Background: Elderly patients who present to the emergency department (ED) with nonspecific complaints (NSC) often undergo troponin testing to assess for atypical presentation of acute coronary syndrome (ACS). However, in this specific population, the rate of ACS and utility of troponin testing have not been previously defined. We sought to determine the rate of ACS and diagnostic yield of troponin testing in elderly patients with NSC.
Methods: We retrospectively identified all patients aged ≥ 65 years triaged in the ED with NSC from 1/1/2017 – 6/30/2017. NSC were defined a priori based on prior literature and included complaints such as weakness, dizziness, or fatigue. NSC were verified in the ED provider notes by trained abstractors blind to testing results. Patients were excluded for focal chief complaint in provider notes, fever at presentation, or if troponin was not ordered. Patients were followed for 30 days. Criteria for ACS were strictly defined and independently adjudicated by 2 trained physician researchers blind to the study hypothesis, with disagreements resolved by discussion. We calculated the proportion of patients with ACS within 30 days and the sensitivity, specificity, and false positive rate of troponin testing to diagnose ACS in the cohort. Elevated troponin was defined by the institutional cutoff, 99th percentile, 4rd generation troponin I.
Results: Initial screening identified 1146 encounters, and 552 were excluded for fever or focal chief complaints in the provider notes. Of the remaining 594 patients, troponin was ordered in 412 (69%), comprising the study cohort. The average age of the study cohort was 79 years, 58% were female and 75% were admitted. Troponin elevation occurred in 81 patients (20%), of whom 5 had ACS. The overall rate of ACS was 5/412 (1.2%). Agreement for adjudication of ACS was 99.5%. Troponin was 100% sensitive (95% CI = 48% to 100%) and 81% specific (77% to 85%) for ACS. Of patients with elevated troponin, 93.8% were false positives (no ACS). All patients with troponin elevation were admitted, but only one underwent angiography and no patients received reperfusion therapy.
Conclusion: While consideration for ACS may be prudent in selected elderly patients with NSC, ACS was rare and reperfusion was not attempted in any patients. Given the high false positive rate, our results do not support routine troponin testing in this population.