CARDIAC BIOMARKERS

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Biomark
er
An indicator used for objective
measurement and evaluation of

Response
Response to
to
therapeutic
therapeutic
intervention
intervention

Normal
Normal biological
biological
process
process
Pathogenic
Pathogenic
process
process

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Shoaib
Ph.D. Scholar

Characteristics of an ideal
biomarker

Standardized

High Sensitivity and Specificity

Accurate

Reproducible

Easy to interpret

Acceptable to patient

Consistent and Cost effective

Has an impact on clinical/risk management

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Cardiac biomarkers

Cardiac biomarkers were first developed for assisting

the cardiac events, especially acute myocardial
infarction.

Better understanding of cardiac disease process and

advancement in detection technology has pushed the
application of cardiac biomarkers beyond the diagnosis
boundaries.

Cardiac biomarkers are now used for staging of cardiac

disease, timing of cardiac events and prognostication.

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Classification
of
Cardiac
Biomarkers
according to
various stages
during cardiac
disease process
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Marker of Inflammation
hsCRP
sCD40L
homocystein

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High-Sensitivity C-Reactive
Protein

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CRP is Pentameric structure consisting of five

identical subunits of 23-kDa.

Its plasma levels can increase rapidly to 10,000x

levels.

It is the most extensively studied marker of

inflammation. Despite some controversy regarding
its clinical use, it appears to be the most promising
to date.

Although considered to be a general nonspecific

marker of inflammation, elevated baseline levels
of hsCRP are correlated with higher risk of future
CV morbidity and mortality among those with or
without clinical evidence of CVD.
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More recent data implicate CRP as an actual mediator of

atherogenesis

Once ligand-bound, CRP can:

Activate the classical compliment pathway

Stimulate phagocytosis
Bind to immunoglobulin receptors
Endothelial dysfunction via NO synthesis
LDL deposition in plaque by CRP-stimulated
macrophages

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Muhammad Shoaib Ph.D Scholar

Clinical Uses
Screening for cardiovascular risk in otherwise
healthy individuals
Predictive value of CRP levels for disease severity
in pre-existing Coronary artery disease

Elevated levels are predictive of

Long-term risk of first MI
Ischemic stroke

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Limitations of CRP

Low specificity
No evidence that lowering CRP levels decreases CV risk
Industry and FDA staff guidelines 2005 had given clinical cut off
value as less than 1 mg/l as safe levels with hs-CRP tests

CRP

Less than 1.0 mg/L

1.0-2.9 mg/L
Greater than 3.0 mg/L

Risk for CVD

Low
Intermediate
High

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sCD40L

Soluble fragment CD 40 ligand.

It is a signalling protein that reflects both inflammatory and

platelate interaction.

levels of sCD40L is associated with risk of cardiac events

However rise is also associated with many other inflammatory

conditions like RA, SCD, SLE etc.

Furthermore,

preanalytical

procedure

such

as

anticoagulant

quantity, temperature, time and centrifugation speed significantly

affect the final result, which proves to be potential barrier to
practical application of test.
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Homocystein

Intermediary amino acid formed by the conversion of methionine

to cysteine

Moderate hyperhomocysteinemia occurs in 5-7% of the population

Recognized as an independent risk factor for the development of

atherosclerotic vascular disease and venous thrombosis

Can result from genetic defects, drugs, vitamin deficiencies

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Homocysteine is implicated directly in vascular injury

including:

Intimal thickening
Disruption of elastic lamina
Smooth muscle hypertrophy
Platelet aggregation

Proposed mechanisms by which it induces vascular injury are

leukocyte recruitment, foam cell formation, and inhibition of
NO synthesis.

Normal levels : < 6micro mol/l

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Elevated levels of homocystein appear to be

an independent risk factor, though less
important than the classic CV risk factors.

Treatment includes supplementation with

folate, B6 and B12.

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Markers of Plaque Destabilization

PAPP-A
LP-PLA

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PAPP-A

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Its high relative stability in plasma, have led to its potential

use in the clinical setting.

Elevated level of PAPP-A are found in patients presenting

with unstable plaques, aggravated unstable angina and
acute MI.

It is also a reliable predictor of mortality in patients with

chronic stable CAD.

FREE PAPP-A >1.74 mIU/L is considered abnormal

Currently there is no standardised assay in widespread

clinical use.
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Lipoprotein-associated
phospholipase A
Lp-PLA is also known as platelate activating
factor acetyl hydrolase.
This phospholipase enzyme is encoded by
PLA2G7 gene.
It is a 45 kDa protein of 441 amino acids.

Lp-PLA
PAF
acetate

LYSO-PAF +

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In the blood it mainly travels with LDL. Less than 20% is

associated with HDL.
It is produced by inflammatory cells and hydrolyzes oxidised
phospholipids in LDL
Two main sources of Lp-PLA are :
1. which is brought from circulation into the intima bound to
LDL
2. which is synthesised de novo by plaque inflammatory cells.

