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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 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
Thankavel P, et al 3/2013 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	-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 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

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