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

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This document addresses the appropriate use of cardiac biomarkers for hospitalists, focusing on high-value care to improve diagnosis and reduce unnecessary testing.<br /><br />Key cardiac biomarkers discussed include troponin and natriuretic peptides (BNP, NT-proBNP). The American Heart Association (AHA) and American College of Cardiology (ACC) endorse troponin and BNP/NT-proBNP as evidence-based markers for diagnosing myocardial injury and heart failure, respectively. High-sensitivity troponin (hsTn) assays are preferred over conventional troponin tests because they provide greater precision, enable rapid detection or rule-out of myocardial infarction (MI), and improve diagnostic accuracy.<br /><br />The document highlights the 4th Universal Definition of MI, distinguishing between myocardial injury and types of MI: type 1 MI results from acute coronary syndrome (ACS), while type 2 MI stems from supply-demand mismatch, and non-ischemic myocardial injury arises from other causes such as heart failure, sepsis, or renal disease. Clinical judgment is crucial to differentiate these entities given that elevated troponin can be present without MI.<br /><br />A clinical case exemplifies common scenarios where elevated hsTn may represent chronic myocardial injury rather than acute MI, emphasizing the need for repeated testing and comprehensive evaluation.<br /><br />The document also covers common pitfalls in biomarker use, especially overuse of CK-MB tests, indiscriminate testing without ischemic symptoms, and overly frequent repeat measurements. These low-value practices contribute to increased costs and may mislead diagnosis.<br /><br />Effective quality improvement strategies to reduce unnecessary testing include clinical decision support (CDS) tools, computerized physician order entry (CPOE) modifications, audit and feedback mechanisms, and evidence-based protocols. Studies demonstrate these interventions can reduce biomarker overuse by around 14-15% without compromising patient safety.<br /><br />Special considerations are noted for older adults, where uniform troponin thresholds may lead to false positives or negatives and testing should align with patient goals of care.<br /><br />In summary, hospitalists are encouraged to use high-sensitivity troponin appropriately, avoid low-value cardiac biomarker testing such as CK-MB, apply clinical judgment to interpret results, and implement quality improvement measures to promote high-value care.

Keywords

cardiac biomarkers

high-sensitivity troponin

BNP

NT-proBNP

myocardial infarction

acute coronary syndrome

myocardial injury

quality improvement

clinical decision support

hospitalists