The annual global mortality associated with acute myocardial infarctions (AMI) is estimated to be three million people, with more than one million deaths in the United States (U.S.) [1]. Missed MI is uncommon (2%); however, it is associated with a 1.9 increased risk of mortality [2]. Rapid identification of patients with suspected AMI is critical.

The U.S. Food and Drug Administration (FDA) approved the use of the fifth-generation hs-cTn assay in January 2017 [3]. It was first available in 2011 and widely used in Europe [4]. Both the 2021 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines and 2020 European Society of Cardiology (ESC) guidelines recognize hs-cTn as the preferred biomarker for cardiomyocyte injury in patients with suspected non-ST elevation-acute coronary syndrome (NSTE-ACS) [5,6]. To note, the ESC guidelines recommend 0-h/1-h and 0-h/2-h algorithms (i.e. obtaining hs-cTn on ED presentation and repeating it 1-h or 2-h after presentation) but downgraded the 0-h/3-h algorithm due to evidence showing it is not as effective to exclude MI.

The newer generation assay can quantify cTn at lower concentrations with higher precision [4]. The advantages of this assay include rapid evaluation of patients who are suspected to have AMI and faster rule-out of ACS in low-risk patients [7]. According to ESC, the hs-cTn assay has a higher negative predictive value for acute myocardial ischemia, an increase of 4% (absolute) and 20% (relative) in the detection of type 1 MI, a decrease in diagnosis of unstable angina, and a 2-fold increase in diagnosis of type 2 MI [6]. The literature on the implementation of hs-cTn demonstrates these findings; it also shows an association between hs-cTn and a reduced length of stay [[8], [9], [10], [11], [12], [13], [14], [15]]. For cardiac studies, hs-cTn has been associated with more electrocardiogram (ECG) tests and transthoracic echocardiogram (TTE) but fewer computed tomography (CT) scans, stress tests, cardiac medications, cardiology evaluations, or hospitalizations [13,16]. Furthermore, with high sensitivity assays becoming more available, there has also been a focus on studying whether measuring different types of cardiac troponin (cardiac troponin T versus cardiac troponin I). A study looking into the association between cardiovascular disease (CVD) related death and the type of cardiac troponin measured has shown that cardiac troponin I is more likely to be related to CVD related death, while cardiac troponin T was more strongly associated with non-CVD related death [17].

From the literature review, resource utilization seems variable across different institutions [18]. The use of hs-cTn has increased over the years; however, according to a recent study, most U.S. hospitals continue to use other assays [16]. At Rush University Medical Center (RUMC), the hs-cTn algorithm was designed based on expert consensus from the Rush Chest Pain Center with adaptation from the 2015 ESC guidelines and a review of protocols from other institutions with successful adaptation. The hs-cTn assay was implemented at RUMC on July 1, 2021. This study sought to evaluate the impact of transitioning from cTn to hs-cTn on hospital resources, with. Since the completion of our study the ACC has published guidelines recommending the implementation of hs-cTn. This study demonstrates that the use of hs-cTn has downstream sequelae [19].