REPLY
Critical Pathway for Chest Pain
Thomas H. Lee, MD, and
Graham Nichol, MD
1 July 1998 | Volume 129 Issue 1 | Pages 70-71
IN RESPONSE:
We appreciate that evidence of the potential role of rapid bedside testing in patients with chest pain in the emergency department is rapidly evolving. Dr. Bosch cites a non-experimental study of use of troponin-T and troponin-I. However, negative test results were insufficient to rule out short-term risks in all subgroups.
The other studies that he cites are worth considering further. Lindahl and colleagues assessed troponin T in patients with crescendo angina or ischemia on electrocardiography. The sensitivity of troponin T was overestimated because testing was conducted up to 24 hours after symptom onset. Furthermore, another prospective study [1] found that the sensitivity of troponin I and creatine kinase-MB were not significantly different when serum sampling was performed within 24 hours of symptom onset.
Ravkilde and colleagues enrolled patients with suspected myocardial infarction into a cohort study of markers of ischemia. Insufficient information was available to compare these patients to our own, but most were at much higher risk for myocardial infarction. Therefore, these results may not be generalizable.
Finally, Antman and colleagues prospectively assessed troponin I levels in patients with unstable angina or non-Q-wave myocardial infarction. Because the sensitivity and specificity of a test may vary with the prevalence of disease, the role of testing with troponin I or troponin T in patients at low risk for myocardial ischemia remains unclear [2].
We agree that evidence-based practice be revised in light of new information.
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Author and Article Information
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Partners Community Health Care, Inc.; Boston, MA 02199
University of Ottawa; Ottawa, Ontario K1Y 4E9, Canada
1. Brogan GX Jr, Hollander JE, McCuskey CF, Thode HC, Snow J, Sama A, et al. Evaluation of a new assay for cardiac troponin I vs creatine kinase-MB for the diagnosis of acute myocardial infarction. The Biochemical Markers for Acute Myocardial Ischemia (BAMI) Study Group. Acad Emerg Med. 1997; 4:6-12.[Medline]
2. Lachs MS, Nachamkin I, Edelstein PH, Goldman J, Feinstein AR, Schwartz JS. Spectrum bias in the evaluation of diagnostic tests: lessons from the rapid dipstick test for urinary tract infection. Ann Intern Med. 1992; 117:135-40.
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