Necessity for Troponin Levels in Pediatric Patients Presenting with Chest Pain
Date First Published:
January 29, 2016
Last Updated:
January 29, 2016
Report by:
Brendan Parker, Student (University of Toledo College of Medicine)
Three-Part Question:
In [pediatric patients presenting with chest pain] are [troponin levels] helpful in [diagnosing cardiac pathology]?
Clinical Scenario:
13 year old, previously healthy male presents with non-specific chest pain for last 3 hours. After a thorough history and physical, no abnormalities are found and diagnostic testing is debated. Knowing that adult patients with similar symptoms cause concern for ACS, you question whether pediatric patients have similar concerns with ACS and whether a full cardiac workup is warranted.
Search Strategy:
PubMed Search (Jan 2016)
Search Details:
(("troponin"[MeSH Terms] OR "troponin"[All Fields]) AND ("chest pain"[MeSH Terms] OR ("chest"[All Fields] AND "pain"[All Fields]) OR "chest pain"[All Fields])) AND ("pediatrics"[MeSH Terms] OR "pediatrics"[All Fields] OR "pediatric"[All Fields])
Outcome:
23 papers were found of which three were helpful, which are listed in Table 1 below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Use and Misuse of Serum Troponin Assays in Pediatric Practice Liesemer K, Casper C, et al Mar-12 USA | 3497 pediatric patients | Multicenter, retrospective | 12% (403 /3564) had elevated cTnI levels | No patients diagnosed with ACS | Retrospective design and changes in sensitivity and specificity of cTnI assays |
| 4% (63/1409) of presenting chest pain had elevated cTnI | Elevated cTnI were predictive for longer hospitalizations, mechanical ventilation and death | ||||
| 23% of presenting trauma and 12% of presenting overdose had elevated cTnI | Absence of fever and/or abnormal EKG results, cTnI were of little diagnostic/prognostic value | ||||
| Of 1409 pts presenting with chest pain, average of $2400 +/- $880 spent per encounter | Chest pain with fever or abnormal EKG had 13 times higher relative risk of elevated cTnI | ||||
| Elevated troponin levels in previously healthy children: value of diagnostic modalities and the importance of a drug screen Thankavel P, Mir A, et al Mar-13 USA | 32 patients with elevated troponin levels | Retrospective, single institution | Final diagnosis: 50% myocarditis, 22% coronary vasospasm, 19% myopericarditis, 6% anomalous coronary arteries | Troponin level >2ng/ml decreases likelihood of non-cardiac diagnosis | #NAME? |
| Absolute troponin levels do not distinguish between cardiac etiologies | |||||
| Further diagnostic testing with positive drug screen did not add to management | |||||
| Recommend thorough history, drug screen, EKG & ECHO | |||||
| Use of Troponin as a Screen for Chest Pain in the Pediatric Emergency Department Brown J, Hirsh D, et al. Nov-11 USA | 212 pediatric patients | Multicenter, retrospective | 47% (100/212) of patients with chest pain and troponin assay were admitted | Selective use of troponin level may be useful to evaluate for other cardiac causes of chest pain | -Different reference ranges of troponin assays and practice variation among providers |
| 17.5% (37/212) of patients presenting with chest pain had elevated troponin | Low likelihood of AMI, data does not support transfer of care to adult facility without other risk factors | ||||
| 32% (12/37) with elevated troponin had EKG changes | Low troponin levels and normal EKG can discharge home | ||||
| Troponin level for patients with increased troponin and cardiac diagnosis significantly different than patients with increased troponin and non-cardiac diagnosis | No correlation of increased morbidity or mortality with greater degree of troponin increase |
Author Commentary:
These studies agreed that the most important aspect of the patient encounter was the H&P and if concerned, further diagnostic testing is warranted. One study concluded elevated troponin levels had little clinical value but good prediction of hospitalization, mechanical ventilation and death in patients who present after trauma, overdose and sepsis. Another study recommended patients with elevated troponin levels should receive a drug scree, EKG and ECHO but the levels and progression did not determine etiology or prognosis. One study suggested that coronary angiography was of little use while another said transfer to a facility with coronary angiography was only necessary with multiple risk factors for cardiac pathology
Bottom Line:
Troponin levels for pediatric patients presenting with chest pain in the ED are unnecessary unless H&P and risk factors are concerning for cardiac pathology
References:
- Liesemer K, Casper C, et al. Use and Misuse of Serum Troponin Assays in Pediatric Practice
- Thankavel P, Mir A, et al. Elevated troponin levels in previously healthy children: value of diagnostic modalities and the importance of a drug screen
- Brown J, Hirsh D, et al. . Use of Troponin as a Screen for Chest Pain in the Pediatric Emergency Department