Demetrio L. Valle Jr., MD, MSc.

, FPSP, FASCP, IFCAP

Anatomic and Clinical Pathologist
Facts About Cardiovascular Diseases
2005- 17.5 Million people died of CVD
2015 – 20 Million (WHO)
Number ONE caused of death in the world, 20% of all
deaths
Unhealthy diet, physical inactivity and tobacco
smoking
CARDIAC MARKERS
Lactate Dehydrogenase (LD)
Creatine Kinase (CK) Total and Isoenzymes
CK-MB Activity
CK- MB Isoenzyme, Mass & Relative Index (RI)
CK-MB Isoenzyme Isoforms & Isoforms Ratio
Troponin T
Troponin I
Myoglobin
Others cardiac markers
LACTATE DEHYDROGENASE
Photometric method

Lactate + NAD = Pyruvate + NADH + H+

30oC – is the preferred temperature for enzyme assay

at 340 nm
Lactate dehydrogenase (LD) activity is present in all
cells of the body with highest concentrations in heart,
liver, muscle, kidney, lung, and erythrocytes.
LACTATE DEHYDROGENASE
Moderate to slight increases in LD levels are seen in
myocardial infarction (MI), pulmonary infarction,
pulmonary embolism, leukemia etc.
Marked elevations in LD activity can be observed in
megaloblastic anemia, untreated pernicious anemia,
Hodgkin's disease, abdominal and lung cancers,
severe shock, and hypoxia.
LACTATE DEHYDROGENASE
Myocardiacl infection assessment
Abnormal after 24-48 hours
Peaks in 3-6 days
Return to normal in 8-14 days
LACTATE DEHYDROGENASE ISOENZYMES
5 FRACTIONS (ISOENZYMES)
LD1 (H4) - Heart
LD2 (H3M)- Heart
LD3 (H2M2)- Pancreas
LD4 (HM3)
LD5 (M4) - Liver
Methods
α- hydroxybutyrate dehydrogenase (HBDH) activity
Electrophoresis
Ion-exchange chromatography
LACTATE DEHYDROGENASE ISOENZYMES
Interpretation
NV (LD1 16-28%, LD2 29-37%, LD3 17-23%, LD4 9-15%
and LD5 8-20%)
Myocardial infarction
 FLIPPED pattern (LD1/LD2 ratio is greater than 1) about 12-24
hours after infarction and remains greater than 1 for as long
as 7 days.
 Samples should be drawn every 24 hours.

 Two or three samples are needed since the “flip” pattern will

occur within 48 hours of a myocardial infarction.

