• Michael Berkwits, A Russell Localio, and Stephen E Kimmel.
• Philadelphia VA Medical Center and the Division of General Internal Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA. berkwits@mail.med.upenn.edu
• J Gen Intern Med. 2005 Jul 1;20(7):584-92.

BackgroundCardiac troponin is more accurate than creatine kinase (CK) testing for detecting myocardial injury in patients with acute coronary syndromes (ACS), but its effects on clinical care compared with CK testing alone is open to question.ObjectiveTo test the effects of troponin I on medical decisions for patients undergoing cardiac enzyme testing.DesignRandomized, controlled trial.SettingUrban academic Veterans Affairs medical center.PatientsThree hundred ninety-two patients presenting to the emergency department (ED) and outpatient settings with symptoms and/or electrocardiograms suggestive but not diagnostic of ACS.InterventionRandom assignment to linked CK-troponin I (CKTnI) testing or CK testing alone.MeasurementsED discharge and cardiac catheterization incidence (primary); ED medication use, inpatient noninvasive testing, revascularization procedures, discharge medications, and 8-week ED visits, hospitalizations, and procedures (secondary).ResultsGroups were similar in all variables except history of heart failure (CK 26.8% vs CKTnI 17.0%). ACS comprised 12.2% of the cohort. ED discharge incidence was greater in the CKTnI arm (18% vs 9.6%; relative risk [RR], 1.83; 95% CI, 1.08 to 3.31; P=.02; number needed to test=12.6; 95% CI, 4.5 to 130). Troponin testing had no significant effect on catheterization incidence (18.2% vs 14.5%; RR, 1.19; 95% CI, 0.72 to 1.92; P>.20) or other outcomes except follow-up echocardiography (13.4% vs 7.4%; RR, 2.24; 95% CI, 1.11 to 4.69; P=.02).ConclusionsIn a veterans population undergoing cardiac enzyme testing, CKTnI testing led to more ED discharges than CK testing alone but had no effect on inpatient care and was associated with more echocardiograms in a follow-up period.

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