BIOMEDIC

II SYSTEM

CARDIOVASCULAR

Department of Biochemistry. Faculty of Medicine, UNHAS Rosdiana Natzir.

Objectives
Cardiovascular system (Heart)
Anatomical and physiology

orientation,etc. Biochemical Cardiac markers**** Thrombus formation

Course Guideline
Outline of labs
Texts required Attendance Grading policy

Learning objectives:
To understand the role of cardium biomarkers.
To know the role of enzymatic and non

enzymatic cardium biomarkers. To understand when the cardium biomarkers were increasing in the blood level.

Functions of Cardiovascular system

system circulates blood throughout body :
transports energy substrates (glucose,

FA, ect.), electrolytes and hormones to tissues removes waste products lactate, CO2 & H2O thermoregulation

Functions of the Heart

Generating blood pressure Routing blood: separates pulmonary and

systemic circulations Ensuring one-way blood flow: valves Regulating blood supply
Changes in contraction rate and force match

blood delivery to changing metabolic needs

Example case examination lab:

Hb WBC Sodium Potassium Chloride Urea Creatinine CreatineKinase Troponin I

Blood Flow Through the Heart

The Cardiovascular System

(cont.)
Blood :
Complex mixture of cells,

water, and various proteins and sugars. Fifty-five percent is plasma (liquid). Forty-five percent is solid.

The Cardiovascular System

(cont.)
Blood (cont.) Hematocrit measurement of percentage of red blood cells. Leukocytes 5 types of white blood cells protect against disease.

Basophils. Eosinophils. Neutrophils. Lymphocytes. Monocytes.

Contractility and Norepinephrine

Sympathetic

stimulation releases norepinephrine and initiates a cyclic AMP secondmessenger system

Figure 18.22

Chemical Regulation of the Heart

The hormones epinephrine and thyroxine increase heart rate
Intra- and extracellular ion concentrations must be

maintained for normal heart function

Myocardium - morphology
> Intercalated disks = the fibers are connected to each

other in Z lines
Provide strong union between fibers

> Actin, myosin, tropomyosin, troponin

> Large amount of mitochondrias in tight contact with

fibrils

Myocardium metabolism
Abundant blood supply, numerous mitochondria,

high content of myoglobin (a muscle pigment) as a storage of O2

Metabolism mostly aerobic, only about 1% anaerobic (during hypoxia possible up to 10% anaerobic, if more --> not enough energy for contractions) Utilization of substrates depending on the nutrition 60% fats (mostly FA), 35% carbohydrates, 5% ketones and AAs

* The Sarcoplasma of muscle cells contains : ATP; phosphocreatine & glycolytic enzymes.
* the mass of a muscle is made of 75% water and > 20% protein ( actin and myosin ).

Carnitine-palmytoyl transferase -1; malonyl-CoA decarboxylase: acetyl CoA carboxylase-2; AMP-activated protein kinase.

CARDIAC MARKER

CARDIAC ENZYMES OTHER CARDIAC MARKERS

OTHER CARDIAC MARKERS

B NATRIURETIC PEPTIDE (BNP)
N-TERMINAL PRO BNP

PRE-PRO BNP

BNP + NT PRO-BNP

Medical tests that are often referred to as cardiac markers include:

cardiac troponin (the most sensitive and specific test

for myocardial damage) creatine kinase (CK, phosphocreatine kinase or creatine phosphokinase)
Aspartate transaminase (AST, Glutamic Oxaloacetic

Transaminase (GOT/SGOT) or aspartate aminotransferase (ASAT)) lactate dehydrogenase (LDH) Myoglobin (Mb) has low specificity for myocardial infarction and is used less than the other markers.

 Depending on the marker, it can take

between 2 to 24 hours for the level to increase in the blood.

Cardiac markers are therefore not

useful in diagnosing a myocardial infarction in the acute phase.

The clinical presentation and results

from an ECG are more appropriate in the acute situation.

Troponin
Troponin is a complex of three proteins that is

integral to muscle contraction in skeletal and cardiac muscle, but not smooth muscle.

Troponin is attached to the protein tropomyosin and lies within between actin filaments in muscle tissue.

