9/11/2019 Cardiac Biomarkers

Cardiac Biomarkers
Also Known As: Cardiac Markers
Formal Name: Cardiac Biomarkers

This article was last reviewed on June 12, 2015. This article was last modified on July 25, 2019.

What are cardiac biomarkers?

Cardiac biomarkers are substances that are released into the blood when the heart is damaged or stressed.
Measurements of these biomarkers are used to help diagnose acute coronary syndrome (ACS) and cardiac
ischemia, conditions associated with insufficient blood flow to the heart. Tests for cardiac biomarkers can also be
used to help determine a person's risk of having these conditions or to help monitor and manage someone with
suspected ACS and cardiac ischemia.

The root causes of both ACS and cardiac ischemia are usually the buildup of plaque in artery walls and
hardening of the arteries (atherosclerosis). This can result in severe narrowing of the arteries leading to the heart
or a sudden blockage of blood flow through these coronary arteries.

Cardiac ischemia is caused when the supply of blood reaching heart tissue is not enough to meet the heart's
needs. When not enough blood gets to the heart, it can cause pain in the chest (angina), shortness of breath,
sweating, and other symptoms. Typical angina occurs when the coronary arteries have been gradually
narrowed over time. The pain starts when a person is active, making the heart work harder, and is quickly
relieved by rest or by drugs that increase blood flow to the heart, such as nitroglycerine.
ACS is caused by rupture of a plaque that results from atherosclerosis. Plaque rupture causes blood clot
(thrombus) formation in coronary arteries, which results in a sudden decrease in the amount of blood and
oxygen reaching the heart. A sudden decrease in the supply of blood to the heart can cause prolonged chest
pain called unstable angina, often occurring at rest or not relieved by rest or nitroglycerine.
When blood flow to the heart is blocked or significantly reduced for a longer period of time (usually for more
than 30-60 minutes), it can cause heart cells to die and is called an acute myocardial infarction (AMI or heart
attack). This leads to death of the affected portion of heart muscle with permanent damage and scarring of the
heart and sometimes can cause sudden death by causing irregular heart contractions (arrhythmia). Unstable
angina and AMI are together called acute coronary syndrome since they are both due to a very acute
decrease in blood flow to the heart.

The symptoms of ACS and cardiac ischemia can vary greatly but frequently include chest pain, pressure,
nausea, and/or shortness of breath. Though these symptoms are most often associated with heart attacks and
angina, they may also be seen with non-heart-related conditions.

It is important to distinguish heart attacks from angina, heart failure, or other conditions that may have similar
signs and symptoms because the treatments and monitoring requirements are different. Cardiac biomarker tests
are ordered to help detect the presence of ACS and cardiac ischemia and to evaluate their severity. Increases in
one or more cardiac biomarkers in the blood can identify people with ACS or cardiac ischemia, allowing rapid
and accurate diagnosis and appropriate treatment of their condition.

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ACS, prompt medical intervention is crucial to prevent death and to minimize heart damage and future
complications. Cardiac biomarker tests must be available to a health practitioner 24 hours a day, 7 days a week
with a rapid turn-around-time. Some of the tests may be performed at the point of care (POC) – in the emergency
department or at a person's bedside. Usually, multiple cardiac biomarker tests are done over several hours to
ensure that a rise in blood levels is not missed and to estimate the severity of a heart attack.

About Cardiac Biomarkers

The Tests

Only a few cardiac biomarker tests are routinely used by physicians. The current biomarker test of choice for
detecting heart damage is troponin. Other cardiac biomarkers are less specific for the heart and may be
elevated in other situations such as skeletal muscle injury.

Current cardiac biomarker tests that may be used to help diagnose, evaluate, and monitor individuals
suspected of having acute coronary syndrome (ACS) include:

Troponin (I or T)—this is the most commonly ordered and most specific of the cardiac markers. It is
elevated (positive) within a few hours of heart damage and remains elevated for up to two weeks. Rising
levels in a series of troponin tests performed over several hours can help diagnose a heart attack.
High-sensitivity troponin—this test detects the same protein that the standard test does, just at much
lower levels. Because this version of the test is more sensitive, it becomes positive sooner and may help
detect ACS earlier than the standard test. The hs-troponin test may also be positive in people with stable
angina and even in people with no symptoms. When it is elevated in these individuals, it indicates an
increased risk of future heart events such as heart attacks. Currently, this test is not approved in the U.S.,
but research is ongoing and it may become available in the near future. It is already routinely used as a
cardiac biomarker in clinical practice in Europe, Canada, and other countries as well.
Creatine kinase (CK) and CK-MB—in the U.S., CK has been largely replaced by troponin. It may
sometimes be used to help detect a second heart attack that occurs shortly after the first. CK-MB is one
particular form of the enzyme creatine kinase that is found mostly in heart muscle; it rises when there is
damage to the heart muscle cells and may be used in follow up to an elevated CK and/or when the
troponin test is not available.
Myoglobin—this test may be used along with troponin to detect a heart attack early, but in the U.S., it is
used less frequently.

