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Come Interpreto le Troponine in OBI …

Come Interpreto le Troponine in OBI …. Andrea Fabbri Dipartimento Emergenza Azienda USL Forlì Email : dr.andrea.fabbri@gmail.com. Defining Increased Troponin. Tpn T and I are not detected in healthy persons Significant Tpn reflects myocardial necrosis

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Come Interpreto le Troponine in OBI …

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  1. Come Interpreto le Troponine in OBI … Andrea Fabbri Dipartimento Emergenza Azienda USL Forlì Email: dr.andrea.fabbri@gmail.com

  2. Defining Increased Troponin • Tpn T and I are not detected in healthy persons • Significant Tpn reflects myocardial necrosis • Detectable Tpn but no  CKMB may indicate microinfarction • Tpn identifies high-risk ACS patients for aggressive therapy • ACC/ESC defined Tpn as a measurement above 99th percentile value of reference group • To reduce false-positive outcomes, CV of 10% at decision limit is recommended

  3. ROC Curve for Tpn T Plot of Sensitivity (TP) vs 1-specificity (FP) Used for establishing best discriminator for cTpnT for predicting AMI Best discriminator point is 0.2 g/L at 9 h after onset of AMi

  4. DiagnosticAccuracyof “hs-Troponin” Assays at Presentation Reichlin T et al, NEJM 2009; 361: 858

  5. 1 ng = 0,000000001 g (nanog) 1 pg = 0,000000000001 g (picog) Analyte, Cut Point Sensitivity Specificity PPV NPV (95%CI), % (95%CI), % (95%CI), % (95%CI), % Diagnostic accuracy for ACS in all pts (AUChsTnT: 0.79) hsTNT, 13 pg/mL 62 (47-78)* 89 (85-92) 38 (26-50) 96 (93-98) cTnT, 0.03 ng/mL 35 (20-50) 99 (96-99) 72 (52-93) 93 (90-95) Diagnostic accuracy for UA pts in pts without MI (AUChsTnT: 0.72) hsTnt, 13 pg/mL 55 (37-74)* 89 (85-92) 30 (18-44) 96 (93-98) cTnT, 0.03 ng/mL 21 (8-40) 99 ( 97-100) 55 (23-83) 94 (90-96) * P<0.001 vs cTnT Jannuzzi Jr, Circulation 2010;121:1227

  6. Position Paper ANMCO 2009 Percorso di valutazione del dolore toracico G Ital Cardiol 2009; 10: 46-63 Ottani F, Binetti N, Casagranda I, Cassin M, Cavazza M, Grifoni S, Lenzi T, Lorenzoni R, Sbrojavacca R, Tanzi P, Vergara G, a nome della Commissione Congiunta ANMCO-SIMEU • Utilizzo appropriato • Sospetta SCA: efficienza diagnostica e prognostica • Screening nel paziente “acuto” in DE: dati incerti e confondenti • Percorso appropriato • Controlli seriati • Almeno 2 controlli • Adeguata finestra temporale dall’inizio del sintomo

  7. Biomarcatori di necrosi miocardica (Troponina) • Elevazione = danno miocardico • Elevazione = non solo IMA • Elevazione = prognosi peggiore

  8. Elevazioni di troponina: diagnosi differenziale …. • SCA • Insufficienza renale • Scompenso cardiaco e shock cardiogeno • Embolia polmonare • Miocardite • Aritmie ipercinetiche e ipocinetiche • Sincope • Trauma cardiaco • Insufficienza respiratoria severa • Stato settico • Ictus, emorragia cerebrale • Terapia antiblastica • Cardioversione elettrica, AICD, ablazione • Interferenze da AC-eterofili • ….

  9. Demand Ischemia Sepsis / SIRS Demand /Supply mismatch Hypotension Decreased perfusion pression Hypovolemia Decreasd filling pressure /output SVT / AF Supply-demand mismatch Left Ventricular Subendocardial Ischemia Hypertrophy Myocardial Ischemia Coronary Prolonghed Vasospasm Ischemia Stroke Imbalance of Autonomic Nervous System Sympathomimetics Adrenergic effect Diagnosis Diagnosis Mechanism Mechanism Direct Myocardial Damage Contusion Cardioversion Infiltrative Dis. Chemother. Myocarditis / Pericarditis Cardiac Transplant Myocardial Strain CHF PE Pulm. Hypertension Strenuous Exercise ESRD Traumatic Traumatic MyociteInjury DirectToxicity Inflammatory Inflammatory Wall stretch RV stretch RV stretch RV stretch Unknown Jeremias A, Ann Intern Med 2005 Boston

  10. 883 patients with increased troponin I levels

  11. Causes for troponin increase in no-ACS patients

  12. Denmark Jensen JK, Am J Cardiol 2007

  13. G1: TnT <0,02 ng/mL (n=33) G2: decreasing TnT (n=10) G3: persistently increased TnT (n=17) Sato,Circulation 2001 Kyoto, Japan

  14. 58 casi Horwich TB, Circulation 2003 USA

  15. You J.J., Am Heart J 2007;153:462-70 Toronto

  16. cTnT: III-gen. test. cTnI II gen. Test. Cut-off 0.1 g/L Pts. with at least 2 positive results (cTnI or cTnT) called “positive.” Ammann P, JACC 2003 Zurich

  17. 23 studi = 4,492 soggetti critici In 20 studi ↑ cTnI nel 43% (IQR 21%-59%) dei casi. In 6 studi (N = 1,706) ↑ cTnI maggior mortalità OR 2.5 (95% CI 1.9–3.4). In 8 Studi (N = 1,019) ↑ cTnI si associa a >ICU stay 3 gg (1.0–5.1. Lim W, Arch Intern Med 2006 Toronto

  18. Toronto Lim W, Arch Intern Med 2006

  19. You J.J., Am Heart J 2007;153:462-70 Toronto

  20. Redfearn DP, Int J Cardiol 2005

  21. Quenot JP, Chest2005

  22. James P, et al. BMJ 2000

  23. Hays A, Neurology 2006

  24. Risk Factors for late diagnosis Rapezzi, Am J Cardiol 2008

  25. Le Conclusioni … Come Interpreto le Troponine in OBI… • Adeguata conoscenza del biomarcatore in uso • Livelli decisionali locali (99° percentile, CV <10%) • Popolazione di riferimento “normale” • Diagnosi di necrosi miocardica, non meccanismo … • Applicazione nel contesto clinico adeguato .. • Controlli seriati (minimo 2, idealmente 3) • Adeguata finestra temporale dall’esordio • Adeguata processazione del campione • Nei casi dubbi: ripetere il dosaggio dello stesso campione • Attenzione ai “positivi” ..

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