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Cardiac troponin testing for diagnosis of acute coronary syndromes in primary care

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Acute coronary syndromes (ACS) are a leading cause of illness and death in Australia. Around 75 000 Australians are hospitalised for ACS each year, with $8 billion spent annually on related inpatient care.1 While mortality caused by ACS is declining because of better control of coronary risk factors and the introduction of new treatments,2 at least 10 000 Australians still die each year as the result of ACS.1

The spectrum of ACS includes unstable angina, where atherosclerotic plaque rupture leads to arterial occlusion and myocardial ischaemia, and myocardial infarction, where ischaemia progresses to myocardial cell necrosis. Further classification into ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) is based on electrocardiographic (ECG) findings. Overall, the rate of inhospital major adverse cardiac events caused by ACS (death, cardiac arrest, recurrent myocardial infarction, worsening heart failure, major bleeding or stroke) approaches 30% for STEMI and 20% for NSTEMI.3 Patients with unstable angina are also at increased risk of death and subsequent myocardial infarction, even in the absence of myonecrosis.4

Diagnosing ACS is challenging in primary care as well as in the tertiary setting; 15% of patients who experience…