Serial Troponin for Atypical Symptoms? – PART III
In general, the literature suggests that elderly patients who present with atypical chest pain should receive at least two troponins for several reasons: 1) though there are many practical reasons to order a single troponin measurement in the ED, the practice of doing so for patients at risk for ACS is not yet supported by rigorous evidence; and 2) elderly patients with atypical presentations (particularly painless shortness of breath) are at risk of worse outcomes and under-treatment compared to patients with classic ischemic chest pain. This being said, there are studies to support the utility of serial troponins at shorter intervals (3-4 hours in particular, but even a 1-hour interval can be justified if a clear time of onset is established). A compromise might be to continue to order serial troponins, but recognize that you don’t always need to adhere to the 6 hour guideline.