Lp-PLA is involved in the development of atherosclerosis and It

is positively correlated with increased risk of developing
coronary artery disease.

Its level in blood is measured by PLAC test, an assay which

uses sandwich ELISA.
Average value
for females is 174 ng/mL
for males is 251 ng/ml

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Marker of Mocardial
Ischemia
IMA
H-FABP

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Ischemia Modified Albumin

Ischemia modified albumin is a marker formed

after damage in the N terminal region of the
albumin in ischemic conditions.
This structural change leads to loss of its ability
to bind with transitional metals (cu/co).
Endothelial or extracellular hypoxia, acidosis
and free oxygen radicals causes increase in IMA.
IMA rises within minutes from onset of ischemia
and remains elevated for several hours after
cessation of ischemia.
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Clinical uses of IMA :

it is used as diagnostic criteria for myocardial
necrosis that develops after CABG operation.
It is a non specific marker, since it is also
reported to be elevated in pulmonary
infarction, critical limb ischemia and
cerebrovascular disorders.
Basically, it is used to rule out ischemia
rather than diagnosing the occurrence of
ischemia. Which is helpful in differentiating
pain of Angina from Myocardial ischemia.
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H-FABP
Heart type fatty acid binding protein is a very
stable low molecular weight (14-15kDa) in the
cytoplasm of myocardial cells.
FABPs are involved in active fatty acid
metabolism where it transports fatty acid from
cell membrane to mitochondria for oxidation.
Small size of H-FABP facilitates rapid diffusion
through interstitial space, appearing as early as
1-3 hrs after onset and peaking within 6hrs. It
return to normal levels with in 12-24hrs.
Normal levels : 1.6 19 ng/ml

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H-FABP is 20 times more specific to cardiac

muscle than myoglobin
H-FABP is recommended to be measured
with troponin to identify MI and ACS in
patient presenting with chest pain.
In addition to its diagnostic potential H-FABP
also has prognostic value. The risk
associated with H-FABP is dependent
upon its concentration. Patients who were
cTnI- but H-FABP+ have more risk of
morbidity and mortality after 1 year follow
up than those with cTnI+HFABP-.

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Marker for cardiac

necrosis
cTn
CK-MB
Myoglobins

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Cardiac
Troponin

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Troponin is a complex of three regulatory

proteins (Troponin C, Troponin I and Troponin T)
that is associated with muscle contraction in
skeletal and cardiac muscle.
Cardiac
troponin is slightly different from
skeletal troponin structurally hence serve as a
potent and specific marker for cardiac disease.

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Muhammad Shoaib Ph.D Scholar

Individual subunits serve different functions:

Troponin Cbinds to calcium ions to produce a
conformational change in TnI
Troponin Tbinds to tropomyosin, interlocking
them to form a troponin-tropomyosin complex
Troponin Ibinds to actin in thin myofilaments to
hold the troponin-tropomyosin complex in place
Normal value : cTnT : .01ng/ml
cTnI : .04ng/ml

Usually, Troponin is not detectable in healthy

individual.

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cTnT :

It is extremely useful in patients who do not seek

attention in the 2 to 3 days window when CK-MB is
elevated.
Rise : with in few hours after onset of chest pain
Peak :
2 days
returns normal : 7-10 days

cTnT may show a biphasic release in some patients with a

first peak occurring during first 24 hr of onset of symptom
and second peak on appx. 4th day after admission.

TnT has cardiac as well as skeletal muscle source.

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cTnI :

It is cardiac specific because it has additional amino

acid residue on its N-terminal that are non existent
in skeletal muscle.
Rise : b/w 4-6 hr after onset of pain
Peaks : 12-18 hrs
Returns normal : 6 days

Its measurement is advantageous over CK-MB as it is

not found in detectable amount in serum of patients
with multiple injuries, renal disease and in those with
acute and chronic skeletal muscle disorders.

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Conditions associated with troponin

elevation
arrhythmia

congestive heart failure

coronary artery disease

coronary vasospasm

Critically ill

hypertension

myocarditis

pericarditis

Pulmonary embolism

severe pulmonary hypertension

Renal failure

septic shock

sepsis related myocardial

dysfunction

SIRS

trauma
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Cardiac myosin light chain :

initially they were thought to be unique

myocardial protein but now it is known that
it does not offer any added advantage over
CK-MB & cTn estimation. So, it is of limited
significance as a biomarker.

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CK-MB

Creatine kinase (CK) is a cytosolic enzyme involved

with the transfer of energy in muscle metabolism.
It catalyses the conversion of creatine to phosphocreatine degrading ATP to ADP.

