1. Cost Containment: Use of Troponin testing in the Inpatient Wards Setting Neal Kaushal, R2 DSR2, May 2013

2. Troponin Assay Used to detect elevated levels of Troponin I and Troponin T in the blood, in order to differentiate between unstable angina and myocardial injury in patients with chest pain or acute coronary syndrome A serum test, when ordered can be returned in a matter of less than a few hours

3. Diagnosis of Myocardial Infarction Detection of a rise and/or fall of cardiac biomarker values (preferably cTn with at least one value above the 99th percentile upper reference limit) and with at least one of the following: Symptoms of ischemia Development of pathologic Q waves in the ECG New or presumed new significant ST-segment-T wave (ST- T) changes or new left bundle branch block (LBBB) Identification of an intracoronary thrombus by angiography or autopsy Imaging evidence of new loss of viable myocardium or a new regional wall motion abnormality.

4. Other Conditions Which Can Cause Elevated Troponin Critical illness, such as sepsis Severe GI bleed (mismatch between O2 supply and myocardial demand) Chemotherapy agents (e.g. anthracyclines) Toxins and venoms Carbon Monoxide or Cynanide poisoning

5. Examining How Troponin is Ordered at UCI on Presentation Study population: n=27 charts of patients admitted to the inpatient ward service by the Emergency Department Inclusion criteria: Patients admitted to the ward services with any presenting complaint Exclusion criteria: Patients discharged from the ED after initial labs and workup were obtained

6. Examining How Troponin is Ordered at UCI on Presentation of Chest Pain n=27 N=13 Chest pain, test (-) N=11 No Chest Pain N=3 Chest pain, test (+)

7. The Non-Chest Pain Admissions N=2: POSS NEW HEART FAILURE N=1: CELLULITIS N=2: ALTERED MENTAL STATUS N=3: SOB POSS PNA N=1: LOWER EXTREMITY SWELLING N=2: ACUTE KIDNEY INJURY

8. Cost of Troponin Testing Cost of a single Troponin Assay: $11.08 In patients who were admitted with a chief complaint of chest pain, all of these patients underwent “serial” troponin assays, i.e. every 6-8 hours to rule out ACT Multiply this by every patient admitted for chest pain, over the course of months or a year will be quite costly

9. Take Home Points Every test we run in the hospital costs money Many are easy to run. But we should always keep in mind the indication and pre-test probability of the tests that we order What may seem like an innocent test on one patient, when multiplied over many patients can add up to a costly sum!