CARDIAC BIOMARKERS

Acute Coronary Syndrome

 A syndrome refers to a spectrum of

conditions compatible with acute myocardial
ischemia and/or infarction that are usually
due to an abrupt reduction in coronary blood
flow or oxygen supply
 ACS classification (focus on ECG and troponin)
 ST-elevation myocardial infarction (STEMI)
 Non-STEMI
(includes "micro-infarctions", i.e. no ECG changes, no
CK-MB , only troponin elevation )
 Unstable angina (no troponin elevation )
 Diagnosis of Acute
Myocardial Infarction

 Triad of Chest pain, ECG manifestations and

elevations of biomarkers of cardiac injury
 Chest Pain: highly variable and subjective
 ECG: Objective ST or T-wave changes
 Biomarker elevations: Objective data defining
ACS/AMI
 The perfect marker

Cardiac markers are substances released from heart muscle when

it is damaged as a result of myocardial infarction.
The perfect marker should be:
 Marker for myocardial necrosis, and also for cardiac ischemia
 Linear relationship between blood levels and extent of
myocardial injury (and prognosis)
 100% sensitive and 100% specific
 Immediate increase (+ constant blood level for hours to days)
 Test kits : reliable, rapid, universally available and inexpensive
What biomarkers are good
for:
 Timely diagnosing AMI/ACS
 Detecting myocardial damage whether due to
AMI or perioperative MI
 Risk-stratifying patients
 Commenting on Prognosis
 In ACS, pre and post PCI /reperfusion therapy after
thrombolysis
 CK-MB

• High specificity for cardiac tissue

• Begins to rise 4-6 hours after onset of infarction
Peaks at about 12 hours
Returns to baseline at 24-36 hours
• Can be used to indicate early re-infarction if level
normalizes and then increases again
 CK-MB mass
• CK-MB mass not activity (assayed by ELISA, IRMA, CIA)
• False elevations in
Skeletal muscle injury,Cardiac injury for reason other
than MI,Chronic renal failure,and Hypothyroidism.
 RI (%) = CK-MB (ug/L) / Total CK (U/L) x 100
RI > 6% = indicative of cardiac damage
RI < 6% = indicative of skeletal damage
 shows a more rapid decline after MI as compared with
cardiac troponin and may provide added value for the
timing of myocardial injury and the detection of early
reinfarction
CK-MB and Reinfarction

 CK-MB is the marker of choice for diagnosis

of reinfarction after STEMI, PCI, or CABG
because of rapid washout
 The ACC/AHA definition of re-infarction
includes both
 re-elevation of CK-MB
 supporting criteria including ECG changes, pain or
hemodynamic instability
CK-MB Isoforms & Ratio

 Two isoforms :CK-MB1 and CK-MB2

 Myocardial damage:
CK-MB2 >1 U/L
CK-MB2 /CK-MB1>1.5
 CK MB Isoforms ratio produces to be highly
sensitive and specific indicator of EARLY AMI
 Troponin
It controls the calcium-mediated interaction of actin and
myosin resulting in contraction and relaxation of striated
muscle.
•Troponin C:which binds calcium in both cardiac and
skeletal muscle.
• Troponin I: which inhibits actin-myosininteractions
•Troponin T: which attaches the troponin complex by
binding to tropomysin, and facilitates contraction.

The amino acid sequences of troponins I and T are

unique to cardiac muscle
 7% of troponin T and 5% of troponin I is free in the
cytoplasm.Various complexes are present in plasma (free
cTnI, T/I/C, I/C and I/T)
 After myocyte damage: a biphasic rise in serum troponin
that corresponds to the initial release of free followed by the
gradual dispersion of myofibril-bound troponin complexes.
 Troponin T and I sensevities 59%–90% and 69%–82% at 2 to
6 hours after admission.The sensitivity approaches 100% by
6 to 12 hours
 Although cTn, especially cTnI, is highly specific for
myocardial damage,they are not able to discern between
ischemic or inflammatory or traumatic injury, as they are
elevated inin Myocarditis, CHF, pulmonary embolism,
pulmonary hypertension and severe renal dysfunction.
 Troponin I Troponin T
Cardiospecific Sensitive
Found in chronic
renal disease