CK is a dimer composed of two subunits B (brain type)

and M (muscle type), resulting in three isoenzyme:
CK-BB (CK1) : is of brain origin, found in blood only
when BBB is damaged.
CK-MB (CK2) : it is relatively specific for myocardial
origin
CK-MM (CK3) : it is found primarily in skeletal muscle

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CK-MB :
it is a valuable tool for the diagnosis of MI
because of its relative high specificity for
myocardial damage.
Rise : 4-6 hrs after onset of symptoms
Peak : 12 hrs
Return to normal : 24-36 hrs

Can be used to indicate early re-infarction if

level normalizes and then increases again.

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CK-MB
Relative Index =

100
Total CK

*The relative index allows the distinction

between increased total CK due to
myocardial damage and that due to skeletal
or neural damage.
*A relative index exceeding 3 is indicative of
AMI

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Myoglobin
Small-size

heme protein found in all tissues mainly

assists in oxygen transport

It

is released from all damaged tissues

Its

level rises more rapidly than cTn and CK-MB.

Released
Normal

from damaged tissue within 1 hour

value: 17.4-105.7 ng/ml

Timing:

Earliest Rise:
1-4 hrs
Peak
6-9 hrs
Return to normal: 12 hrs

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CONDITIONS FOR MYOGLOBIN INCREASE :

Acute myocardial infarction

Skeletal muscle damage, muscular dystrophy,

inflammatory myopathies

Renal failure, severe uremia

Shock and trauma

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Clinical usefulness of myoglobin :

*if myoglobin concentration remains within
the reference range 8 hours after the onset of
chest pain, AMI can be ruled out essentially.
*because of its rapid clearance by the kidney,
a persistently normal Mb concentration will
rule out reinfarction in patient with recurrent
chest pain after AMI
*Rapid monitor of success of thrombolytic
therapy

DRAWBACKS
Due to poor specificity, myoglobin levels do
not always predict myocardial injury
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 upper limit of reference interval

Comparison of cTn, CK-MB , Mb

7
6
5
myoglobin
CK-MB
cTnT
cTnI

4
3
2
1
0

12 16 20 24 28 32 36 40 44 48
Time after onset of AMI (hours)
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Marker for haemodynamic stress

natriuretic peptides

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 The

natriuretic peptides (NP) are a group of structurally similar but

genetically distinct peptide hormone.
It includes :
ANP : -atrial natriuretic peptide (28 a.a.)
N-terminal proANP (98 a.a.)
BNP : brain natriuretic peptide (32 a.a.)
N-terminal proBNP (76 a.a.)
CNP : C-type natriuretic peptide (22 and 53 a.a.)
DNP : D- type natriuretic peptide

The NPs play important role in regulation of salt and water

balance (CV homeostasis)

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ANP is released primarily in response to atrial wall

stretching and intravascular volume expansion.

BNP is mainly secreted by the ventricles

CNP is found predominantly in the brain and also

synthesized by vascular endothelial cells

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BRAIN NATRIURETIC PEPTIDE

(BNP)

Circulating levels of BNP are raised in

patients with cardiovascular or renal
disease

BNP is More important than ANP in heart

failure

Greatest proportion of circulating BNP is

thought to come from the ventricles (left)

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Synthesis in myocyte :

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BNP and the terminal fragment of its prohormone (NTproBNP) are released on ventricular stretch or stress
to the myocyte in the absence of the necrosis.

Therefore, BNP is increased in diseases characterised

by an expanded fluid volume (e.g. CHF,renal
failure,hepatic cirrhosis etc.)

BNP has circulating T/ of 20 minutes, so it is

indicative of snapshot of myocardial function, while
NT-proBNP has T/ of 90 minutes giving a longer view
of myocyte .

BNP <20pmol/L unlikely to have CHF

>20pmol/L high probability of CHF
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Future Cardiac Biomarker

miRNA

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miRNAs are appx. 20-25 nucleotide long non

coding RNAs, that negatively regulate or inhibit
gene expression by binding to sites in the
untranslated regions of targeted messenger RNAs.

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miRNA are found to be involved in almost

every biological process, from cellular
differentiation and proliferation to cell death
and apoptosis
Many different types of miRNA can be
detected in circulating blood and these
miRNA are present in remarkably stable
form that even withstand repetitive
freezing/thawing cycle and are protected
against Rnases.
Thousands of miRNAs have been described
in human to date which ehibits tissue
specific pattern of expression.

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miRNAs that regulates cardiovascular system can be

divided into 4 groups :

1. miRNA regulating endothelium function and

angiogenesis : miR126, miR17-92 cluster, miR130a,
miR221, miR21
2. cardiac myocyte specific mRNA : miR208a
3. cardiac myocyte and skeletal muscle miRNA : miR1,
miR133a, miR499
4. smooth muscle miRNAs :miR143, miR145
miRNAs hold promise as very specific and accurate
marker of cardiac dysfunction.
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Muhammad Shoaib Ph.D Scholar