Abstract
Background
High-sensitivity cardiac troponin (hs-cTn) assays underpin accelerated diagnostic protocols for non-ST elevation myocardial infarction (NSTEMI). The 2023 European Society of Cardiology (ESC) guidelines recommend 0/1-hour or 0/2-hour algorithms. Despite strong evidence, adherence in practice is inconsistent. This study aimed to assess and enhance the compliance with the ESC 0/2-hour algorithm in a large UK district general hospital.
Methodology
A retrospective cross-sectional study was conducted at Blackpool Victoria Hospital. Adults presenting with chest pain who underwent hs-cTn testing between November 2024 and June 2025 were included. Interventions introduced between cycles included targeted education, visual algorithm dissemination, and collaboration with laboratory services. Primary outcomes were adherence to the ESC 0/2-hour algorithm, unnecessary repeat testing, and inappropriate testing in non-cardiac presentations. Data were analysed using descriptive statistics, t-tests, and z-tests with p < 0.05 considered significant.
Results
Pre-implementation cohort included 595 patients; Post-implementation cohort included 340. Following intervention, adherence to the ESC algorithm increased from 74.2% to 94.4% (p < 0.0001). Unnecessary repeat testing among chest pain patients with very low troponin fell from 24.6% to 4.4% (p < 0.0001). Time to first hs-cTn decreased by 13.5 minutes, the 0-2 hour troponin interval by 133.8 minutes, and length of stay by 313 minutes (all p < 0.0001). Documentation of the ESC pathway (1.0% vs 74.1%) and use of HEART score (1.0% vs 62.8%) significantly improved. There was no increase in missed NSTEMI or 30-day major adverse cardiac events. However, >70% of troponin tests in both cycles were ordered for non-cardiac presentations.
Conclusions
Structured education, algorithm prompts, and multidisciplinary collaboration substantially improved compliance with the ESC 0/2-hour pathway, reducing unnecessary testing and enhancing efficiency without compromising safety. Persistent overuse in non-cardiac presentations highlights the need for system-level strategies and ongoing staff education to optimise troponin use.
Comments
Interesting Result for Clinical Practice
Clear reference to guidelines and well thought out project. Interesting to see simple prompts and teaching sessions to highlight existing pathways had real benefit for patient care and safety. A re-audit after education/prompting into when not to perform hs-cTN testing for non-cardiac chest pain would be interesting to see if similar effects could be achieved in reducing the number of unecessary investigations.
Non-cardiac presentations
I'd be interested to hear your ideas in reducing inappropriate measuring of troponin in non cardiac presentations as I find this a big resource waster but in reality difficult to tackle effectively