Rise 2-4hr
Peak 14-18 hr
Normal 5-9 days 14 days
Methods ELISA, Chemiluminscent Assay
 Troponin in risk stratification
and prognosis
 NSTEMI patients had a large clinical benefit (55% reduction in
the odds of death or MI) when an early invasive strategy in
patients with only minor troponin elevations.
Non elevated troponin patients :no detectable benefit was
associated with early angiography and revascularization
 STEMI reperfusion therapy should not be delayed waiting for
confirmatory biomarkers of myocardial injury
 Prognosis :Patients presenting with clinical evidence of
ischemia and increased troponin have worse outcomes than
those without detectable troponin in the circulation
 Methods of assay
 Problematic standardization
 Different assays measure different epitopes and
different fragments of cTnI. Thus, there are
differences in the responses of specific assays to the
various troponin forms
cTnI assays use antibodies specific to epitopes in the
central part of the troponin molecule that are not
affected by the numerous modifications found in
human blood noted .
The heterogeneity of assays is not a problem for cTnT
because there is only one assay.
Hs- troponin assays

 Hs- troponin assays can measure troponin concentrations

approximately 10-fold lower than conventional assays, the
99th percentile value for the first-generation troponin T
assay was reduced to 0.01 ug/L by the fourth generation
assays.
 High specificity of hs-troponin assays, with NPV of 97%–
99%, helped to reliably rule out MI on the basis of an initial
measurement rapidly initiate effective
 • Reduce the “troponin-blind” interval leading to earlier
detection of acute MI.
• Result in a ~4% absolute and ~20% relative increase in the
detection of type 1 MI and a corresponding decrease in the
diagnosis of unstable angina.
Levels of hs-cTn should be interpreted as quantitative markers
of cardiomyocyte damage (i.e. the higher the level, the greater
the likelihood of MI):
• Elevations beyond 5-fold the upper reference limit have high
(>90%) PPV for acute type 1 MI.
• Elevations up to 3-fold the upper reference limit have only
limited (50–60%) PPV for acute MI
 High-sensitivity troponins first, the
imprecision (CV) at the 99th percentile value
should be ≤10% (“guideline acceptable”), .
Second, the assay should be able to measure
cTn concentrations below the 99th percentile
in ≥95% of normal individuals
A dual-marker strategy combining normal levels of cardiac
troponin together with low levels of copeptin (<10 pmol/L) at
presentation showed very high negative predictive value for
MI, obviating the need for serial testing in selected patients.

Due to the higher sensitivity and diagnostic accuracy for the

detection of acute MI at presentation, the time interval to the
second cardiac troponin assessment can be shortened with
the use of high-sensitivity assays
0h/3h rule-out algorithm in NSTMI using
hs-cTn
0h/1h rule-out algorithm in NSTMI using
hs-cTn
Myoglobin

 The major protein responsible for O2 supply of

striated muscle (Muscle Haem)
 It is released into blood as early as 1 hour after
damage to muscle cell
 Rise: 1-3 hr Peak: 6-9 hr Normal: 24-36 hr
 High negative predictive value
 Lacks cardio specificity (elevated in patients with
renal insufficiency and crush injuries)
 It is suitable for the detection of reinfarction.
 Methods: ELISA, Turbidimetry/Nephelometry
Diagnosis of early recurrent
myocardial infarction
 The pattern of re-elevation in the level of
short lived biochemical markers, such as
myoglobin, Ck-MB and Ck-MB subform and
not Troponin can be used as an indicator of
early recurrent myocardial infarction.
 Biomarkers in Renal Failure
 Chronically elevated troponin levels indicate a worse long-
term prognosis for cardiovascular outcomes in this patient
population
 False positives have been reported with use of troponin-T in
ESRD patients
 CK: plasma concentrations are elevated in 30-70% of dialysis
patients at baseline, likely secondary to skeletal myopathy,
intramuscular injections and reduced clearance
 CK-MB: 30-50% of dialysis patients exhibit an elevation in the
MB fraction >5% without evidence of myocardial ischemia
 The most specific marker for suspected AMI in ESRD patients
is Troponin-I with an appropriate sequential rise
 Markers and Prognostic Markers
of Risk Stratification
 C-reactive protein
 Myeloperoxidase
 Homocysteine
C-reactive protein

 is an acute-phase reactant protein made in the liver

 Values> 10 mg/l are likely caused by acute disease
 CRP is marker of high risk in cardiovascular disease
 Values >3 mg/l are associated with higher risk
 values <1 mg/l are associated with low risk
 Those between 1 and 3 mg/l are considered intermediate
 If one has an elevation and is acutely ill or has evolving
infarction, the test should be repeated at least 2 weeks
later
 Myeloperoxidase
 Released by activated leukocytes at elevated
levels in vulnerable plaques
 Independent cardiovascular risk factor in
patients with chest pain but with a negative
serum TnT
 May be useful in triage of ACS (levels elevate in
the 1st two hours)
Homocysteine

