Troponina
Troponinosi
?
NonècardiospecificaNonèsinonimodiIMA
NonèimportanteIlpazientenonècardiologico
Latroponinaècardiospecifica?
LetroponinecardiachesonocomponenEdell’apparatocontraGledeimiociE
TroponinaTeI:ada9earilevareundannomiocardicoperchèespressecomeisoformecardiospecifiche
Aumentasolosecondariamenteanecrosimiocardica?
ischemic,inflammatory,infiltra:ve,directtrauma,andtoxiccauses
1%annualturnoverattheageof25to0.45%attheageof75years15minofmildischemia:developmentoftroponinIdegrada:onproducts
Reversibleinjurytothemyocytemembrane:myocardialstretch,ischemia.
IMA=TROPONINA?
Troponina:goldstandardperladiagnosidiinfartomiocardicoacutoTipicacurvadellatroponinasoprail99°percenEledellapopolazione
IMA:necrosimiocardicadovutaadischemia
IncrementodellatroponinanonèsinonimodieventocoronaricoacutoomalaGa
cardiaca
E’sinonimodimalaSacoronarica?
CarenzadiO2almiocardioperaumentaterichiesteeridoXoapporto(ipossia,ipotensione,anemia):IMA:poII
DannomiocardicodireXodaendotossine,citochine,radicalitossici,
Dannomiocardiconeuromediato(adrenalina)
Stretchventricolare,strainventricolodestro
Qualsiasiincrementoditroponinaanchesenonèsinonimodisindromecoronaricaacutarappresentaunaanomaliacardiacaehaunvaloreprognos:co.
Troponinosi:falsiposi:vi?
……..manonindicailmeccanismoso9ostante
Conclusioni
Unincrementoditroponina:• E’sempreunimportantemarkerdigravitàdelpaziente• E’sempresinonimodidannomiocardico• E’condizionenecessariamanonsufficienteperladiagnosidiIMA• E’unfaXoreprognos:camentenega:vonell’IMA,nellealtre
causecardiacheenoncardiachedidannomiocardico• IlvaloreassolutoelevatoèunacaraXeris:caprognos:canega:va• LapresenzadiunacurvaèunacaraXeris:caprognos:canega:va• Nonfornisceindicazionisulmeccanismodinecrosi/ischemia/
dannomiocardicochepuòsoloessereiden:ficatoclinicamente
TherearenoguidelinestotreatpaEentswithelevatedcTnlevelsandnocoronarydisease.ThecurrentstrategyoftreatmentofpaEentswithelevatedtroponinandnon-ACSinvolvestreaEngtheunderlyingcauses.
Agewall,EuropeanHeartJournal(2011)32,404–411
• Cos’èlatroponina• Perchélatroviamonelsangue• DiagnosidiIMA• IeII:po• AltopotereprediSvnegtaivo• Significatoprognos:co• Altrecondizionicardiache• Significatoprognos:co• Condizioninoncardiache• Significatoprognos:co• Importanzadelvaloressoluto• Importanzadelladinamica• Importanzadellaclinica
• Approximately5%to8%oftroponinIandTisunboundin• thecytosol(11)oraspartofanearlyreleasablepool(12).• Thisunboundpooloftroponinisreleasedfirst,regardlessof• thecauseofthetypeofmyocyteinjury(Table1).Itwould• beexpectedthatifthereisreleasefromthispoolthatthe• troponinwouldbereleasedquicklyandthatbloodlevels• wouldfallwithrapidwashout.Thehalf-lifeoftroponinT• andtroponinIinthebloodisabout2h(13).Rapidriseand• fallwithin24hmaythereforebeconsistentwithreleaseof• thispoolandreversiblemyocytedamageratherthanmyocyte• necrosiswherea:me-dependentfalloveralonger• period(4to10days)wouldbeexpectedbecauseofgradual• degrada:onofmyofibrilsandreleaseofthetroponincomplex• (11).Theprolongedhalf-lifeseeninACSmaybedue• tocon:nuedbreakdownofthecontrac:leproteins.
