DIAGNOSTIC CARDIAC

ENZYMES
Lotfi S. Bin Dahman
Associate Professor and Consultant of Clinical Biochemistry
HUCOM
CARDIOVASCUALR DISEASE
• Cardiovascular disease (CVD) commonly occurs in the general population
and affects the majority of people older than 60 years.
• There are four major types of CVD based on the location in which it occurs:
1. Coronary heart disease (CHD)
2. Cerebrovascular disease
3. Peripheral arterial disease
4. Aortic atherosclerotic disease.
• CHD manifests as myocardial infarction (MI) (heart attack), angina pectoris
(chest pain), heart failure, and sudden cardiac death.
CARDIOVASCUALR DISEASE
• One of the most common reasons people go to the emergency
department is for the acute onset of chest pain. While nearly seven
million people end up in emergency departments for this reason, only
15% to 25% of them actually have acute coronary syndrome (ACS)
resulting from CHD.
DIAGNOSIS OF CHEST PAIN
Patients with chest pain are initially evaluated by:
1. Physical examination (HTN, pulmonary disease, heart failure, cardiac
valve disease)
2. Electrocardiogram (ECG): obtained within 10 minutes after
presentation; presence of new or transient changes (>1 mm) in the ST
segment of the ECG is strongly suggestive of acute ischemia
3. Chest x-ray (pneumonia, pneumothorax, and aortic dissection)
4. Detection of cardiac biomarkers by laboratory tests: European Society
of Cardiology and the ACC (ESC/ACC) consensus report recommended
samples be collected at presentation, at 6–9 hours, and again at 12–
14 hours if the earlier samples were negative
CARDIAC ENZYMES
• Cardiac enzymes – also known as cardiac biomarkers including
myoglobin, troponin, creatine kinase (CK, CK-MB), lactate
dehydrogenase (LDH).
• Cardiac enzymes are proteins released into the blood stream when
myocardial necrosis occurs as seen in MI.
• A biomarker is a biological molecule whose concentration in the blood
changes in response to a specific disease.
1. Enzymes and their associated coenzymes or cofactors.
2. Structural tissue proteins.
3. Intermediates of metabolic pathways.
4. Messenger molecules.
BIOMARKERS AND TISSUE DAMAGE
• A change in the concentration of a biomarker can be a signal that a tissue
is undergoing injury.
• The tissue may find itself under abnormal stress due to injury from
disease and respond by increasing the amount of the biomarker
produced as a corrective response.
• Increased amounts of the biomarker may then leak into the bloodstream,
causing its concentration there to increase to measurable levels.
• If the damage to the cell is permanent and the cell dies (cellular
necrosis), then all of the cellular contents can leak into the bloodstream.
Degeneration of a Healthy Cardiac
Muscle Cell to Necrotic Death
(a) Shows normal state, with background levels of
cellular leakage and degradation and normal levels of
production of messenger molecules

(b) Represents reversible damage to the cell. There is

increase in the amounts of some enzymes that may leak
from the cell, the release of some small cytosolic
molecules and changes in the production of messenger
molecules

