Updated Chest Pain Pathway: Incorporating High-Sensitivity Troponin

Drew Kalnow, DO, Andy Little, DO, and Cameron Berg, MD

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The summary below is from an episode of ERcast: Clinical Perspectives

High-sensitivity troponin changes ED chest pain evaluation because it detects myocardial injury far more often than older assays, and an elevated value is not the same as acute coronary syndrome. Safe use depends on assay-specific cutoffs, timed delta testing, and ECG-guided clinical context.

High-Sensitivity Troponin in Chest Pain

Assay-specific interpretation matters: High-sensitivity troponin I is not interchangeable with conventional troponin or with other manufacturers’ assays, so reference ranges, units, and delta rules must match the exact test your lab uses.
Elevation is not ACS: Most elevated hs-TnI results are not occlusive MI; roughly 80% reflect myocardial injury from causes like renal dysfunction, heart failure, systemic illness, or severe hypertension.
Timed delta drives disposition: A single hs-TnI rarely settles the question in intermediate results because the pathway depends on repeat testing at defined intervals and whether the value is rising, flat, or falling. We walk through that timing logic in the episode.
ECG plus troponin framing: A nonischemic ECG with a normal hs-TnI supports discharge, while a clearly elevated hs-TnI generally warrants admission for further workup even though it does not by itself diagnose AMI.
Sex-specific cutoffs matter: Intermediate hs-TnI ranges are sex-specific, and using the correct female thresholds can identify myocardial infarction that older pathways were more likely to miss.
Order it when it matters: Because hs-TnI is much more likely to return abnormal than prior-generation troponin, indiscriminate testing can increase admissions without helping care unless the result will change management or disposition.

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References:

Sandoval Y, et al. Myocardial Infarction Risk Stratification With a Single Measurement of High-Sensitivity Troponin I. J Am Coll Cardiol. 2019;74(3):271-282. PMID: 31319909
Christenson RH, et al. Pivotal findings for a high-sensitivity cardiac troponin assay: Results of the HIGH-US study. Clin Biochem. 2020;78:32-39. PMID: 31669511
Nowak RM, et al. Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study. Ann Emerg Med. 2020;76(1):1-13. PMID: 32046869
Sandoval Y, et al. Single High-Sensitivity Cardiac Troponin I to Rule Out Acute Myocardial Infarction. Am J Med. 2017;130(9):1076-1083.e1. PMID: 28344141
Sandoval Y, et al. Clinical Features and Outcomes of Emergency Department Patients With High-Sensitivity Cardiac Troponin I Concentrations Within Sex-Specific Reference Intervals. Circulation. 2019;139(14):1753-1755. PMID: 30933618
Sandoval Y, et al. Type 1 and 2 Myocardial Infarction and Myocardial Injury: Clinical Transition to High-Sensitivity Cardiac Troponin I. Am J Med. 2017;130(12):1431-1439.e4. PMID: 28739197
Writing Committee, Kontos MC, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022;80(20):1925-1960. PMID: 36241466

Faculty

Drew Kalnow, DO
Dr. Drew Kalnow is an emergency medicine physician and educator based in Columbus, Ohio. He completed his emergency medicine training at OhioHealth Doctors Hospital Emergency Medicine Residency. Dr. Kalnow is passionate about advancing emergency medicine through high-quality education, with a particular focus on simulation, learning theory, and innovative teaching.
Andy Little, DO
Dr. Andy Little is an emergency medicine physician and educator. He earned his medical degree from the Ohio University Heritage College of Osteopathic Medicine and completed his emergency medicine residency at OhioHealth Doctors Hospital Emergency Medicine Residency, where he served as Chief Resident. He has received multiple national awards, including recognition from the American Osteopathic Association, American College of Osteopathic Emergency Physicians, and Emergency Medicine Residents' Association.
Cameron Berg, MD
Based in Minneapolis, MN, Dr. Berg focuses on simplifying complex patient care processes, such as chest pain, syncope, and heart failure treatment. Since 2020, he has also been navigating his own recovery from a TBI after a bicycle accident. When he isn't in the clinic, Cameron is usually busy keeping his three young children alive and happy.