 Intermediary amino acid formed by the conversion of

methionine to cysteine
 Recognized as an independent risk factor for the
development of atherosclerotic vascular disease and
venous thrombosis
 Screening recommended in patients with premature CV
disease (or unexplained DVT) and absence of other risk
factors
Perioperative myocardial injury
 Perioperative MI usually occurs on days 1–4 after
surgery.
 Causes :
rupture of a coronary arterial atherosclerotic
plaque in 50% of cases. result from an imbalance
between myocardial oxygen supply and demand
in 50% of cases.
cTnI or cTnT for the detection of perioperative
MI in non‐cardiac and cardiac surgery patients
NEW MARKERS
 Copeptin

 The C-terminal fragment of vasopressin

precursor hormone and is released together with
vasopressin during precursor processing.
 Emerging data suggests that copeptin could
provide additional value to cTn in the early rule-
out patients presenting with suspected ACS.
 ISCHEMIA MODIFIED ALBUMIN
 When exposed to ischemic tissue, human serum albumin
loses its ability to bind cobalt, and the structurally altered
albumin IMA
 Measured by: the albumin cobalt-binding spectrophotometric
assay.
 IMA rise within minutes after the onset of ischemia, and
return to baseline within 24 hours
 Serum IMA can differentiate myocardial ischaemic patients
from non‐ischaemic individuals
 It is a poor discriminator between ischaemic patients with
and without MI.
 Rule out " ACS in low to moderate pretest probability
condition with negative necrosis markers and a negative ECG.
HEART FATTY ACID BINDING
PROTEIN (HFABP)
 Cytosolic protein transport of hydrophobic long‐chain
fatty acids from the cell membrane to the mitochondria
 Expressed primarily in cardiac tissue
 Detecte d 1-3 h after onset of chest pain peak at 6-8 h
return normal within 24 hr
 clinical diagnostic value is very limited in the presence of
renal failure and skeletal muscle diseases as it is
completely renally eliminated.
 marker of reperfusion following MI
 CHF: FABP and CK‐MB correlated with that of BNP in a
group of patients with heart failure
GLYCOGEN PHOSPHORYLASE (GP)-BB

 GP-BB isoenzyme - present in the brain and

myocardium
 It + glycogenolysis in ischaemic tissue, released into the
cytoplasm, and then into the circulation through the
damaged cell membrane.
 Early and specific marker for myocardial necrosis and
ischemia
 GP‐BB appears to be r ises 2–4 h after myocardial injury
return to normal within 36 h of damage
 Methods: ELISA and Immunochromatographic
Myosin light chains

 modulation of the interaction between myosin and actin.

 Two types : MLC 1 and MLC 2
 Detected 3-6 h after onset of chest pain peak at 4 days return normal
within 10-14 days
 Assay: immunoradiometric ,enzyme immunoassays
 Used to asses clinical severity, prognosis and in risk stratification for
patients with unstable angina
 MLC 1 with BNP is used in the assessment of patients with heart
failure.
Pregnancy-associated plasma
protein-A.
 Released when neovascularization occurs and
thus may be a marker of incipient plaque
rupture.
 It does not correlate with any of the presently
available markers of cardiac injury
 It seems to identify patients at risk for
subsequent events
Cystatin C

 Some studies suggest that it is useful for

prognostication in heart failure and ACS ,and
that would make sense given that it is well
accepted that renal function is a critical
determinant of prognosis.
Placental growth factor

 member of the vascular endothelial growth factor family

that initiate the inflammatory process into atherosclerotic
lesions
 A biomarker for plaque instability, myocardial ischemia,
and prognosis of patients in the spectrum of ACS
B-type natriuretic peptide

 counterregulatory peptide released in response to

cardiac stretch.
 cutoff values of 100 ng/ml for congestive heart failure
 Patients with higher values on admission and/or
discharge to hospital generally do worse.
 Those with marked reductions during treatment do
better
 In ACS patients, BNP and NT-proBNP
elevations are prognostic for death
BNP Assay

 Approved by the FDA for diagnosis of cardiac

causes of dysnpea
 Especially useful in ruling out heart failure as
a cause of dyspnea given its excellent
negative predictive value
 Currently measured via a rapid, bedside
immunofluorescence assay taking 10 minutes