(c) Cell death, with loss of structural and other cytosolic

proteins such as messenger molecules.
CARDIAC ENZYMES
• The first biochemical markers of cardiac damage were discovered in
1954 when Karmen et al. hypothesized that “destruction of cardiac
muscle, reported rich in transaminase activity, might result in a
release of this enzyme into the blood stream and might thus increase
the serum transaminase activity.” AST (GOT)…
• Today, serum biomarkers have become the centerpiece of evaluation
and management of patients presenting with chest pain.
• Detection of cardiac proteins in plasma provides insight into the
occurrence, extent, and timing of MI - critical for proper medical
management of patients with MI.
LACTATE DEHYDROGENASE (LD)
• Compared with AST, LD was found to be a more sensitive marker of MI
that remains elevated for significantly longer post-MI, up to 2 weeks.
• But LD is involved in NADH-dependent reactions in the glycolytic
pathway, which takes place in nearly all cells in the body, and its
specificity to cardiac muscle is thus quite low (also elevated in cancer,
anemia).
• Specifically, five different isoforms of LD (LD1 to LD5) are found in
human plasma, 22 which correspond to the organ from where the
enzyme originates. LD1 is most abundant in the myocardium, and LD5 is
expressed mainly in the skeletal muscle and liver.
LACTATE DEHYDROGENASE (LD)
• Therefore, diagnosis of MI was made by comparing plasma LD1 and LD2
levels.
• Because LD1 is specific to the myocardium, plasma normally contains
greater levels of LD2 than LD1; however, damage to the myocardium and
subsequent release of LD1 can cause plasma LD1 levels to surpass LD2.
• Early studies demonstrated that plasma LD1:LD2 ratio exceeds
approximately 0.75 24 to 48 hours past the onset of symptoms of MI and
remains elevated for up to 2 weeks.
• LD1:LD2 ratio was thus of great utility as an early biomarker in the
management of patients presenting several days after possible MI.
LACTATE DEHYDROGENASE (LDH)
CRETINE KINASE (CK)
• Like LD, CK is found in nearly all cells in the body, but unlike LD, CK
catalyzes a reaction important for high-energy phosphate production (the
conversion of creatine to creatine phosphate), which is greatly
upregulated in the muscle cells and brain.
• High levels of CK are thus found in all muscle cells; striated muscle.
Damage to the muscle or brain results in rapidly detectable increases in
plasma CK, which can be readily detected in plasma with a high sensitivity
at short times after muscle injury.
• In a typical patient with acute MI, serum CK levels were found to exceed
the normal range within 6 to 8 hours, to reach a peak of two- to tenfold
normal by 24 hours, and then decline to the normal range after 3 to 4 days
CRETINE KINASE (CK)
• In spite of its high sensitivity. CK elevations were readily detected in conditions such as
stroke, pulmonary disease, and chronic alcoholism and after strenuous exercise
• Three cytoplasmic isoenzymes (CK-MM, CK-MB, CK-BB). Cytoplasmic isoenzymes are
dimers composed of combinations of M and B subunits (M is for muscle and B is for
brain).
• Dimers of 2 M subunits (CK-MM), 2 B subunits (CK-BB), and 1 M and 1 B subunit (CK-MB).
• Elevated plasma levels of CK-MM or CKBB can be found after injury to the muscle or brain,
respectively.
• After it was found that 15% to 30% of CK in the myocardium is MB, compared with 1% to
3% in normal striated muscle (highly specific to myocardial damage).
• Additionally, elevations in serum CK-MB could be detected at 4 to 6 hours after the onset
of MI symptoms.
• Like its rapid rise post-MI, CK-MB levels quickly drop to baseline levels by 2 to 4 days post-
MI, compared with 10 to 14 days for LD.
CRETINE KINASE (CK)
• Assaying the individual isoenzymes can help in distinguishing
between the CK activities from cardiac muscle and skeletal
muscle damage.
• Creatine kinase MB activity starts to increase slightly earlier
than the overall CK levels and peaks 21 hours after a MI.
• To better distinguish between cardiac and skeletal muscle
damage the amount of CKMB can be expressed as the ratio
CKMB/total CK.
CRETINE KINASE (CK)
LD AND CK DISTRIBUTION
CARDIAC TROPONIN
• Troponin is a complex of three proteins that regulate the calcium-dependent
interactions of myosin heads with actin filaments during striated muscle contraction.
1. Troponin T (TnT) binds the troponin complex to tropomyosin
2. Troponin I (TnI) inhibits the binding of actin and myosin
3. Troponin C (TnC) binds to calcium to reverse inhibitory activity of TnI
4. Troponin complex is responsible for transmitting the calcium signal that triggers
muscle contraction
