Il tempo di risposta del Laboratorio (turnaround time, TAT) per la troponina (cTn). Raccomandazione del GdS MM SIPMeL
Tóm tắt
La tempestività della risposta della troponina (cTn), misurata come turnaround time (TAT), è critica nella diagnostica della sindrome coronarica acuta (SCA), ma tradizionalmente deve tenere conto della necessità di prelievi multipli con tempistiche definite dalle linee guida. Lo scopo del lavoro è la valutazione della letteratura dal 2013 a oggi nella definizione del TAT di cTn necessario nella diagnosi di SCA nel Dipartimento di Emergenza (DE). È stata condotta una ricerca bibliografica in PubMed e in siti istituzionali e di Società scientifiche per verificare, nell’arco degli ultimi 5 anni, se le linee guida cliniche e di laboratorio che affrontano la diagnosi di SCA definiscano raccomandazioni concernenti TAT di cTn e se sono emerse prove di efficacia, dirette o indirette, degli effetti di TAT cTn sugli esiti clinici e/o organizzativi dei pazienti in DE. Tre su otto linee guida cliniche e cinque su cinque linee guida di laboratorio, così selezionate, convergono nell’indicazione di un TAT di cTn di 1 ora (1 h) o inferiore, che però non si basa su “evidenze” certe del suo effetto sugli esiti organizzativi e/o clinici se non sulla permanenza (length-of-stay, LOS) in DE, che peraltro può produrre effetti negativi sugli outcome del paziente. Tuttavia, la diffusione degli algoritmi diagnostici con troponina ad alta sensibilità (high sensitivity troponin, hs-cTn) per il rule in/rule out di SCA sempre più veloci a 1 h, 30 min e all’ingresso (T0) e di protocolli (accelerated diagnostic pathways, ADP), che di solito contemplano anche ECG e valutazioni del rischio (risk score), permette una decisione clinica in 1 ora per oltre i due terzi e al tempo zero in oltre un terzo dei pazienti presenti in DE con sospetto NSTEMI (non-ST elevation myocardial infarction) in sicurezza (NPV per eventi avversi 98,7–100% e 95,5–100%, rispettivamente). Esiste, però, una discrepanza nell’esatta definizione del TAT di cTn, in particolare del punto di partenza (richiesta, prelievo, arrivo in Laboratorio). Si raccomanda che il TAT di hs-cTn sia inferiore all’ora per rispondere agli algoritmi diagnostici proposti e sia definito identificando il punto di partenza nel prelievo, secondo le linee guida valide ormai da quasi vent’anni.
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