Cardiac Biomarker Testing Underutilized in US Emergency Departments

Cardiac biomarker testing across emergency departments (EDs) in the United States, utilized to determine the likelihood of acute coronary syndrome (ACS), revealed that 7% of all presenting patients underwent testing, with approximately two-thirds reporting no chest pain.1

The serial cross-sectional analysis of adult ED visit data found ACS was ≥2% among the subgroup without chest pain, remaining below a benefit-risk threshold for myocardial infarction screening. In contrast, approximately three-fourths of patients with chest pain did not undergo chest pain biomarker testing.

“While undertesting could result in missed myocardial infarction, overtesting may lead to incorrect diagnoses, prolonged hospital stays, and unnecessary cascades of testing,” wrote the investigative team, led by Eric A. Secemsky, MD, MSc, division of cardiology, department of medicine, Beth Israel Deaconess Medical Center. “Little is known regarding recent temporal trends in cardiac biomarker testing in US EDs.”

Symptoms at presentation, alongside individual characteristics, help clinicians stratify patients evaluated in the ED based on their risk of ACS.2 This analysis used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2014 to 2022, classifying the reason for the visit as ‘chest pain,’ ‘non-chest pain anginal equivalent,’ and ‘no anginal symptoms.’

Diagnosis in the ED and hospital primary discharge diagnosis were used to identify ACS. For the analysis, the primary outcome was the proportion of ED visits with cardiac biomarker testing, either troponin or creatine kinase MB. Variables for cardiac biomarker testing were evaluated in survey-weighted logistic regression, adjusting for patient and hospital characteristics, year, and clinician type.1

Among 97,085 ED visits, representing a weighted total of 731,977,412 visits, approximately half (52.4%; 95% CI, 50.8–54.0) included laboratory testing. Analyses showed cardiac biomarker testing represented in 7.0% (95% CI, 6.1%–8.1%) of all ED visits, with no significant changes over time (P = .22).

For the population undergoing cardiac biomarker testing, 34.7% had chest pain, 39.3% had non-chest pain anginal equivalent symptoms, and 26.0% had no anginal symptoms. Among those presenting with chest pain, 25.6% (95% CI, 22.3–29.2) underwent cardiac biomarker testing. Older adults and men showed more frequent rates of testing.

Secemsky and colleagues observed irregular vital signs, including hypotension (odds ratio [OR], 4.13; 95% CI, 1.52–11.20), Asian versus White race (OR, 2.61; 95% CI, 1.57–4.36), and cerebrovascular disease (OR, 2.03; 95% CI, 1.68-2.44) were among the most notable factors in cardiac biomarker testing for those without anginal symptoms.1

Among those evaluated with cardiac biomarker testing, 2.8% were diagnosed with ACS (95% CI, 2.3–3.4), with a similar trend over time (P = .70). Secemsky and colleagues found ACS more common in individuals with chest pain (5.6%; 95% CI, 4.5–7.0) versus non-chest pain anginal equivalent (1.1%; 95% CI, 0.7–1.8) and non-anginal symptoms (1.5%; 95% CI, 0.8–2.9).

“Study limitations include a lack of granular cardiac biomarker data and an inability to adjudicate the appropriateness of testing and ACS diagnosis,” Secemsky and colleagues added.1 “The study data suggest refinements in cardiac biomarker testing strategies are needed to optimize ACS diagnosis.”

References

1. McCarthy CP, Watson NW, Wasfy JH, Baugh CW, Januzzi JL, Secemsky EA. Cardiac Biomarker Testing in US Emergency Departments. JAMA Intern Med. Published online January 27, 2025. doi:10.1001/jamainternmed.2024.7554
2. Yukselen Z, Majmundar V, Dasari M, Arun Kumar P, Singh Y. Chest Pain Risk Stratification in the Emergency Department: Current Perspectives. Open Access Emerg Med. 2024;16:29-43. Published 2024 Feb 4. doi:10.2147/OAEM.S419657