The use of biomarkers in acute chest pain and dyspnea is well established and point-of-care testing (POCT) is increasingly used in emergency departments and chest pain units for this purpose. However, few data give evidence that POCT has advantages for the patient or the medical process over central laboratory testing. Especially for troponin testing in patients with myocardial infarction, the newest guidelines define prerequisites on diagnostic test quality which most POC assays do not fulfill. Additionally, no data are available showing that POCT has relevant effect on a change of physician’s diagnostic and therapeutic thinking compared to laboratory testing. Regarding patient outcomes and societal costs, central laboratory testing seems to be even superior to POCT. The main limit of currently available POC troponin assays is the higher limit of detection and higher imprecision compared to the new high sensitive laboratory assays. However, new upcoming POC technologies may perform comparable to today’s laboratory analyzers. 1. Introduction Biomarkers are regularly used to guide diagnosis in patients with acute chest pain and acute dyspnea. In acute chest pain—with and without dyspnea—the use of troponins to diagnose acute coronary syndrome is well established, and clear guidelines are available [1]. The same is true for the use of D-dimer to exclude acute pulmonary embolism [2]. In other causes of dyspnea, natriuretic peptides can help to distinguish between a cardiac or pulmonary etiology [3]. In case of infections of the respiratory tract, C-reactive protein is a valuable laboratory marker and blood gas analysis is long-time established for monitoring of ventilation. Simple test strips or more complex analyzer systems are available for point-of-care testing (POCT) of all of these biomarkers, and many are regularly used in emergency departments, intensive care units, and smaller hospitals as solely available laboratory testing or in ambulatory care. However, there are few data given evidence if point-of-care testing of cardiac biomarkers has advantages for the patient or the medical process over central laboratory testing. Diagnostic test quality is defined by six test characteristics which can be used to assess if an assay performs better than another, in our case point-of-care testing versus central laboratory testing. These qualities are (1) technical quality of test information, (2) diagnostic accuracy, (3) change in the referring physician’s diagnostic thinking, (4) change in the patient management plan, (5) change in patient outcomes, and (6)
References
[1]
K. Thygesen, J. S. Alpert, A. S. Jaffe, M. L. Simoons, and R. Bernard, “Third universal definition of myocardial infarction,” Journal of the American College of Cardiology, vol. 60, no. 16, pp. 1581–1598, 2012.
[2]
A. Torbicki, A. Perrier, S. Konstantinides, et al., “Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC),” European Heart Journal, vol. 29, pp. 2276–2315, 2008.
[3]
J. J. McMurray, S. Adamopoulos, S. D. Anker, et al., “ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC,” European Heart Journal, vol. 33, pp. 1787–1847, 2012.
[4]
D. G. Fryback and J. R. Thornbury, “The efficacy of diagnostic imaging,” Medical Decision Making, vol. 11, no. 2, pp. 88–94, 1991.
[5]
R. Twerenbold, T. Reichlin, M. Reiter, and C. Müller, “High-sensitive cardiac troponin: friend or foe?” Swiss Medical Weekly, vol. 141, Article ID w13202, 2011.
[6]
F. S. Apple, R. Ler, and M. M. Murakami, “Determination of 19 cardiac troponin I and T assay 99th percentile values from a common presumably healthy population,” Clinical Chemistry, vol. 58, pp. 1574–1581, 2012.
[7]
R. Body, S. Carley, G. McDowell, et al., “Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a high-sensitivity assay,” Journal of the American College of Cardiology, vol. 58, pp. 1332–1339, 2011.
[8]
T. Reichlin, C. Schindler, B. Drexler, et al., “One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T,” Archives of Internal Medicine, vol. 172, pp. 1211–1218, 2012.
[9]
F. S. Apple and P. O. Collinson, “IFCC task force on clinical applications of cardiac biomarkers. Analytical characteristics of high-sensitivity cardiac troponin assays,” Clinical Chemistry, vol. 58, pp. 54–61, 2012.
[10]
R. Body, S. Carley, G. McDowell, et al., “Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a high-sensitivity assay,” Journal of the American College of Cardiology, vol. 58, pp. 1332–1339, 2011.
[11]
A. J. Singer, H. C. Thode Jr., G. B. Green et al., “The incremental benefit of a shortness-of-breath biomarker panel in emergency department patients with dyspnea,” Academic Emergency Medicine, vol. 16, no. 6, pp. 488–494, 2009.
[12]
P. Venge, C. ？hberg, M. Flodin, and B. Lindahl, “Early and late outcome prediction of death in the emergency room setting by point-of-care and laboratory assays of cardiac troponin I,” American Heart Journal, vol. 160, no. 5, pp. 835–841, 2010.
[13]
S. van Wijk, L. Jacobs, L. W. Eurlings, et al., “Troponin T measurements by high-sensitivity vs conventional assays for risk stratification in acute dyspnea,” Clinical Chemistry, vol. 58, pp. 284–292, 2012.
[14]
C. J. Lindsell, D. Raab, M. Sperling, L. Jacobus, and R. J. Ryan, “A time-and-motion study of the processes required to obtain cardiac biomarker assays using both central laboratory and point-of-care testing,” Annals of Emergency Medicine, vol. 52, no. 4, p. S66, 2008.
[15]
R. Bingisser, C. Cairns, M. Christ, et al., “Cardiac troponin: a critical review of the case for point-of-care testing in the ED,” American Journal of Emergency Medicine, vol. 30, pp. 1639–1649, 2012.
[16]
D. Gill, S. Galvin, M. Ponsford, et al., “Laboratory sample turnaround times: do they cause delays in the ED?” Journal of Evaluation in Clinical Practice, vol. 18, pp. 121–127, 2012.
[17]
I. R. Lazarus and W. M. Novicoff, “State of the industry 2004: six sigma enters the healthcare mainstream: six sigma proves its staying power in a crowded field of performance improvement alternatives,” in Managed Healthcare Executive, Advanstar Communications, 2004.
[18]
L. L. Holland, L. L. Smith, and K. E. Blick, “Total laboratory automation can help eliminate the laboratory as a factor in emergency department length of stay,” American Journal of Clinical Pathology, vol. 125, no. 5, pp. 765–770, 2006.
[19]
S. Goodacre, M. Bradburn, P. Fitzgerald et al., “The RATPAC (Randomised Assessment of Treatment using Panel Assay of Cardiac markers) trial: a randomised controlled trial of point-of-care cardiac markers in the emergency department,” Health Technology Assessment, vol. 15, no. 23, pp. 1–102, 2011.
[20]
S. W. Goodacre, M. Bradburn, E. Cross, P. Collinson, A. Gray, and A. S. Hall, “The Randomised Assessment of Treatment using Panel Assay of Cardiac Markers (RATPAC) trial: a randomised controlled trial of point-of-care cardiac markers in the emergency department,” Heart, vol. 97, no. 3, pp. 190–196, 2011.
[21]
N. Christodoulides, F. N. Pierre, X. Sanchez, et al., “Programmable bio-nanochip technology for the diagnosis of cardiovascular disease at the point-of-care,” Methodist DeBakey Cardiovascular Journal, vol. 8, pp. 6–12, 2012.
