Widely Used Test to Diagnose Heart Attacks Adds No Value, Review Finds

Investigators from Johns Hopkins University and the Mayo Clinic called on their peers to stop using a popular test to diagnose heart attacks, saying it has no value.

Their report, appearing today in JAMA Internal Medicine, crafts a guideline based on peer-reviewed evidence and points to a prior statement from the American College of Cardiology (ACC) that says the creatine kinase-myocardial band (CK-MB) test can no longer be considered an effective biomarker for detecting damaged heart muscle.

This report starts a series of peer-reviewed guidelines from the High-Value Practice Academic Alliance, created by Johns Hopkins School of Medicine and involving faculty from more than 80 institutions. The consortium covers 18 specialties to advance high-value care.

Like the Choosing Wisely initiative, an activity across specialties advanced by the American Board of Internal Medicine Foundation, the initiative seeks to advance high-value care by eliminating those tests or practices which no longer provide actionable information in light of new information, more advanced diagnostic tools, or cheaper, less invasive techniques.

“This article is the first in a series of collaborative multi-institutional publications designed to bridge knowledge of high-value practice,” Jeffrey Trost, MD, assistant professor of medicine at Johns Hopkins School of Medicine and one of the paper’s authors, said in a statement.

A key part of the alliance’s mission is to engage the next generation of medical students in advancing improvements in healthcare.

In starting with heart disease, the alliance addressed the leading cause of death in the United States. Each year, 735,000 people have heart attacks that cause heart muscle damage, and 120,000 people die, according to CDC. About 20% of these are “silent” attacks without symptoms, as opposed to those that present with nausea, pain, dizziness, and fatigue.

Two diagnostic tools that detect heart attacks are cardiac troponin and CK-MB; the first was endorsed by ACC and the European Society of Cardiology as a more ideal biomarker in 2000 due to its higher sensitivity to detect injury. In 2014, the American Heart Association and ACC concluded that CK-MB offered no diagnostic value and should be stopped, since the test adds $416 million annually to healthcare costs.

Trost said the new report is designed to highlight the need to phase out CK-MB in 4 steps:

• Create hospital awareness and education campaign
• Partner with stakeholders in cardiology, emergency medicine, internal medicine, and pathology to remove CK-MB from routine care
• Enlist laboratory personnel and health information technology personnel to create best practice “alerts” to appear on provider systems if clinicians order CK-MB
• Measure test use and include quality care outcomes before and after interventions to eliminate the test.

Reference

Alvin MD, Jaffe AS, Ziegelstein RC, Trost JC. Eliminating creatine kinase—myocardial band testing in suspected acute coronary syndrome: a value-based quality improvement [published online August 14, 2017]. JAMA Intern Med. 2017; doi:10.1001/jamainternmed.2017.3597.