CME: Cardiac Biomarker Testing in the ED

CME: Cardiac Biomarker Testing in the ED
Author Information (click to view)

Anil N. Makam, MD, MAS

Assistant Professor
Division of Internal Medicine
Department of Clinical Sciences
UT Southwestern Medical Center

Anil N. Makam, MD, MAS, has indicated to Physician’s Weekly that he is currently supported by the National Center for Advancing Translational Sciences of the NIH (KL2TR001103).

Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

  1. Review the findings of a study of the overall use of cardiac biomarker testing and stratified testing by disposition status and selected characteristics among adult emergency department visits.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at

Credit Available(click to view)


CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.


AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Anil N. Makam, MD, MAS
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.


Anil N. Makam, MD, MAS (click to view)

Anil N. Makam, MD, MAS

Assistant Professor
Division of Internal Medicine
Department of Clinical Sciences
UT Southwestern Medical Center

Anil N. Makam, MD, MAS, has indicated to Physician’s Weekly that he is currently supported by the National Center for Advancing Translational Sciences of the NIH (KL2TR001103).

Cardiac biomarker testing in the ED is common, even among those without symptoms suggestive of acute coronary syndromes. Such testing is also frequently used during visits with a high volume of other tests or services. Efforts are needed to use cardiac biomarkers more appropriately.

Cardiac biomarkers have emerged as a powerful tool to rapidly detect an acute coronary syndrome (ACS), but these biomarkers can also be detected in various other illnesses (eg, false-positive result). Throughout the United States, EDs are increasingly using sensitive assays for cardiac biomarkers to diagnose ACS early so that clinicians can initiate potentially life-saving evidence-based therapies in a timely fashion.

Non-traumatic chest pain is a symptom that is typically associated with suspected ACS and ranks among the most common reasons for visits to the ED. However, cardiac biomarker testing is not routinely recommended for all patients who present to the ED. “Most patients who are diagnosed with ACS initially present to the ED with chest pain,” explains Anil N. Makam, MD, MAS. He notes that even with highly sensitive assays, decisions to test for cardiac biomarkers should be considered in the context of patients’ clinical presentation.

“Using cardiac biomarker testing in patients with an extremely low probability of ACS is likely to result in substantial downstream harms from false-positive test results,” Dr. Makam says. “These include patient anxiety, inappropriate additional testing, and unnecessary treatments.” However, it is challenging to estimate the potential extent of harm from false-positive test results because little is known about the current rates of cardiac biomarker testing in EDs.

Assessing Test Use

For a study published in JAMA Internal Medicine, Dr. Makam and Oanh K. Nguyen, MD, MAS, sought to determine the overall use of cardiac biomarker testing and stratified testing by disposition status and selected characteristics. The retrospective study involved adult ED visits that were selected from the 2009 and 2010 National Hospital Ambulatory Medical Care Survey, a probability sample of ED visits in the U.S. Cardiac biomarker tests assessed in the study included creatinine kinase MB, troponin I, and troponin T. ACS-related symptoms were defined broadly to capture all individuals who may have had even the slightest suspicion of ACS (ie, malaise). “We wanted to look at how cardiac biomarker testing is used in EDs and assess patient and visit characteristics that correlated with testing,” says Dr. Makam.

According to the results, cardiac biomarkers were tested in 16.9% of ED visits, representing 28.6 million visits during the 2-year study period (Figure). Cardiac biomarker testing occurred in 8.2% of visits in the absence of ACS–related symptoms, representing 8.5 million visits. “Among visits with cardiac biomarker testing performed, almost one-third had testing in the absence of ACS symptoms.” Dr. Makam says. Among ED patients who were later hospitalized, cardiac biomarkers were tested in 47.0% of all visits. In this patient group, testing of cardiac biomarkers occurred in 35.4% of visits despite the absence of ACS-related symptoms.

Examining Potential Reasons

The study also highlighted several potential reasons why healthcare providers may perform cardiac biomarker testing even in the absence of symptoms that are suggestive of ACS. Increasing patient age and disposition status were significant predictors of cardiac biomarker testing. This suggests that testing occurs disproportionately among patients who are perceived as being sicker.

“The number of other tests or services performed was the strongest predictor of biomarker testing, independent of symptoms of ACS,” says Dr. Makam. When compared with zero to five other tests or services being performed, more than 10 other tests or services being performed was associated with 59.6 times the odds of cardiac biomarker testing.

There are many reasons why high-volume testing may occur. Healthcare providers who order these tests may be fearful of missing a diagnosis and, as a result, order these tests just in case. Pressures to ascertain a quick diagnosis, diagnostic uncertainty, and practice culture are other potential reasons for testing of cardiac biomarkers when there are no symptoms suggestive of ACS.

Considering the Implications

Cardiac biomarkers are extremely useful when tested in patients with suspected ACS. However, testing patients without symptoms suggestive of ACS can lead to harm. “When we extrapolate our findings, our conservative estimate is that there were 1.7 million U.S. patients with a false-positive cardiac biomarker test over our 2-year study period,” Dr. Makam says. “We need to consider the downstream ramifications of inappropriate cardiac biomarker testing, including unnecessary additional tests and treatments. Our study is a first step toward gaining a better understanding of the potential harms of both inappropriate testing and false-positive results. More attention is needed to better characterize these harms and to develop strategies for targeted and appropriate use of cardiac biomarker tests in the ED setting.”

Readings & Resources (click to view)

Makam AN, Nguyen OK. Use of cardiac biomarker testing in the emergency department. JAMA Intern Med. 2015;175:67-75. Available at:

Newby LK, Jesse RL, Babb JD, et al. ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2012;60:2427-2463.

de Lemos JA, Morrow DA, de Filippi CR. Highly sensitive troponin assays and the cardiology community: a love/hate relationship? Clin Chem. 2011;57:826-829.

Bandstein N, Ljung R, Johansson M, Holzmann MJ. Undetectable high-sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction. J Am Coll Cardiol. 2014;63:2569-2578.

Lindsell CJ, Anantharaman V, Diercks D, et al; EMCREG-International i*trACS Investigators. The Internet Tracking Registry of Acute Coronary Syndromes (i*trACS): a multicenter registry of patients with suspicion of acute coronary syndromes reported using the standardized reporting guidelines for emergency department chest pain studies. Ann Emerg Med. 2006;48:666-677.

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