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Cardiac Enzymes - Kul
Cardiac Enzymes - Kul
Cardiac Enzymes
for Diagnosis of
Myocardial Infarction
Dr. Suhaemi, SpPD.
What is Myocardial Infarction?
• Myocardial ischemia results from the reduction of coronary
blood flow to an extent that leads to insufficiency of oxygen
supply to myocardial tissue
anaerobic glycolysis
decrease in pH
1- Clinical Manifestations
2- ECG
3- Biochemical Markers
criteria for ideal markers
for myocardial infarction
1- Specific: to myocardial muscle cells (no false positive)
2- Cardiac proteins:
Myoglobin
Troponins
CARDIAC MUSCLE CELL
- not specific for cardiac tissue (also in sk.ms. & renal tissue)
cTnI:
2- Sample
Type: plasma
Timing: i. on admission
ii. serial ( at least every one hour in a period 6-9 hours)
should be referenced to admission & onset of pain
definitive markers: Troponin: appears in blood later than myoglobin (within 6 hours)
BUT 100% specific, prognostic & stays longer (one week)
Low MW protein •
Skeletal & cardiac muscle Mb identical •
Serum levels increase within 2h of muscle damage •
Peak at 6 – 9h •
Normal by 24 – 36h •
Excellent NEGATIVE predictor of myocardial injury •
2 samples 2 – 4 hours apart with no rise in levels virtually –
excludes AMI
Rapid, quantitative serum immunoassays •
ASPARATATE
AMINOTRANFERASE (AST)
An enzyme that catalysis the transfer of amino •
group from amino acid to keto acid which is
important for providing α keto acid for tricarboxylic
acid cycle (energy production) and providing
amino acid for urea cycle.
It is widely distributed in hear, liver, skeletal •
muscle, kidney and RBCs.
AST activity is increased after myocardial •
infarction
It is elevated in other conditions as: •
Liver disease: hepatitis, liver cirrhosis, neoplasia •
Muscle diseases: muscular dystrophy and •
dermatomyositis
LACTATE
DEHYDROGENASE (LDH)
LDH is a hydrogen transfer enzyme that catalysis the •
oxidation of L-Lactate to Pyruvate.
It is composed of 4 subunits of 2 types •
M type encoded by a gene on ch 11
H type encoded by a gene on ch 12.
There are 5 isoenzymes: •
LD-1 (4 H subunits)
LD-2 (3 H and 1 M sumunits)
LD-3 (2 H and 2 M sumunits)
LD-4 (1 H and 3 M sumunits)
LD-5 (4 M subunits)
ISCHAEMIA-MODIFIED ALBUMIN
(IMA)
Serum albumin is altered by free radicals released from ischaemic •
tissue
Angioplasty studies show that albumin is modified within minutes of •
the onset of ischaemia.
IMA levels rise rapidly, remain elevated for 2-4 h + return to baseline •
within 6h
Clinically may detect reversible myocardial ischaemic damage •
Not specific (elevated in stroke, some neoplasms, hepatic cirrhosis, •
end-stage renal disease)
Thus potential value is as a negative predictor •
Spectrophotometric assay for IMA adapted for automated clinical •
chemistry analysers
FDA approved as a rule-out marker in low risk ACS patients (2003) •
Glycogen phosphorylase BB
(GPBB):
Proinflammatory Cytokines •
IL-6 •
Plaque Destabilization •
MPO •
Plaque Rupture •
sCD40L •
Acute Phase Reactants •
hs-CRP •
Ischemia •
IMA •
Necrosis •
cTnT •
cTnI •
Myocardial Dysfunction •
BNP •
NT-proBNP •
BIOCHEMICAL MARKERS IN
MYOCARDIAL ISCHAEMIA / NECROSIS
RECENT Traditional
CK-MB (mass) • AST activity •
c.Troponins (I or T) • LDH activity •
LDH isoenzymes •
Myoglobin •
CK-Total •
FUTURE: CK-MB activity •
Ischaemia Modified Albumin CK-Isoenzymes •
Glycogen Phosphorylase BB
Fatty Acid binding Protein
Highly sensitive CRP.
BIOCHEMICAL MARKERS IN ACS
CURRENT RECOMMENDATIONS