www.aemj.org
interesting one as a potential follow up study- why do
physicians order troponins- is it for prognostic pur-
poses? risk stratification? to help admit? or concern for
ACS?
Christian H. Nickel (@replynickel): Great study,
great podcast @TheSGEM – topic merits prospective
study. HsTroponin algorithms (such as 1 hr rule out)
are derived from patients with “symptoms suggestive
of ACS” – should (IMHO) not be extrapolated to
NSCs [nonspecific complaints]!
Dr. Ken Milne – EBM and Rural (@TheSGEM)
responds: Good history, followed by a directed physi-
cian examination and then judicious use of investiga-
tions. #SGEMHOP
Christian H. Nickel (@replynickel) responds: We
seem to have similar problems: Biomarkeritis (Tro-
poninitis) disseminate
Daniel Jafari (@DanielJafari): Interesting paper. I
wish the poll was a bit more nuanced (well appearing,
I’ll appearing). Paper’s pop admitted 75% of the time,
so likely sicker. Also, worth noting single trop 100%
sensitive. Question remains: how many unnecessary
procedures for 93% FP trops.
Dr. Ken Milne – EBM and Rural (@TheSGEM)
responds: Wait until high-sensitivity is widely available
in North America. Combine that with an aging popu-
lation, indiscriminate testing and a zero-miss culture,
I’m concerned.
Marc A. Probst (@probstyMD) responds: I agree,
there is definitely a risk of doing harm by over-testing
and overreacting to “positive” HS-trop. We may need
to rethink the clinical significance of a positive trop
with these high-sensitivity assays. . . more of a prognos-
tic factor than diagnostic factor in many cases.
3
Rick Body (@richardbody) responds: Definitely.
The advance in the assays needs to be matched by an
advance in our thinking. We need to understand
more about what troponin is telling us. It’s a marker
of myocardial injury. Our job is to understand what
caused that
Paper in a Pic by Dr. Kristy Challen:
TAKE-TO-WORK POINTS
The yield of troponin testing is low in elderly patients
presenting with nonspecific complaints, and there are
many more false positives than true positives. However,
limitations in this study prevent any strong recommen-
dations for practice change. Physicians will need to con-
tinue to apply clinical judgment in deciding which
patients require a workup for ACS.
References
1. Quinn K, Herman M, Lin D, Supapol W, Worster A.
Common diagnoses and outcomes in elderly patients who
present to the emergency department with non-specific com-
plaints. CJEM 2015;17:516–22.
2. Vanpee D, Swine C, Vandenbossche P, Gillet JB. Epidemi-
ological profile of geriatric patients admitted to the emer-
gency department of a university hospital localized in a
rural area. Eur J Emerg Med 2001;8:301–4.
3. Rutschmann OT, Chevalley T, Zumwald C, Luthy C, Ver-
meulen B, Sarasin FP. Pitfalls in the emergency department
triage of frail elderly patients without specific complaints.
Swiss Med Wkly 2005;135:145–50.
4. Chew WM, Birnbaumer DM. Evaluation of the elderly
patient with weakness: an evidence based approach. Emerg
Med Clin North Am 1999;17:265–78.
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