Creatine Kinase (CK)
Enzyme found in various types of tissues (skeletal,
cardiac and brain)
Its concentrations are comparatively high due to its
function in energy metabolism.
Conc of Ck in skeletal muscle is 5-10 times higher
than that of cardiac muscle
Elevated in AMI, cerebrovascular accident, myositis,
skeletal muscle diseases like progressive Duckenne
muscular dystrophy
Creatine Kinase Isoenzymes
Electrophoresis on cellulose acetate of agarose gel,
differential inhibition, column chromatographym
batch absorption and radioimmunoassay
Three isoenzymes
CK-BB (CK1) - Brain
CK-MB (CK2)- Cardiac
CK-MM (CK3)- Skeletal Muscle
CK-MB, Activity
Method – Immunoinhibition method
Anti-CK-M inactivates the M sub-unit of CK-MM and
CK-MB. Residual B subunit enzyme is measured by the
production of NADPH at 340 nm
Appears 4 hours after infarction
Peaks: 12-24 hours
Decline > 48 hours
Normal:
< 16 IU/L
CK-MB Isoenzyme Mass Assay
Gold standard biochemical marker for AMI
Methods: ELISA, IRMA, Chemiluminescent
Rise: 4-6 hr
Peak: 12-24 hr
Normal: > 48 hr
Normal Value (ELISA)
< 4 ng/mL (< 10 ug/L)
CK-MB Isoenzyme with Relative Index
(RI)
Relative index (%) relates the CK-MB isoenzyme
mass concentration to the total CK activity.
It is used to evaluate increased total CK activity
Formula
RI (%) = CK-MB (ug/L) / Total CK (U/L) x 100
RI > 6% = indicative of cardiac damage
RI < 6% = indicative of skeletal damage
CK-MB Isoforms & Ratio
Develop to improve the sensitivity of the biochemical
diagnosis of AMI
Two isoforms of CK-MB isoenzyme
CK-MB1 and CK-MB2
Have equal levels
Myocardial damage:
CK-MB2 rises above CK-MB1
 CK MB Isoforms ratio produces to be highly sensitive and
specific indicator of EARLY AMI
CK-MB Isoforms & Ratio
Rise: 2-6 hr
Peak: 6-12 hr
Normal: 24-36 hr
Normal Value
CK-MB1 : 0.5- 1.0 U/L
CK-MB2: 0.5 – 1.0 U/L
Ratio: < 1.5 Isoform ratio
Troponin
Located on the thin filament of striated muscle
Three subunit proteins
TnT – tropomyosin binding subunit that binds the
troponin complex to tropomyosin along actin.
TnI – is the myosin ATPase inhibiting subunit blocking
myosin (thick filament) movement in the absence of
calcium.
TnC – calcium binding subunit
Troponin
Early increase after cardiac injury
Broad diagnostic window
Excellent cardiospecificity
Diagnostic potential in identifying patients with
unstable angina pectoris
High risk patients – therapy from platelet receptor
antagonists
Troponin I
Complete cardiospecific
Not detected in adult skeletal muscle
Absent in diseased human skeletal muscle
Indicated for:
AMI
Risk stratification of UAP
Therapy decision making
Minor myocardial damage
Reperfusion
Troponin I
Also elevated in viral myocarditis, scleroderna or
cardiac trauma
Rarely elevated in musculo-skeletal diseases and renal
insufficiency
Rise: 4-8 hr
Peak: 14-18 hr
Normal: 5-9 days
Troponin I
Methods:
ELISA, Chemiluminscent Assay
Normal Values:
0.0 – 0.04 ng/mL
Troponin T
Complete cardiospecific
Present in fetal skeletal muscle
Absent in healthy skeletal muscle
Indicated for:
AMI
Risk stratification of UAP
Therapy decision making
Minor myocardial damage
Reperfusion
Troponin T
Found in chronic renal disease
Reexpressed in skeletal muscle diseases such as
chronic tissue damage.
Rise: 4-8 hr
Peak: 14-18 hr
Normal: 14 days
Troponin T
Methods:
ELISA, Chemiluminscent Assay
Normal Values:
0.0 – 0.04 ng/mL
Myoglobin
Major protein responsible for oxygen supply of
striated muscles.
Due to its abundancy in muscle tissue and low
molecular weight it is released into blood rapidly as
early as 1 hour after cell damage of heart or skeletal
muscle
More sensitive than troponins during the first hours
after AMI.
Primarily utility  to assist in ruling out an infarct.
Myoglobin
E.g. myoglobin remains within the reference range
about 10 hours after chest pain onset AMI can be
ruled out with high probability (High negative
predictive value)
Lacks cardiospecificity,
Rise: 1-3 hr
Peak: 6-9 hr
Normal: 24-36 hr
Methods: ELISA, Turbidimetry/Nephelometry
Normal Value: o-0.09 ug/mL
CARBONIC ANHYDRASE III
Cytoplasmic protein mainly present in skeletal muscle,
only trace amount found in cardiac muscle
Similar rise and fall pattern as myoglobin
Myoglobin: Carbonic anhydrase III ratio useful in
determining if the rise of myoglobin is due to skeletal
or cardiac muscle.
GLYCOGEN PHOSPHORYLASE (GP)-BB
GP-BB isoenzyme - present in the brain and
myocardium
GP-LL and GP MM
Early and specific marker for myocardial necrosis and
ischemia
Early diagnosis of acute coronary syndrome and
reversible myocardial ischemia
Methods: ELISA and Immunochromatographic
HEART FATTY ACID BINDING
PROTEIN (HFABP)
a novel small cytosolic protein that is abundant in the
heart.
highly cardiac-specific (i.e. expressed primarily in
cardiac tissue), but is also expressed at low
concentrations in tissues outside the heart.
can be detected in the blood as early as 1-3 h after
onset of chest pain
peak values reached at 6-8 h and plasma levels
returning to normal within 24-30 hr
HEART FATTY ACID BINDING
PROTEIN (HFABP)
clinical diagnostic value is very limited in the
presence of renal failure and skeletal muscle diseases
as it is completely renally eliminated the diagnosis
of acute myocardial infarction (AMI) may be
overestimated
ISCHEMIA MODIFIED ALBUMIN
When exposed to ischemic tissue, human serum albumin
loses its ability to bind cobalt, and the structurally altered
albumin DUBBED IMA
IMA - can be measured by the albumin cobalt-binding
test.
sensitivity of the IMA assay for detecting ischemic chest
pain was 82%, compared with sensitivities of 45% for ECG
and 20% for cTnT
IMA values were significantly higher in patients with ACS
or UA than in those with nonischemic chest pain, and
higher in patients with UA than in those with AMI.
Khawp jai lai lai &
Santiphap
(Laos)