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Biochemical Markers For Diagnosis of Myocardial Infarction - Cardiac Troponin
Biochemical Markers For Diagnosis of Myocardial Infarction - Cardiac Troponin
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Diagnosis
Accurate and timely biochemical marker testing for aiding the diagnosis of
myocardial infarction (MI) has been important for the appropriate disposition
and treatment of patients for the past several decades. Creatine kinase (CK)
muscle and brain (CK-MB) mass and myoglobin measurements were the
standard up to the mid-1990s, when assays for the cardiac-specific isoforms
of troponin I and troponin Thereafter referred to collectively as cardiac
troponins (cTn)became available. The data for cTn were so compelling that
in 2000 a global task force comprising representatives from the European
Society of Cardiology (ESC) and the American College of Cardiology (ACC)
was convened to redefine the diagnosis of MI based on cTn measurements.1
Recently, the National Academy of Clinical Biochemistry (NACB) has published
updated guidelines for clinical utilization of biochemical markers in the
context of acute coronary syndrome (ACS) and MI diagnosis.2,3 Also, this
NACB committee developed guidelines for logistics, measurement
specifications, and point-of-care testing of these biochemical markers.4 The
recommendations and strength of scientific data supporting each NACB
guideline statement were rated using scoring criteria adopted from the
American Heart Association (AHA)/American College of Cardiology (ACC),
which are summarized in Table 1. For each recommendation, the designations
I, IIa, IIb, and III describe the indications, and the upper-case letters A to C
describe the weight of evidence.5
Who Should Be Tested with Biochemical Markers?
It is well known that the clinical signs and symptoms of patients presenting
with suspected ACS are frequently vague and non-specific, and mimic a
number of other conditions. For this reason, measurement of biomarkers
should be obtained in all patients presenting with ACS symptoms, as indicated
in Recommendation 1 in Table 2. Although quantitative measurement of
biochemical markers is important for objectifying the diagnostic process of the
MI work-up, Recommendation 2 in Table 2 is a reminder that the patients
clinical presentation (history, physical examination) and electrocardiogram
(ECG) must be used in conjunction with biomarkers in the diagnostic
evaluation of suspected MI.
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1.
2.
3.
4.
10
11
Class IIa
12
Institutions that cannot consistently deliver cardiac marker turnaround times of
approximately one hour should implement point-of-care testing devices. (Level of
Evidence: B)
Class I
13
Members of emergency departments, divisions of cardiology, primary care
physicians, hospital administrations, and clinical laboratories should work
collectively to develop an accelerated protocol for the use of biochemical markers
in the evaluation of patients with possible ACS. (Level of Evidence: C)
From the National Academy of Clinical Biochemistry (NACB) guideline documents.2,3,4 See Table 1
for interpretation of recommendation class and level of scientific data supporting each NACB
guideline statement.
ECG = electrocardiogram; CV = cardiovascular; CK-MB = creatine kinase muscle and brain;
ACS = acute coronary syndromes.
must be utilized, the guidelines state that the maximal concentration must
exceed the 99th percentile of values for a sex-specific reference control group
on two successive samples (see Recommendation 9, Table 2).
What Is the Need for Speed?
The consensus among cardiology and emergency medicine (EM) physicians is
that cardiac markers should be available within one hour of specimen
collection, and optimally within 30 minutes or less (see Recommendation 10,
Table 2). To meet this stringent requirement, several measures are necessary.
First, the specimen for analysis should be either anticoagulated whole blood,
so that centrifugation and handling is not necessary, or plasma, to avoid a delay
due to the clotting process (see Recommendation 11, Table 3). Second,
institutions that cannot consistently deliver cardiac marker turnaround times of
approximately one hour should implement point-of-care testing devices (see
Recommendation 12, Table 2). Although it should go without saying, the
guidelines remind us that members of EM, cardiology, primary care, hospital
administrations, and laboratory medicine should work to develop an
accelerated protocol for the use of biochemical markers in the evaluation of
patients with possible ACS (see Table 2).
Summary and Path Forward
cTn measurements are an essential part of the MI evaluation and should be
measured in all patients with signs and symptoms of ACS. Sampling is
necessary at presentation and at six to nine hours, and in some cases again at
1224 hours. The troponin cut-off that should be used is the 99th percentile
of a reference control population. cTn results should be available within one
hour after specimen collection, and optimally in 30 minutes or less. Use of
anticoagulated whole blood or plasma facilitates shorter turnaround times,
and point-of-care testing is an attractive alternative when turnaround
times are suboptimal.
Apple FS, Jesse RL, Newby LK, et al., Clin Chem, 2007;53:54751.
Storrow AB, Apple FS, Wu AHB, et al., National Academy of Clinical
Biochemistry laboratory medicine practice guidelines for point of care
5.
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