In a relaxed muscle, tropomyosin blocks the

attachment site for the myosin crossbridge, thus preventing contraction.

The main difference is that the TnC subunit of

troponin in skeletal muscle has 4 calcium ion binding sites, whereas in cardiac muscle there are only 3 Ca.

Functional characteristics
Role of troponins :
Both cardiac and skeletal muscles are controlled by

changes in the intracellular calcium concentration

When calcium rises, the muscles contract, and when calcium falls the muscles relax.

Troponin is a component of thin filaments (along with

actin and tropomyosin), and is the protein to which calcium binds to accomplish this regulation.

Troponin has three subunits, TnC, TnI, and TnT. When calcium is bound to specific sites on TnC, tropomyosin rolls out of the way of the actin filament active sites,

In the absence of calcium, tropomyosin interferes with this action of myosin, and therefore muscles remain relaxed.

Role of troponins :
Troponin I has also been shown to inhibit angiogenesis in vivo

and in vitro

Individual subunits serve different functions:

Troponin C > binds to calcium ions to produce a

conformational change in TnI

Troponin T.> binds to tropomyosin, interlocking them to

form a troponin-tropomyosin complex

Troponin I .> binds to actin in thin myofilaments to hold

the troponin-tropomyosin complex in place

Diagnostic

use :

Certain subtypes of troponin (cardiac troponin I and T) are very sensitive and specific indicators of damage to the heart muscle (myocardium). They are measured in the blood to differentiate between unstable angina and myocardial infarction (heart attack) in patients with chest pain.

Detection of cardiac troponin

Cardiac troponin T and I are measured by

immunoassay methods.

Creatine kinase
Creatine kinase (CK), also known as phosphocreatine

kinase or creatine phosphokinase (CPK) is an enzyme expressed by various tissue types.

It catalyses the conversion of creatine to

phosphocreatine, consuming adenosine triphosphate (ATP) and generating adenosine diphosphate (ADP).
In tissues that consume ATP rapidly, especially

skeletal muscle, brain and smooth muscle, phosphocreatine serves as an energy reservoir for the rapid regeneration of ATP.
Thus Creatine Kinase is an important enzyme in such

tissues.

Clinically, creatine kinase is assayed in blood tests as a marker of myocardial infarction (heart attack), rhabdomyolysis (severe muscle breakdown), muscular dystrophy and in acute renal failure.

Types :
In most of the cell, the CK enzyme consists of two

subunits, which can be either : B (brain type) or M (muscle type).

There are, therefore, three different isoenzymes:

CK-MM, CK-BB CK-MB.

 The genes for these subunits are located on

different chromosomes: B on 14q32 and M on 19q13.

The myocardium (heart muscle), in contrast, expresses CK-MM at 70% and CK-MB at 25-30%. CK-BB is expressed in all tissues at low levels and has little clinical relevance. The mitochondrial creatine kinase (CKm), which produces ATP from ADP by converting creatine phosphate to creatine, is present in the mitochondrial intermembrane space.

Apart from the mitochondrial form, there are three forms present in the cytosol
CKa : (in times of acute need, produces ATP in the cytosol at the cost of creatine phosphate),

CKc : (maintains critical concentration of creatine and creatine phosphate in the cytosol by coupling their phosphorylation and dephosphorylation respectively with ATP and ADP) and

CKg : (which couples direct phosphorylation of creatine to the glycolytic pathway.

creatine

Creatin kinase, muscle

Aspartate transaminase
Aspartate transaminase (AST) also called serum glutamic oxaloacetic transaminase (SGOT) or aspartate aminotransferase (ASAT/AAT)
is similar to alanine transaminase (ALT) in that it

is another enzyme associated with liver parenchymal cells.

Function AST
It facilitates the conversion of aspartate and alpha-ketoglutarate to oxaloacetate and glutamate

Isozymes

Two isoenzymes are present in humans. They have high similarity. GOT1, : the cytosolic isoenzyme derives mainly from red blood cells and heart. GOT2, : the mitochondrial isoenzyme is predominantly present in liver

Aspartate aminotransferase. Aspartate aminotransferase from Escherichia coli bound with cofactor pyridoxal 5-phosphate (PDB 1AAM)

Lactate dehydrogenase
Lactate dehydrogenase (LDH) is an enzyme present in a wide variety of organisms, including plants and animals.
Reactions:

It catalyses the interconversion of pyruvate and lactate with concomitant interconversion of NADH and NAD+. .

