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La Rivista Italiana della Medicina di Laboratorio 2021 Jan 08

DOI: 10.23736/S1825-859X.21.00084-0


language: Italian

Working Group on Myocardial Markers (GdS MM) of the Italian Society of Clinical Pathology and Laboratory Medicine (SIPMeL) Recommendations for the use of myocardial markers in NSTEMI. Second Part: evidence for diagnosis

Lucia MALLOGGI 1, Piero CAPPELLETTI 2 , Marco MORETTI 3, Francesca VENEZIANI 4, Massimiliano MANNO 5, Maria Aurora BURGIO 6, Alessio GAMBONI 7, Matteo CASSIN 8, Elisabetta STENNER 9, Margherita MORANDINI 10, Giulio MARINO 11, Martina DI PIETRO 12, Deborah MAZZEI 1, Jessica VIOLA 13, Dina DI MARIA 14, Daniela RUBIN 15, Gianni A. GALLI 16, a nome del Gruppo di Studio sui Marcatori Miocardici (GdS MM) della Società Italiana di Patologia Clinica e Medicina di Laboratorio (SIPMeL)

1 Laboratorio Analisi, AOU, Pisa, Italy; 2 SIPMeL, Castelfranco Veneto, Treviso, Italy; 3 Medicina di Laboratorio, AOU Ospedali Riuniti Ancona, Ancona, Italy; 4 Laboratorio Analisi, Ospedale S. Maria Nuova, USL Centro Toscana, Florence, Italy; 5 Laboratorio Analisi, Città di Lecce Hospital-GVM Care&Research, Lecce, Italy; 6 Patologia Clinica Ospedale Barone Lombardo, Canicattì, Agrigento, Italy; 7 Medicina d’Urgenza, ASL2, Foligno, Perugia, Italy; 8 Cardiologia, Casa di Cura San Giorgio, Pordenone, Italy; 9 Laboratorio Analisi Chimico Cliniche, Ambito Territoriale Livorno, Azienda USL
Toscana Nordovest, Livorno, Italy; 10 Laboratorio Analisi, ASFO, Pordenone, Italy; 11 Laboratorio Analisi, AUSL Bologna, Vergato, Bologna, Italy; 12 Laboratorio Unica Metropolitano, AUSL BO, Bologna, Italy; 13 Patologia Clinica, Asp4 Enna, Enna, Italy; 14 Laboratorio Analisi Polimedica, Ravanusa, Agrigento, Italy; 15 Laboratorio Analisi AULSS2, Conegliano Veneto, Treviso, Italy; 16 Fondazione Estote Misericordes, Borgo San Lorenzo, Florence, Italy


BACKGROUND: According to international guidelines, the use of hs-cTn in the diagnosis of NSTEMI (non-ST elevation myocardial injury) improves diagnostic accuracy and the time of the rule in / rule out.
MATERIALS: We conducted non-systematic research on the impact of hs-cTn on improving diagnostic accuracy in NSTEMI, and systematic reviews on the use of the different rapid diagnostic strategies - i.e. rapid algorithms at 0/3 h, 0/2 h, 0/1 h; use of hs-cTn on admission (T0); accelerated diagnostic protocols (ADPs) -.
RESULTS: Literature data show 4% increase in the diagnosis of acute myocardial infarct (AMI) with the use of hs-cTn, mainly due to reclassification of cases of unstable angina in "myocardial injury". The systematic reviews show that the suggested rapid diagnostic strategies have different performance in terms of effectiveness (patients’ allocation) and risk (MACE, major adverse cardiovascular events): the 0/3 h algorithm has an effectiveness > 80%, the 0/2 h > 75% and the 0/1 > 70%, with observation groups of 20-25% and a 0-2% short/long term risk of MACE. The use of T0 determines effectiveness in rule out of 60% and in rule in of 11-23%. ADPs improve safety in terms of MACE (NPV> 99.5%) but reduce effectiveness to 40%. Researches of guidelines and evidence prove that hs-cTn is the biomarker of choice, necessary and sufficient in diagnosis of NSTEMI. No other biomarker should be used either as an alternative or coupled.
CONCLUSIONS: The recommendations proposed by the GdS MM SIPMeL are the following: 1. In the diagnosis of NSTEMI it is recommended to use high sensitivity troponin alone (hscTn). CLASS I; LEVEL OF EVIDENCE A 1.1 For the diagnosis of AMI, “obsolete” biochemical markers (AST, LDH and its isoenzymes, total CK, CK-MBa) must not be used. CLASS III; LEVEL OF EVIDENCE A. 1.2. For the diagnosis of AMI, CK-MB determined as "mass" (CK-MBm) must not be used. CLASS III; LEVEL OF EVIDENCE A. 1.3. For the diagnosis of AMI myoglobin must not be used. CLASS III; LEVEL OF EVIDENCE A. 1.4. For the diagnosis of AMI copeptin should not be used. CLASS III; LEVEL OF EVIDENCE B.

KEY WORDS: Troponin; Hs-cTn; ACS; AMI; NSTEMI; Diagnosis

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