Rapid Clinical Updates: High-Value Care in Practice: Appropriate Cardiac Biomarker Use for Hospitalists-Handout

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This rapid clinical update from the Society of Hospital Medicine addresses key topics related to cardiac biomarkers, myocardial injury after non-cardiac surgery (MINS), and acute coronary syndrome (ACS).<br /><br />Cardiac Biomarkers: Biomarkers, especially troponin, are frequently ordered indiscriminately in emergency and inpatient settings, with 79% of elevated troponin not due to acute coronary syndrome (ACS). There is a gap between current practices and optimal high-value care, which when implemented leads to cost savings and more test-free patient days without compromising safety. Use of computerized clinical decision support tools can reduce unnecessary testing.<br /><br />MINS: Myocardial Injury after Non-Cardiac Surgery occurs in up to 20% of patients, mainly within 48 hours post-op, with 65% asymptomatic cases and associated increased 30-day and 1-year mortality. Guidelines vary, recommending serial troponin monitoring in high-risk patients (older age, male sex, elevated cardiac risk indices, cardiac history, elevated BNP). Diagnostic and management guidance is evolving and depends on whether injury is due to plaque rupture or supply-demand mismatch. Current evidence is low quality; considerations include statins, aspirin, or noninvasive testing. No consensus exists on follow-up timing or interventions to improve outcomes.<br /><br />ACS and MI Types: ACS encompasses a spectrum including STEMI (total occlusion), NSTEMI (partial occlusion, biomarker positive, more common), and unstable angina. High-sensitivity troponin assays improve precision but have limitations, including false negatives in younger women and false positives in older men. Accurate diagnosis relies on clinical history, ECG, and biomarker patterns. Anti-ischemic therapy recommendations emphasize oral beta blockers (primarily for patients with heart failure with reduced ejection fraction), nitrates for symptomatic relief without mortality benefit, calcium channel blockers for ischemia, and oxygen only if hypoxemic.<br /><br />These updates highlight ongoing challenges in diagnosis, testing utilization, and management strategies, emphasizing the need for further research and nuanced clinical judgment.

Keywords

Cardiac Biomarkers

Troponin

Myocardial Injury after Non-Cardiac Surgery (MINS)

Acute Coronary Syndrome (ACS)

High-Sensitivity Troponin Assays

Clinical Decision Support Tools

Serial Troponin Monitoring

STEMI and NSTEMI

Anti-Ischemic Therapy

Diagnostic Challenges in Cardiology