ISOENZYMES

Enzymes are organic biological catalysts that accelerate the chemical reactions inside the
biological systems (living cells). Although they are involved in the reaction, they are not
consumed.

Isoenzymes:
Isoenzymes (isozymes) are multiple forms of the enzyme that have the same catalytic activity.
Although they have the same catalytic activity, they are physically distinct & differ in:

Electrophoretic mobility,
Liability to inhibitors
Biochemical properties as amino acid composition & immunological reactivities.

Many enzymes are present in isoenzyme forms e.g:

Lactate dehydrogenase
Creatine kinase

Lactate dehydrogenase (LDH):

Its level in plasma increases in:

1- Myocardial infarction (heart diseases).
2- Viral hepatitis (liver disease).
3- Leukaemia (blood disease).

LDH enzyme is a tetramer formed of 4 protein subunits; each subunit is called protomer.
The protomers of LDH are of 2 types: H (heart) and M (muscle)
So, LDH has 5 isoenzymes:
LDH1 is formed of HHHH. It increases in myocardial infarction
LDH2 is formed of HHHM. It increases in myocardial infarction.

LDH3 is formed of HHMM. It increases in leukaemia.

LDH4 is formed of HMMM. It increases in viral hepatitis.
LDH5 is formed of MMMM. It increases in viral hepatitis.
So, LDH isoenzymes are clinically important to differentiate between heart, liver and blood
diseases.

Creatine kinase (CK)

It is an enzyme that catalyzes phosphorylation of creatine. Its level in plasma increases in:
1. Brain tumors.
2. Myocardial infarction (heart disease).
3. Skeletal muscle diseases.

CK enzyme is a dimmer formed of 2 protein subunits (protomers), B (brain) and M (muscle).

So, CK has 3 isoenzymes:
CK BB which increases in brain tumors.
CK MB which increases in heart diseases.
CK MM which increases in skeletal muscle diseases.
So, CK isoenzymes are clinically important to differentiate between brain, heart and skeletal
muscle diseases.

Source of isoenzymes:
1. Isoenzymes may be produced by more than one gene, each gene produces one subunit.

2. Isoenzymes may be produced by the same gene but the subunits undergo different posttranslation modifications in different organs.

Medical importance of isoenzymes:

-Isoenzymes are not only important for diagnosis of diseases but also indicate the diseased organ.
For example, lactate dehydrogenase enzyme (LDH) increases in:

Myocardial Infarction (Heart Disease)

Viral Hepatitis (Liver Disease)
Leukaemia (Blood Disease)

-LDH isoenzymes indicate the diseased organ as:

LDH1 and LDH2 isoenzymes increase only in myocardial infarction.

LDH3 increases in leukaemia
LDH4 and LDH5 increase in viral hepatitis.

Cardiac marker:
Cardiac markers are biomarkers measured to evaluate heart function. They are often discussed
in the context of myocardial infarction. Most of the early markers identified were enzymes, so
the term "cardiac enzymes" is sometimes used. However, not all of the markers currently used
are enzymes.

A) Creatine Kinase (CK-MB):

-It is relatively specific when skeletal muscle damage is not present.
-It rises to high peak within 1024 hours.
-Since it has a short duration, it cannot be used for late diagnosis of acute MI but can be used to
suggest infarct extension if levels rise again.
-This is usually returned back to normal within 23 days.

B) Lactate dehydrogenase:
-LDH is not as specific as troponin.
-It rises to high peak within 72 hours.
-LDH1 and LDH2 are called heart-type or heartspecific isoenzymes
-LDH-1 isozyme is normally found in the heart muscle and LDH-2 is found more in blood
serum.
-Normally, LDH-1/LDH-2 ratio is less than 1.
-A reversal of this ratio is called "flipped LDH".
-Following an acute myocardial infarct the flipped LDH ratio will appear in 12-24 hours and is
definitely present by 48 hours in over 80% of patients.
-A rise in LDH1 is the most significant in diagnosis of MI
-Also important is the fact that persons suffering chest pain due to angina only will not likely
have altered LDH levels.
-It is usually returns back to normal within 1014 days.

C) Transminases:
-Transaminases are intracellular enzymes.
-Their levels in plasma are low under normal conditions.
-There are two types of transaminases:

Alanine transaminases (ALT or GPT) is present mainly in the cytoplasm of liver .

Aspartate transaminases (AST or GOT) is present in both cytoplasm and mitochondria in
liver, heart, and skeletal muscles.

-In myocardial infarction, there is an increase in AST or GOT.

-It reaches its peak within 1-2 days and returns to normal level after 4- 6 days.

D) Glycogen phosphorylase isoenzyme BB:

-It has a high sensitivity and specificity early after chest pain and reaches to high peak within 7
hours.
-Glycogen phosphorylase exists in 3 isoforms.
-One of these Isoforms is GP-BB.
-This isoform exists in heart and brain tissue.
-Because of the blood-brain barrier, GP-BB can be seen as heart specific.
-During the process of ischemia, GP-BB is converted into a soluble form and is released into the
blood.
-GP-BB 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.
-GP-BB elevated 13 hours after process of ischemia.

Cardiac Enzymes for the diagnosis of myocardial infarction:

BE AWARE OF: Appropriate times to measure cardiac enzymes after an episode of chest pain.
The time course of release of (CK), (AST) and (LDH). CK and LDH isoenzymes in monitoring
cardiac damage.

Other important tests help in diagnosis:

a) Myoglobin:
-The earliest thing that goes up (LMW)
-Very sensitive
-Useful in early detection- Typical rise 2-4 hours after onset of AMI
-Not very specific can come from skeletal muscle
-Returns to normal very quickly

b) Troponins (T and I):

-Specific for myocardial cells even though it is found in skeletal muscle (theyre structurally
different)
-Extremely sensitive
-Elevated in blood when there is myocardial cell death
-Difficulty to make diagnosis early might take up to 9 hours.
-Troponin T can remain elevated for up to 2 weeks following myocardial cell death..useful in
late presentation of chest pain.