Insufficienzarenalethesourceofthetroponinisclearlyofcardiacorigin.TheexactdegreeofdependenceoftroponinIorTonrenalfunc:onfortheirclearanceremainsunknown;however,itisincreasinglyheldthatalargepercentageofcircula:ngtroponinsinpa:entswithchronickidneydiseasemaybeexplainedbyunderlyingstructuralheartdiseaseand/ordirecttoxiceffectsofrenalfailureonthemyocardium,ratherthananyeffectontroponinclearance;52basedonthemolecularweightoftroponin,itsclearanceshouldbelessdependentonglomerularfiltra:on.whenelevatedinapa:entwithrenalfailure,troponinsaremarkedlyprognos:c.Thus,atroponinabovethe99thpercen:leinanHFpa:entwithrenalfailureshouldnotbesimplydiscardedasa‘falseposi:ve’duetoreducedclearance.WhiletroponinTappearstobemorelikelytobemeasurableorfranklyelevatedinpa:entswithrenalfailurecomparedwithtroponinI,withthegrowinguseofhighlysensi:vemethodsfortroponintes:ng,itremainstobeseenifthisdifferencebetweentroponinTandIinrenalpa:entswillpersist.
Scompensocardiacoacuto
Inacuteheartfailure†Thetroponinvalueshouldbepromptlymeasured,withthegoaltoconfirmorexcludeTypeIMIastheprecipitant†AnelevatedtroponinshouldalwaysbeinterpretedwithahighlevelofsuspicionforTypeIMI,par:cularlyinthecontextofariseorfallofthemarker,typicalsymptoms,orsignsofischaemiaonnon-invasivetes:ngorevidencefornewlossofmyocardialfunc:on†TroponinvaluesmayriseintheacuteseSngandfallduringtreatmentofHFinhospitalizedpa:ents.PaXernsoftroponinreleasecannotbeusedtoinferacoronaryvs.non-coronarymechanismandnoassump:onsregardingthepresenceorabsenceofanacutecoronarysyndromeshouldbemade†Troponinvaluesabovethe99thpercen:lehaveconsistentlybeenassociatedwithahighlikelihoodforanadverseoutcomeinacuteHFindependentofincidentMI.Higherconcentra:onsareassociatedwithaworseoutcome†BesidesappropriatetreatmentforTypeIMI,dataarelackingaboutspecifictherapeu:cinterven:onfortroponinvaluesabovethe99thpercen:leinacuteHF
Cardiactroponinsarecomponentsofthecontractualapparatusincardiacmyocytesandareexpressedexclusivelyintheheart.Anumberofnonischemiccondi:onsincludingmyocardi:s,pulmonaryembolism,acuteandchronicheartfailure,andsepsismaybeassociatedwithelevatedtroponinlevels(1,2),althoughtheymayincludesupply–demandimbalanceandthusatleastsomeelementofischemia.Eleva:onoftroponinswiththesecondi:onsisassociatedwithworseprognosisthantheprognosisforpa:entswithouttroponineleva:ons,andtheprognosisisusuallyworsethanthatforpa:entswithtroponineleva:onwithacutecoronarysyndromes(ACS)(
White,JACC2011
Incrementoditroponinadacausenoncardiache
1) CarenzadiO2almiocardioperaumentaterichieste(tachicardia,febbre)eridoXoapporto(ipossiaperinsufficienzarespiratoria,disfunzionemicrovascolare,ipotensione,anemia):IMA:poII
2) DannomiocardicodireXodaendotossine,citochine,radicalitossici.
Insufficienzarenalethesourceofthetroponinisclearlyofcardiacorigin.TheexactdegreeofdependenceoftroponinIorTonrenalfunc:onfortheirclearanceremainsunknown;however,itisincreasinglyheldthatalargepercentageofcircula:ngtroponinsinpa:entswithchronickidneydiseasemaybeexplainedbyunderlyingstructuralheartdiseaseand/ordirecttoxiceffectsofrenalfailureonthemyocardium,ratherthananyeffectontroponinclearance;52basedonthemolecularweightoftroponin,itsclearanceshouldbelessdependentonglomerularfiltra:on.whenelevatedinapa:entwithrenalfailure,troponinsaremarkedlyprognos:c.Thus,atroponinabovethe99thpercen:leinanHFpa:entwithrenalfailureshouldnotbesimplydiscardedasa‘falseposi:ve’duetoreducedclearance.WhiletroponinTappearstobemorelikelytobemeasurableorfranklyelevatedinpa:entswithrenalfailurecomparedwithtroponinI,withthegrowinguseofhighlysensi:vemethodsfortroponintes:ng,itremainstobeseenifthisdifferencebetweentroponinTandIinrenalpa:entswillpersist.