Other biomarker tests that may be used include:

hs-CRP—this test may be used to help determine risk of future heart attacks in people who have already
suffered one in the past.
BNP (or NT-proBNP)—although usually used to recognize heart failure, an increased level in people with
ACS indicates an increased risk of recurrent events.

On the horizon: several biomarkers are being investigated for their potential use in helping to evaluate
people for ACS. These are currently only used in research settings and are not available in clinical practice.

General lab tests are frequently ordered along with cardiac biomarkers to evaluate a person's general
health status and the current status of the individual's kidneys, liver, electrolyte and acid/base balance,
blood sugar, and blood proteins. They may include:

Blood gases
Comprehensive metabolic panel (CMP) or basic metabolic panel (BMP)
Electrolytes
Complete blood count (CBC)
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Non-laboratory Tests
These tests allow health practitioners to look at the size, shape, and function of the heart as it is beating.
They can be used to detect changes to the rhythm of the heart as well as to detect and evaluate damaged
tissues and blocked arteries.

EKG (ECG, electrocardiogram)

Nuclear scan
Coronary angiography (or arteriography)
Echocardiogram (Cardiac echo, transthoracic echocardiography (TTE))
Stress testing
Chest X-ray

For more about these, visit the Non-Invasive Tests and Procedures article on the American Heart
Association web site.

Table of biomarkers used for diagnosing and monitoring acute coronary syndrome

These tests are used to help diagnose, evaluate, and monitor people suspected of having Acute
Coronary Syndrome (ACS).

REASON TIME
TISSUE TIME TO WHEN/HOW
MARKER WHAT IT IS FOR BACK TO
SOURCE INCREASE USED
INCREASE NORMAL

Diagnose heart
Regulatory
attack, risk
protein
Remains stratification,
complex;
Cardiac Injury to 3 to 4 elevated assist in
two cardiac- Heart
Troponin heart hours for 10 to deciding
specific
14 days management,
isoforms: T
assess degree
and I
of damage

High-sensitivity Same as above;

cardiac may also be
troponin Same as elevated in
above, just stable angina
Currently not Within 3
measures and people
approved in Injury to hours of Same as
the same Heart without
U.S. but may heart onset of above
protein at a symptoms and
be soon; it is symptoms
much lower indicates risk of
routinely used
level future cardiac
in Canada,
events (e.g.,
Europe
heart attacks)

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REASON TIME
TISSUE TIME TO WHEN/HOW
MARKER WHAT IT IS FOR BACK TO
SOURCE INCREASE USED
INCREASE NORMAL

Frequently
performed in
3 to 6 48 to 72 combination
Enzyme; Heart, Injury to
hours after hours, with CK-MB;
total of brain, skeletal
injury, unless sometimes to
CK three and muscle
peaks in due to detect second
different skeletal and/or
18 to 24 continuing heart attack
isoenzymes muscle heart cells
hours injury occurring
shortly after the
first

3 to 6
Heart 48 to 72
Injury to hours after Less specific
Heart- primarily, hours,
heart heart than troponin,
related but also unless
CK-MB and/or attack, may be ordered
isoenzymes in new or
muscle peaks in when troponin
of CK skeletal continuing
cells 12 to 14 is not available
muscle damage
hours

Used less
Heart 2 to 3 frequently;
Injury to Within
Oxygen- and hours after sometimes
muscle one day
Myoglobin storing other injury, performed with
and/or after
protein muscle peaks in 8 troponin to
heart cells injury
cells to 12 hours provide early
diagnosis

Table of Biomarkers Used for Prognosis

These tests may be used to evaluate risk of future cardiac events.

WHAT IT REASON FOR

BIOMARKER WHEN/HOW USED
IS INCREASE

May help determine risk of future cardiac events in

hs-CRP Protein Inflammation
those patients who have had a heart attack

Heart failure;
Usually used to recognize heart failure, but an
BNP and NT- Heart increased risk of
increased level in people with ACS indicates an
proBNP hormone another heart
increased risk of recurrent events
attack

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Related Content

On This Site

Conditions: Heart Attack and Acute Coronary Syndrome , Angina, Congestive Heart Failure

Elsewhere on the Web

American Heart Association: Symptoms and Diagnosis of Heart Attack

National Heart, Lung and Blood Institute: What is a heart attack?
Cleveland Clinic: Heart Attack

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