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New Blueprint Helps EDs End Use of CK-MB Testing for Diagnosing Heart Attack

Several studies have found that creatine kinase-myocardial band (CK-MB) testing can no longer be considered an effective biomarker for detecting damaged heart muscle, and the American College of Cardiology issued a statement more than a decade ago saying the assay can be safely eliminated from practice.

Now, researchers from the Johns Hopkins University School of Medicine and the Mayo Clinic have compiled peer-reviewed evidence and created a guideline designed to help emergency departments, other hospital departments, and physicians end their use of the commonly used blood test.

Their special communication in JAMA Internal Medicine underscores that the test, which adds no value in evaluating patients with suspected heart attack, has continued to be used at higher than expected rates.

The peer-reviewed implementation guide was co-authored by faculty from the High Value Practice Academic Alliance (HVPAA), a national coalition created by the Johns Hopkins University School of Medicine. The coalition involves representatives from more than 80 academic institutions, representing 15 medical specialties and subspecialties.

“This article is the first in a series of collaborative multi-institutional publications designed to bridge knowledge to high value practice,” explained corresponding author Jeffrey Trost, MD, assistant professor of medicine at the Johns Hopkins University School of Medicine. “We present multiple quality improvement initiatives that safely eliminated CK-MB to give providers reassurance about trusting troponin levels when managing patients with suspected acute coronary syndrome."

For many years in the ED, cardiac troponin and CK-MB were measured to help diagnose heart attacks. In 2000, the American College of Cardiology and the European Society of Cardiology determined that cardiac troponin is the superior biomarker because of its high sensitivity for detecting injury to the heart. Four years later, the American Heart Association and the American College of Cardiology guidelines concluded that CK-MB provides no additional diagnostic value for diagnosing heart attacks.

Trost pointed out that despite these recommendations, a 2013 survey conducted by the College of American Pathologists found that 77% of nearly 2,000 labs in the U.S. still used CK-MB as a cardiac damage biomarker.

The report noted that the continued use of CK-MB testing adds $416 million each year to the cost of care. The research team suggested that those expenses are unnecessary since cardiac troponin is not only better for initial diagnosis, but it also is a more definitive predictor of in-hospital mortality and severity of disease.

For EDs and other hospital departments who still measure the biomarker, Trost and his colleagues provide a plan for phasing out CK-MB testing based on the U.S. Health Resources and Services Administration's strategies for implementing any quality improvement initiative.

The plan involves the following four steps:

  • Design and implement a hospitalwide education campaign.
  • Partner with clinical stakeholders (in cardiology, emergency medicine, internal medicine, laboratory/pathology) to remove CK-MB from standardized heart disease routine order sets.
  • Enlist information technology/laboratory medicine staff to create and integrate a best practice "alert" that appears on any computerized provider order entry system when clinicians order CK-MB.
  • Measure use of the test, patient care quality, and safety outcomes before and after the intervention.