Scompensocardiacoacuto
Inacuteheartfailure†Thetroponinvalueshouldbepromptlymeasured,withthegoaltoconfirmorexcludeTypeIMIastheprecipitant†AnelevatedtroponinshouldalwaysbeinterpretedwithahighlevelofsuspicionforTypeIMI,par:cularlyinthecontextofariseorfallofthemarker,typicalsymptoms,orsignsofischaemiaonnon-invasivetes:ngorevidencefornewlossofmyocardialfunc:on†TroponinvaluesmayriseintheacuteseSngandfallduringtreatmentofHFinhospitalizedpa:ents.PaXernsoftroponinreleasecannotbeusedtoinferacoronaryvs.non-coronarymechanismandnoassump:onsregardingthepresenceorabsenceofanacutecoronarysyndromeshouldbemade†Troponinvaluesabovethe99thpercen:lehaveconsistentlybeenassociatedwithahighlikelihoodforanadverseoutcomeinacuteHFindependentofincidentMI.Higherconcentra:onsareassociatedwithaworseoutcome†BesidesappropriatetreatmentforTypeIMI,dataarelackingaboutspecifictherapeu:cinterven:onfortroponinvaluesabovethe99thpercen:leinacuteHF
Cardiactroponinsarecomponentsofthecontractualapparatusincardiacmyocytesandareexpressedexclusivelyintheheart.Anumberofnonischemiccondi:onsincludingmyocardi:s,pulmonaryembolism,acuteandchronicheartfailure,andsepsismaybeassociatedwithelevatedtroponinlevels(1,2),althoughtheymayincludesupply–demandimbalanceandthusatleastsomeelementofischemia.Eleva:onoftroponinswiththesecondi:onsisassociatedwithworseprognosisthantheprognosisforpa:entswithouttroponineleva:ons,andtheprognosisisusuallyworsethanthatforpa:entswithtroponineleva:onwithacutecoronarysyndromes(ACS)(
White,JACC2011
Qualsiasi enEtà di danno miocardico evidenziatomediante la determinazione delle troponine cardiache,comportaunpeggioramentodellaprognosidelpazienteabreve,medioelungotermine:• Scompenso tropo + BNP + > 12 volte la probabilità dimorte• Stroketropo+mortalitàcirca40%vs13%tropo–• TEPtropo+mortalitàospedalieraècompresatrail30edil50%
L’ampio spe9ro di patologie associate ad un rialzo deivalori di troponina cardiaca è potenzialmente causa diconfusione diagnosEca e genera una grande incertezzaneltra9amentodelpaziente.
• CardiactroponinIandTarecomponents• ofthecontrac:leapparatusofmyocardialcellsandare
• expressedalmostexclusivelyintheheart.
• Althougheleva:onsof• thesebiomarkersinthebloodreflectinjuryleadingtonecrosis
• ofmyocardialcells,theydonotindicatetheunderlyingmechanism.
• Troponinsshouldbeinterpretedwithinthecontextofthespecificclinicalpresenta:oninwhichtheyaremeasured
• Inpa:entswithHF,therearenumerouscausesforcircula:ngtroponinconcentra:onsabovethe99thpercen:le,includingcoronaryandnon-coronarymechanisms.
• Therecogni:onofatroponinthatisabovethe99thpercen:leanditsrisingand/orfallingdoesnotabsolutelyindicatethepresenceofaTypeIMI
• Withthegrowinguseofhighlysensi:vetroponinmethods,anevenlargerpercentageofHFpa:entswillhavemeasurableorelevatedtroponin
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