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Praticare l’appropriatezza: il caso della troponina

Practicing appropriateness: the case of troponin

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La Rivista Italiana della Medicina di Laboratorio - Italian Journal of Laboratory Medicine

Riassunto

Gli esami di laboratorio contribuiscono in maniera considerevole al processo decisionale clinico e il numero di test che un moderno Laboratorio clinico esegue è oggi considerevole. L’impatto della Medicina di Laboratorio in Cardiologia è aumentato considerevolmente nel corso degli ultimi anni. Le troponine cardiache T e I (cTnT e cTnI) sono universalmente ritenute i biomarcatori di riferimento per la rilevazione di danno miocardico, e quindi anche per la diagnosi di infarto del miocardio. Recentemente sono stati introdotti nuovi metodi di determinazione delle cTn, caratterizzati da un considerevole miglioramento della sensibilità analitica e dell’imprecisione alle basse concentrazioni. Questi dosaggi, definiti di “ultima generazione”, consentono infatti di rilevare concentrazioni di cTn che non erano quantificabili con i metodi precedenti. Se da un lato ciò ha portato a un presunto aumento della sensibilità diagnostica per infarto miocardico, la controparte è stata una perdita di specificità. Per ovviare a tale problematica sono stati proposti algoritmi diagnostici basati su valutazioni seriali del biomarcatore, anche se il punto focale rimane comunque l’appropriatezza della richiesta. In conclusione, come spesso è accaduto in Medicina di Laboratorio, la sfida maggiore nell’utilizzo dei metodi ad alta sensibilità per la determinazione delle cTn è rappresenta dalla richiesta inappropriata e dall’inappropriata interpretazione del risultato, e non dal biomarcatore per sé.

Summary

Laboratory testing significantly contributes to the clinical decision making, and the number of tests that a modern clinical laboratory can now perform is considerable. The impact of Laboratory Medicine in Cardiology has substantially evolved and increased over the past years. The cardiac troponin I and T (cTnI and cTnT) are universally regarded as the reference biomarkers for detection of myocardial injury and, understandably, for the diagnosis of myocardial infarction. Novel immunoassays for measurement of cTns have been recently introduced, which are characterized by a considerable improvement of analytical sensitivity and lower imprecision at low concentrations of the proteins. This assays, defined as last generation or high-sensitivity, allow to detect cTn concentrations that were virtually undetectable with the previous methods. On the one hand this has remarkably improved the diagnostic sensitivity for diagnosing myocardial infarction but, on the other, this has reduced the diagnostic specificity. A potential solution of this problem entails diagnostic algorithm based on the serial evaluation of these biomarkers, although the crucial issue still remains the appropriateness of the request. In conclusion, as often occurred in Laboratory Medicine, the leading problem with the use of highly-sensitivity cTn assays is the inappropriateness of ordering and interpretation of test results, and not the biomarker in itself.

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Authors and Affiliations

  1. Laboratorio di Biochimica Clinica, Ospedale Regionale di Bolzano, Via L. Boehler 5, 39100, Bolzano, Italia

    Massimo Daves & Erika Jani

  2. Divisione di Cardiologia, Ospedale Regionale di Bolzano, Bolzano, Italia

    Roberto Cemin

  3. Pronto Soccorso e Astanteria, Ospedale Regionale di Bolzano, Bolzano, Italia

    Giuseppe Sacco

  4. Laboratorio di Chimica Clinica ed Ematologia, Ospedale Universitario di Parma, Parma, Italia

    Giuseppe Lippi

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  1. Massimo Daves
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  2. Roberto Cemin
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  3. Erika Jani
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  4. Giuseppe Sacco
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  5. Giuseppe Lippi
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Correspondence to Massimo Daves.

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Daves, M., Cemin, R., Jani, E. et al. Praticare l’appropriatezza: il caso della troponina. Riv Ital Med Lab 10, 82–88 (2014). https://doi.org/10.1007/s13631-014-0056-0

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