CARDIAC BIOMARKERS

dr. Arthur E. Mongan, M.Sc., Sp.PK

SEMESTER-3 BLOK-2 MODUL-1

KARDIOVASKULAR
FK UNSRAT MANADO
2008
 THE HEART

→ TO MAKE BLOOD CIRCULATE THROUGHOUT THE

BODY

→ TO PUMP DE-OXYGENATED BLOOD INTO THE

LUNGS

→ TO PUMP OXYGENATED BLOOD TO FEED THE

BODY’S BIOLOGICAL FUNCTION
THE HEART FUNCTION
 THE HUMAN HEART

Human heart removed from a 64-year-old male.

http:// en.wikipedia.org
 THE HUMAN HEART

http:// en.wikipedia.org
 THE HUMAN HEART

http:// en.wikipedia.org
 HEART ATTACK

2. ISCHEMIC / INFARCT
http:// en.wikipedia.org
 HEART ATTACK

http:// en.wikipedia.org
 THE SINUS RHYTME

http:// en.wikipedia.org
  ISCHEMIA ACS(a sudden decrease
in the amount of blood and
oxygen reaching the heart →
chest pain / angina pectoris)
 INFARCTION (when blood flow
to the heart is blocked causing
heart cells to die → AMI / acute
myocardial infarction or heart
attack)
Henry’s Laboratory Methods4
 Cardiac Biomarkers

are substances that are released into the

blood when the heart is damaged.

Henry’s Laboratory Methods4

 Cardiac Biomarkers

Measurement of these biomarkers is used to

help diagnose, evaluate, and monitor patients
with suspected ACUTE CORONARY
SYNDROME (ACS).

Henry’s Laboratory Methods4

 Cardiac Biomarkers Tests
are ordered to help detect the presence of ACS
and to evaluate its severity as soon as possible
so that appropriate therapy can be initiated.

Henry’s Laboratory Methods4

 TRANSAMINASES
 GOT (glutamate-oxaloacetate
transaminase; now, aspartate
transaminases, AST)
 GPT (glutamate-pyruvate
transaminase; now, alanine
transaminase, ALT)
→ abundance in the liver, skeletal muscle, and other tissues
→ PHASED OUT BIOMARKERS, not specific for damage to the heart, no
longer recommended
Henry’s Laboratory Methods4
 LACTATE DEHIDROGENASE,
LDLD (HHHM),
 LD1 (HHHH), 2
LD3 (HHMM), LD4 (HMMM),
LD5 (MMMM)
 AMI →’FLIPPED’ LD (LD1
> LD2) (the normal finding LD2 >
LD1)
→ found in all types of muscle, also in brain
→ PHASED OUT BIOMARKERS, not specific for damage to the heart, no
longer recommended
Henry’s Laboratory Methods4
 CURRENT CARDIAC
 CK and CKMB
BIOMARKERS TESTS
 TROPONIN
 MYOGLOBIN

ADDITIONAL BIOMARKERS TESTS

 BNP (or NT-proBNP)
 Hs-CRP
http:// en.wikipedia.org
 CREATINE KINASE
ISOENZYMES:
 CK1 (BB)
 CK2 (MB) , in the normal heart, an average of 15 –
20% of the CK is CK-MB
 CK3 (MM)

http:// en.wikipedia.org
 CARDIAC TROPONIN, cTn

TROPONIN (Tn):
 is a regulatory complex of three proteins
residing at regular intervals in the thin
filament of striated muscle.

Henry’s Laboratory Methods4

 CARDIAC TROPONIN, cTn
The three individual proteins are:
 TnT (tropomyosin-binding subunit, 37 kDa)
 TnI (inhibitory subunit, 24 kDa)
 TnC (calcium-binding subunit, 18 kDa)

Henry’s Laboratory Methods4

 CARDIAC TROPONIN, cTn
The three individual proteins are:
 c(cardiac)TnT and cTnI: more specific to
muscle fibers of cardiac myocytes
 TnC, the forms found in type-2 fibers
(skeletal) and cardiac muscle are
identical (therefore, less use as marker)

Henry’s Laboratory Methods4

 CHANGE IN THE PATTERN OF CARDIAC
MARKERS

Henry’s Laboratory Methods4

 MYOGLOBIN
→ is a heme-containing protein that binds
oxygen within cardiac and skeletal
muscle.
→ its usefulness as cardiac marker derives
from its kinetics. Elevated serum levels
are apparent within 2-3 h following onset
of MI, earlier than with troponin or other
markers.
Henry’s Laboratory Methods4
 The kinetics of several cardiac markers
following an MI

Henry’s Laboratory Methods4

 MARKERS OF CORONARY RISK (CHD)
→ LABORATORY:
○ LIPID PROFILE
○ C-REACTIVE PROTEIN (CRP, hsCRP)
○ HOMOCYSTEINE (Hcy)
○ etc., e.g.: BNP (Brain natriuretic peptide) or NT-proBNP (N-
terminal pro b-type natriuretic peptide) → markers of
Congestive Heart Failure (CHF)

→ NON-LABORATORY (risk factors):

○ cigarette smoking
○ hypertension (≥ 140/90 mmHg)
○ family history (CHD)
○ age (♂45, ♀55)
○ obesity
○ diabetes mellitus
○ sedentary lifestyle
Henry’s Laboratory Methods4
 REFERENCES:
1. Mayne PD. Clinical Chemistry in Diagnosis and Treatment, 6th
ed., ELBS, London UK, 1994.

