LVHN Ahead of the Chest Pain Curve

Like clues at a crime scene, our bodies can leave important evidence to point doctors in the right direction for treatment.

With a suspected heart attack, one of those clues is the level of a protein in your bloodstream called troponin (trow-puh-nuhn).

Since late 2021, Lehigh Valley Health Network (LVHN) doctors have been using high-sensitivity troponin testing to assess people with chest pain.

The result – more patients found to have no heart damage and a low risk for a heart attack are being safely discharged home, providing more resources for patients who need to be admitted for monitoring or emergency testing, such as an angiogram. Last year, 10% more patients were safely discharged home than the previous year.

“Within three hours, we can assess a patient and if results are good, we can release them with the reassurance that there’s nothing going on and that’s a big deal,” Richard MacKenzie, MD, Senior Vice Chair, Emergency and Hospital Medicine, LVHN, says.

In addition to an electrocardiogram (ECG), which remains the first and most immediate test for chest pain patients, high-sensitivity troponin testing is used to determine if a heart attack has occurred or is in progress. ECGs performed and interpreted within 10 minutes of a chest pain patient’s arrival measure heart rhythm and electrical activity. But a seemingly normal ECG doesn’t rule out a heart attack.

How sensitive is high-sensitivity troponin testing? It’s measured in nanograms per liter. That’s an extremely minute quantity – a nanogram is a billionth of a gram.

Troponin is normally present in your blood in extremely low levels. A heart attack damages heart muscle, releasing more troponin when heart muscle cells die. If you’re having a heart attack, troponin levels will rise in your bloodstream and be detected by the new high-sensitivity testing. Rising troponin levels can signal a heart attack from a blocked artery or other causes.

High-sensitivity troponin testing provides an extremely detailed method for detecting heart muscle injury. “We can detect even the slightest elevation in the troponin molecule. Importantly, high sensitivity troponin tests also allow identification of people with a very low risk of a heart attack. That’s what makes this so wonderful,” says cardiologist Bruce Feldman, DO, with LVH Cardiology–1250 Cedar Crest and Lehigh Valley Heart and Vascular Institute.

But it’s not always so cut and dried. If you have chest pain and are in the emergency room 10 minutes later, your troponin levels may be normal because it usually takes 1-3 hours for the troponin to be detected in the blood. Under the new testing regimen, patients are tested when they arrive and then an hour later. The sensitivity of the testing finds even small increases in troponin undetected by prior testing methods.

“We could see a significant change in the troponin level, indicating a high risk for a heart attack,” Feldman says. “Even if that second troponin level remains in the normal range, a significant change means the patient is at high risk and needs additional testing and treatment. Measuring the high sensitivity troponin level this way also shortens the time for the emergency room physician to decide on discharge versus the additional in-hospital testing.”

Decisions on whether to discharge or keep a chest pain patient are now typically made within 3-4 hours of the patient arriving at the hospital. That’s a stark contrast to the former method of testing, where patients would need 4-12 hours before a decision was made. On top of that time frame, many patients also were advised to have a stress test before discharge, extending the time in the hospital up to 24 hours. “The whole process was prolonged,” Feldman says. “Now, using the new high-sensitivity troponin test, we can rapidly decide if the patient is having heart injury.”

According to one study, just one in three hospitals nationwide were using high-sensitivity troponin testing at the end of 2021, a number that is expected to rise.

At LVHN, doctors are not only using high-sensitivity troponin data to assess chest pain patients accurately and quickly, they also have a powerful and unique digital dashboard with real-time information on chest pain cases across the network. That’s 15,000 cases a year.

“We can measure real time how many people are having major adverse cardiac events. We’re on top of the data,” Mackenzie says. Among discharged patients with no heart injury and a low risk for a heart attack, MacKenzie says, the dashboard data showed nearly 100% don’t have a major heart-related problem for the next 90 days.

Being able to see cardiac patient experience across the network lets Lehigh Valley Heart and Vascular Institute plot trends and react to changing data. “It lets us know how we can better treat our patients, to give better care,” MacKenzie says.

MacKenzie and Feldman credit LVHN’s Enterprise Analytics Group with custom development of the dashboard.

Chad Keller, a medical student with the LVHN-University of South Florida Morsani SELECT medical school program, says LVHN’s chest pain dashboard is revolutionizing how the health network monitors the way it cares for patients who come to the emergency room with chest pain.

“This groundbreaking dashboard allows for a streamlined approach to assessing the care of chest pain patients in real time without the need to review charts individually,” Keller says. “The removal of this time-intensive step will expedite the study of chest pain care at LVHN, enabling the network to stay at the forefront of best medical practices.”

Feldman says the dashboard “allows us to assess the quality of care and identifies opportunities for improving the care process.”

Feldman has been with LVHN for 37 years and has seen the evolution of chest pain and heart attack care nationally. About 25 years ago, he and MacKenzie were part of a multi-disciplinary group at LVHN, organized to improve the care of patients with an acute heart attack. The team created a process to rapidly identify the high-risk patient and provide rapid emergency care. Reducing the time from symptom onset to treatment saved lives.

Feldman then turned his attention to improving the process of care for those at low risk for a heart attack. A very low percentage of patients coming into an emergency room with chest pain are having a heart attack. Last year, among 15,000 chest pain patients who came to LVHN’s emergency rooms, only about 400 were having a life-threatening heart attack.

In late fall 2021, LVHN shifted to high-sensitivity troponin testing and Feldman led the effort to educate emergency department doctors, nurses and other clinicians. He helped implement a new process of care for doctors using the new high-sensitivity troponin to perform risk assessment and categorize patients as low, intermediate or high risk. The dashboard was developed to see if the new risk assessment system was effective and safe.

One year later, Feldman and MacKenzie are excited to see that dashboard data confirmed the new care process quickly identified low risk patients safe for discharge. The data also highlighted areas for improvement.

“World-class heart care like this is just one more reason why LVHN is the region’s heart care leader, why more people trust LVHN and Lehigh Valley Heart and Vascular Institute,” Eric Elgin, MD, Chief, Division of Cardiology, Lehigh Valley Heart and Vascular Institute says. “Taking care of the toughest heart challenges is important, but so is giving peace of mind to chest pain patients whose problem isn’t heart related. Our community’s trust in us grows in each case.”