At high concentrations of lactate, the enzyme exhibits feedback inhibition and the rate of conversion of pyruvate to lactate is decreased

Catalytic function of LDH

Enzyme isoforms :
LDH-1 (4H) - in the heart LDH-2 (3H1M) - in the reticuloendothelial system LDH-3 (2H2M) - in the lungs LDH-4 (1H3M) - in the kidneys LDH-5 (4M) - in the liver and striated muscle

 The major isozymes of skeletal muscle and liver, M4,

has four muscle (M) subunits; while H (heart)4 is the main isozymes for heart muscle in most species, containing 4 H subunits.

The other variants contain both types of subunits.

Usually LDH-2 is the predominant form in the serum.

Myoglobin
Myoglobin is a single-chain globular

protein of 153 amino acids,

containing a heme (iron-containing

porphyrin) prosthetic group in the center around which the remaining apoprotein folds. daltons, and is the primary oxygencarrying pigment of muscle tissues.

It has a molecular weight of 16,700

Model of helical domains in myoglobin

Molecular Function:
oxygen transporter activity iron ion binding oxygen binding heme binding metal ion binding

Biological Process:
response to hypoxia transport oxygen transport enucleate erythrocyte differentiation

Role in disease
Myoglobin is a sensitive marker for muscle injury, making

it a potential marker for heart attack in patients with chest pain.

CK-MB and TnT is used in combination with ECG, and

the clinical signs to diagnose AMI

The released myoglobin is filtered by the kidneys but is

toxic to the renal tubular epithelium and so may cause acute renal failure.

Glycogen phosphorylase isoenzyme

is an isoenzyme of glycogen phosphorylase. This isoform of the

enzyme exists in cardiac (heart) and brain tissue.

The enzyme is one of the "new cardiac markers" which are

discussed to improve early diagnosis in acute coronary syndrome. A rapid rise in blood levels can be seen in myocardial infarction and unstable angina.
Other enzymes related to glycogen phosphorylase are

abbreviated as (liver) and (muscle).

Normal ranges
Test

Low 136 3.5 2.5 7 62 53 0.7 0.6

High 145 4.5 6.4 18 115 97 1.3 1.1

UnitComments mmol/L mmol/L mmol/L BUN - blood urea nitrogen mg/dL mol/L mol/L mg/dL mg/dL

Sodium (Na) Potassium (K) Urea Urea Creatinine male Creatinine female Creatinine male Creatinine female

Glucose (fasting)
Glucose (fasting)

3.9
70

5.8
105

mmol/L See also glycosylated hemoglobin

mg/dL

Thrombus formation

Functions
There are six functions: 1. Transportation
O2 lungs cells CO2 cells lungs Nutrients GI cells waste from cells kidneys

Functions
2. Defense
WBC disease blood proteins antibodies

Functions

3. Temperature regulation - absorbs and distribute heat throughout body and skin 4. Prevents loss blood clots 5. Hormone movement endocrine gland cells 6. Regulates pH through buffers

Imbalances (Disorders of Hemostasis)

Thrombus clot that develops and persists in an

unbroken vessel which can lead to thrombosis where tissue/organ die because of obstruction (coronary thrombosis) Embolism when small vessel is obstructed from embolus . Thrombocytopenia number of platelet is deficient in blood

Clinical Manifestation Myocardial Infarction Lab Diagnostics

Cardiac Protein Troponin T
More sensitive than CK Elevates 3 hr peak 24-48 hrs; normal 5-14 days

Cardiac Enzyme Creatine kinase (CK-MB)

Released when cardiac cells die Elevates 3 hrs peak 12-24 hrs; normal 2-3 days

Cardiac Marker - Myoglobin

First to elevate Lacks cardiac specificity Normal range within 24 hours

For your attention

Thank you very much