Lit Matters 3: Can We Sub hsTn for Conventional Troponin in the HEART Pathway?

High-sensitivity troponin changes emergency department chest pain risk stratification when paired with the HEART pathway. In a large multicenter cohort, hsTn identified more acute MI during the index visit, reduced 30-day missed MI, and was associated with fewer admissions and downstream stress tests.

hsTn in the HEART Pathway

• Index MI detection: High-sensitivity troponin found more acute MI during the ED visit than conventional troponin, shifting diagnoses earlier rather than after discharge.
• Thirty-day miss reduction: The key signal was fewer AMI diagnoses in the following 30 days with hsTn, suggesting safer identification of truly low-risk chest pain patients.
• Resource use signal: Hospital admission fell from 15% to 12.2% and stress testing from 12.8% to 10.2% after switching to hsTn within the pathway, with implementation nuances we get into in the episode.
• Mortality unchanged: Thirty-day all-cause mortality did not differ between hsTn and conventional troponin pathways, supporting efficiency gains without an obvious mortality tradeoff.
• Complete HEART documentation: Patients with troponin testing but no fully documented HEART score had worse 30-day outcomes, a reminder that the pathway only works when the score is actually completed.
• Assay-specific cutpoint problem: High-sensitivity troponin is not a plug-and-play swap because absolute thresholds and delta changes depend on the specific assay. We walk through why local validation matters in the chapter.