• Thin filaments are composed of actin, which plays a structural role, and troponin
and tropomyosin, which line actin filaments and regulate calcium-dependent
interactions with myosin on thick filaments to stimulate contraction.
• In absence of calcium, the binding of the troponin-tropomyosin complex to actin
inhibits contraction.
CK-MB, LD, TnT and TnI
• CK-MB levels elevate rapidly post-MI (4 to 6 hours) but return to baseline after 2
to 4 days
• CK-MB can thus only be used within a short window of time after a suspected
MI.
• LD levels remain elevated for up to 1 week but are not detectable until 24 to 48
hours post-MI.
• Cardiac troponins are detectable in the plasma at 3 to 12 hours after myocardial
injury, peaking at 12 to 24 hours and remaining elevated for more than 1 week
1. 8 to 21 days for TnT
2. 7 to 14 days for TnI
TnT and TnI
• Cardiac troponin (I or T) is currently the preferred biomarker for
myocardial necrosis, recognized to have nearly absolute myocardial
tissue specificity as well as high clinical sensitivity, detecting even
minor cardiac damage (as utilized in the universal definition of MI)
• Current guidelines recommend drawing blood for the measurement
of troponin as soon as possible after onset of symptoms of a possible
MI (universal definition of MI).
• If troponin assays are not available, the next best alternative is CK-MB
MYOGLOBIN
• Myoglobin is iron- and oxygen-binding protein found exclusively in the muscle
and is normally absent from the circulation.
• The myoglobin found in the muscle forms pigments, giving the muscle its
characteristic red color.
• Myoglobin is a small protein, which is released quickly when the muscle is
damaged (very short half-life of 9 minutes).
• Because myoglobin is released so quickly, it has been proposed as an adjunct
marker for troponin or CK-MB in the early diagnosis of MI.
• However, it is not specific for the heart, being elevated with any cause of skeletal
muscle damage.
• Recent studies have also shown that high-sensitivity troponin assays can detect
elevated troponin levels prior to elevations in myoglobin making myoglobin's use
less attractive
CASE STUDY
• A 68-year-old man presented to the emergency department with
sudden onset of chest pain, left arm pain, dyspnea, and weakness while
away from home on a business trip. His prior medical history is not
available, but he admits to being a 2-pack per day smoker for longer
than 20 years. Cardiac markers were performed at admission and 8
hours postadmission with the following results: 26 September
7:30 AM 4:00 PM
• CK-MB (0-5 ng/L) 5.3 9.2
• Myoglobin (<70 ug/L) 76 124
• TnT (0.0-0.1 ug/L) <0.1 1.3
QUESTIONS
1. Do these results indicate a specific diagnosis?
2. If so, what is the diagnosis?
3. What myoglobin, CK-MB, and TnT results would be
expected if assayed at 4 PM on September 27?
4. Can any assumptions be made about the patient's
lifestyle/habits/health that would increase his risk for this
condition?
5. Are there any assays that might indicate his risk for further
events of this type?
CASE STUDY
83-year-old man with known severe coronary artery disease, diffuse small vessel disease,
and significant stenosis distal to a vein graft from previous CABG surgery was admitted
when his physician referred him to the hospital after a routine office visit. His symptoms
included 3+ pedal edema, jugular vein distention, and heart sound abnormalities.
Significant laboratory data obtained on admission were as follows:
BUN : 53 mg/dl
Creatinine : 2.2 mg/dl
Total protein : 5.8 g/dl
Albumin: 3.2 g/dl
Glucose: 310 mg/dl
Calcium : 4.1 mg/dl
Phosphorus: 2.4 mg/dl
Total CK : 134 U/L
CK-MB : 4 U/L
TnT : 0.2 ug/L
Questions
1. Do the symptoms of this patient suggest acute MI?
2. Based on the preceding laboratory data, would this diagnosis be
acute MI? Why or why not?
3. Based on the preceding laboratory data, are there other organ
system abnormalities present?
4. What are the indicators of these organ system abnormalities?
5. Is there a specific laboratory test that might indicate congestive
heart failure in this patient?
American College of Cardiology/American Heart
Association/European Society of Cardiology Recommended
Laboratory and Clinical Tests for Patients with Suspected Heart
Failure
• CBC : anemia or infection
• Serum electrolyte levels : fluid retention
BUN/creatinine : renal damage due to hypoperfusion
• FBG levels : hyperglycemia is a high risk factor for HF
• Liver function tests (AST, ALT, LD) : indicate if liver function is affected
• Lipid profile (TC, TG, HDL-C, LDL-C) : to determine the risk of CHD
• TSH : hyperthyroidism or hypothyroidism; primary cause of HF
• URINALYSIS : proteinuria; strong relationship with CV risk