2. Bishop ML, Duben-Engelkirk JL, Fody EP. Clinical Chemistry.

Lippincott Williams & Wilkins. Philadelphia USA, 2000.

3. Burtis CA, Ashwood ER, Bruns DE. TIETZ Textbook of

Clinical Chemistry and Molecular Diagnostics. 4th ed., Saunders
Elsevier. St Louis, Missouri USA, 2006.

4. McPherson RA, Pincus MR. Henry’s Clinical Diagnosis and

Management by Laboratory Methods, 21st ed., Saunders
Elsevier. Philadelphia USA, 2007.
 CASE
A 49-year old man admitted to hospital early in the morning was complaining chest
pain, dyspnea, and excessive sweating, which had begun the night before, particularly
during exertion. On questioning, he presented a few years history of diabetes mellitus.
On examination, he was pale with a blood pressure of 170/100 mmHg, respiratory rate
30/minute. Laboratory tests were done on admission with the following results:
hemoglobin (Hb)14 mg/dL (n : 12-15), white blood cells (WBC) 12.000/uL (n: 5000-
1000), ESR 50mm (first 1 hour), (random) blood glucose level 320 mg/dL (n/fasting:
65-126), total protein 8.0 mg/dL (n: 6-8), albumin 5 mg/dL (n: 3-5), total cholesterol 350
mg/dL, blood urea 14 mg/dL (n: 20-40), creatinine 1.0 mg/dL (n: 0.5-1.4), AST 120 U/L
(n ≤37), LDH 250 U/L (n : 150-450). Additional information: height 1.75 m, weight 105
kg (BMI?).

1. What is the most probable working diagnosis?

2. What are the differential diagnosis (other possible organs / systems)
3. What kind of laboratory tests are needed to establish the diagnosis, and what are
the expected results? Explain!
4. What kind of laboratory tests are needed to follow up the disease?
Pilihlah SATU JAWABAN yang paling tepat!

 Hasil hitung indeks masa tubuh pasien (IMT), adalah:

A. 34.3 B. 24.3 C. 43.2 D. 33.4 E. 32.3

2. Diagnosis kerja yang paling mungkin pada pasien saat ini adalah:
A. Infark miokardium akuta B. Infeksi bakterial akuta C. DM tak terkendali
D. Gagal ginjal akuta E. Penyakit paru kronis

3. Diagnosis banding apakah yang paling mungkin pada pasien ini (menyangkut organ / sistem lainnya):
A. Paru B. Sistem saraf pusat C. Sistem urogenitalia D. Kelenjar pankreas
E. Sistem reproduksi

4. Untuk konfirmasi diagnosis, pemeriksaan lanjutan apakah yang dianjurkan pada pasien ini:
A. CK dan CK-MB B. LDH C. AST dan ALT D. Homosistein E. BNP / NT-proBNP

5. Pemeriksaan non-laboratorik lainnya yang diperlukan pada pasien ini, adalah:

A. Treadmill B. EKG C. Tes fungsi paru D. CT-scan thorax E. Tes fungsi ginjal
Pilihlah SATU JAWABAN yang paling tepat!

6. Kadar Troponin-T serum menjadi penting pada pasien dengan infark miokardium akuta (IMA), bila:
A. Pemeriksaan laboratorium dilakukan dalam waktu 3 – 6 jam sebelum terjadi serangan
B. Kadar CK-MB telah mencapai puncak dan turun (setelah 3 jam serangan)
C. Kadar mioglobin meningkat ekstrim
D. Kadar Troponin-I telah kembali normal
E. Terjadi ‘flipped’ LDH

7. Kadar mioglobin serum ternyata normal sampai setelah 8 jam munculnya gejala dugaan serangan jantung:
A. Berarti tidak menunjang diagnosis IMA B. Berarti konfirmasi diagnosis IMA
C. Perlu diinterpretasi bersama kadar Troponin-T D. Sama artinya dengan CK-MB total
E. Perlu pemeriksaan BNP / NT-proBNP lagi

8. Analit berikut ini mempunyai spesifisitas tertinggi terhadap jejas jantung (cardiac injury):
A. Troponin-I B. esai massa CK-MB C. CK-MB total D. AST E. LD

9. Parameter pemeriksaan laboratorium manakah yang menunjang Congestive Heart Failure (Gagal Jantung):
A. Homosistein B. Kolesterol-LDL C. BNP / NT-proBNP D. hs-CRP E. Glukosa darah

10. Yang bukan merupakan dampak iskemia jantung:

A. Aritmia B. Angina pektoris C. Decompensatio Cordis D. Obesitas E. Infak miokard