Biochemical markers for acute coronary syndrome (ACS)

Acute Myocardial Infarction

Universal definition of MI (know this)

- Detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the
99th percentile of the upper reference limit together with one of the following:
Symptoms of ischemia
ECG changes of new ischemia (new ST-T changes or new LBBB)
Pathological Q waves in ECG
Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
- One elevated sample + rise/fall pattern needed to confirm Dx unless PT present >24 hrs after onset
- New universal definition increased # of people diagnosed with MI

No longer used:
- AST (aspartate transaminase)
-Nonspecific: also raised in liver and skeletal muscle dz

- LDH (lactate dehydrogenase)

-Elevated post MI; useful for late PT presentation;
-Replaced by cTn
-Nonspecific: also raised in liver and skeletal muscle dz
e.g. macrocytic megaloblastic anemia

Myoglobin
- Early marker for AMI (raised in 1 hr, cleared after 12 hrs)
- Nonspecific: also in skeletal muscle injury

Total CK (creatine kinase)

- Nonspecific: also raised in skeletal muscle diseases
e.g. dermatomyositis; can rise to 30 kU/L vs. usually
<5000 U/L for MI
- Duration: 36-48 hours

CK-MB activity
- Nonspecific: also raised in skeletal muscle problems,
but more specific than total CK
- Measured as % of CK-MB activity over total CK activity
- 5-25% indicates CK-MB activity from cardiac source

CK-MB mass (i.e. concentration)

- Cutoff = 99th percentile < 10% Duration: myoglobin < CK < LDH = cTn
- Best alternative if Tn is not available
- If raised again after 48-72 hours reinfarction

cTnI, cTnT (cardiac troponin)

- Cutoff = 99th percentile, preferable <10% imprecision (not achievable in contemporary kit however)
- Elevated 3-12 hours after onset of symptoms
- Elevated for longer duration, up to 7-14 days (vs. <2 days for CK)
- Take cTn level again 6-9 hours after first sample
- >20% increase in the cTn value between 2 samples taken 3-6 hours apart signifies reinfarction
- Specific for cardiac source not but the cause (i.e. not necessary AMI, can be other heart problem)
- More sensitive and specific than CK-MB; not benefits of taking both CK-MB and cTn together
- Absolute cutoff “number” depends on the brand of biochemical kit used; unit usually in µg/dL
High-sensitive cTn assays
- Can achieve <10% imprecision
- Improves early Dx of AMI
- High specificity i.e. negative assay result = no AMI, reliably

Heart failure (HF) – inability of heart to fill/eject blood due to any conditions

Natriuretic Peptide (NP) – 3 major types

- ANP
Atrial NP, not useful, as it is released w/ only minor triggers such as exercise

- BNP/NT-pro BNP
Released in response to cardiac wall stretch
Uses:
1. Diagnosing heart failure in patient w/ acute dyspnea
- Proposed cutoff to rule out HF: NT-pro BNP <300ng/L (note unit)
2. Prognosis marker for CHF and acute coronary symptoms (high level = poor prognosis)
3. Identifying the involvement of heart failure in systemic diseases
4. Monitor and guide drug therapy (some controversy)
- Target patient BNP < 100 ng/L reduce mortality and hospital stay