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Necessity for Troponin Levels in Pediatric Patients Presenting with Chest Pain

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)
(("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])

Search Outcome

23 papers were found of which three were helpful, which are listed in Table 1 below.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Liesemer K, et al
3/2012
USA
3497 pediatric patientsMulticenter, retrospective12% (403 /3564) had elevated cTnI levelsNo patients diagnosed with ACSRetrospective design and changes in sensitivity and specificity of cTnI assays
4% (63/1409) of presenting chest pain had elevated cTnIElevated cTnI were predictive for longer hospitalizations, mechanical ventilation and death
23% of presenting trauma and 12% of presenting overdose had elevated cTnIAbsence 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 encounterChest pain with fever or abnormal EKG had 13 times higher relative risk of elevated cTnI
Thankavel P, et al
3/2013
USA
32 patients with elevated troponin levelsRetrospective, single institutionFinal diagnosis: 50% myocarditis, 22% coronary vasospasm, 19% myopericarditis, 6% anomalous coronary arteriesTroponin level >2ng/ml decreases likelihood of non-cardiac diagnosis-Retrospective design, single institution, small sample size, uncertainty of myocarditis diagnosis
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
Brown J, et al
11/2011
USA
212 pediatric patientsMulticenter, retrospective47% (100/212) of patients with chest pain and troponin assay were admittedSelective 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 troponinLow 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 changesLow 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 diagnosisNo correlation of increased morbidity or mortality with greater degree of troponin increase

Comment(s)

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

Clinical 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

  1. Liesemer K, Casper C, et al Use and Misuse of Serum Troponin Assays in Pediatric Practice American Journal of Cardiology 2012 Mar 20; 110:284-289
  2. Thankavel P, Mir A, et al Elevated troponin levels in previously healthy children: value of diagnostic modalities and the importance of a drug screen Cardiology in the Young 2013 Mar 5; 24:283-289
  3. Brown J, Hirsh D, et al. Use of Troponin as a Screen for Chest Pain in the Pediatric Emergency Department Pediatric Cardiology 17 Nov 2011; 33:337-342