1

CARDIAC BIOMARKERS:

Felix Botchway PhD

 History
2

 1950’s: Clinical reports that transaminases released

from dying myocytes could be detected via
laboratory testing, aiding in the diagnosis of
myocardial infarction1
 The race to define clinical markers to aid in the
diagnosis, prognosis, and risk stratification of
patients with potential cardiovascular disease
begins

1 Circulation 108:250-252
 History
3

 Initial serum markers included AST, LDH, total CK

and α-hydroxybutyrate
 These enzymes are all released in varying amounts
by dying myocytes
 Lack of sensitivity and specificity for cardiac muscle
necrosis fuels continued research
 History: CK and Isoenzymes
4

 CK known to be released during muscle necrosis

(including cardiac)
 Quantitative assays were cumbersome and difficult
to perform
 Total CK designed as a fast, reproducible
spectrophotometric assay in the late 1960’s
 History: CK and Isoenzymes
5

 CK isoenzymes are subsequently described

 MM, MB and BB fractions

 1970’s: MB fraction noted to be elevated in and

highly specific for acute MI1

1 Clinical Chemistry 50(11): 2205-2213

 History: CK and Isoenzymes
6

 CKMB now measured via a highly sensitive

monoclonal antibody assay
 It was felt for a time that quantitative CKMB
determination could be used to enzymatically
measure the size of an infarct
 This has been complicated by release of additional
enzymes during reperfusion
 History: CK and Isoenzymes
7

 As CK-MB assays become more sensitive,

researchers come to the paradoxical realization that
it too is not totally cardiac specific
 The MB fraction is determined to be expressed in
skeletal muscle, particularly during the process of
muscle regeneration
 The search for cardiac specificity continues…

Clinical Chemistry 50(11): 2205-2213

 History
8

 Research turns towards isolation of and

development of assays for sarcomeric proteins

 Myosin light chains were originally isolated and

then subsequently abandoned because of
specificity issues
 History: Troponin
9

 Troponin I first described as a biomarker specific for

AMI in 19871; Troponin T in 19892

 Now the biochemical “gold standard” for the

diagnosis of acute myocardial infarction via
consensus of ESC/ACC

1 Am Heart J 113: 1333-44

2 J Mol Cell Cardiol 21: 1349-53
 History
10

 This work encourages development of other clinical

assays for diagnosis and prognosis of a wide
spectrum of cardiac diseases
 Notable examples:
 BNP (FDA approved in November 2000 for diagnosis
of CHF)
 C-reactive protein
 11

MARKERS OF CARDIAC
NECROSIS
12
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

 When this ischemia is prolonged & irreversible, myocardial

cell death & necrosis occurs ---this is defined as:
myocardial infarction
 Biochemical Changes in Acute Myocardial Infarction
(mechanism of release of myocardial markers)
13

ischemia to myocardial muscles (with low O2 supply)

anaerobic glycolysis

increased accumulation of Lactate

decrease in pH

activate lysosomal enzymes

disintegration of myocardial proteins

cell death & necrosis

clinical manifestations release of intracellular ECG

(chest pain) contents to blood changes
BIOCHEMICAL
MARKERS
 Diagnosis of Myocardial Infarction
14

SHOULD depend on THREE items

(as recommended by WHO)

1- Clinical Manifestations
2- ECG
3- Biochemical Markers
 Markers of Cardiac Necrosis
15

 Cardiac biomarkers an integral part of the most

recent joint ACC/ESC consensus statement on the
definition of acute or recent MI:
 “Perfect” Cardiac Marker
16

 Early appearance

 Accurate, specific, precise

 Readily available, fast results

 Cost-effective
 Markers of Cardiac Necrosis
17

Typical rise and gradual fall (troponin) or more rapid

rise and fall (CK-MB) of biochemical markers of
myocardial necrosis with at least (1) of the following:
Ischemicsymptoms
Development of pathologic Q waves
ST segment elevation or depression
Coronary artery intervention
 Markers of Cardiac Necrosis
18
 Troponins
19

 Troponin T (cTnT) and troponin I (cTnI) control the

calcium-mediated interaction of actin and myosin
 cTnI completely specific for the heart
 cTnT released in small amounts by skeletal muscles,
though clinical assays do not detect skeletal TnT
 Troponins
20
 Troponins
21

 4-6 hours to rise post-infarct, similar to CKMB

 6-9 hours to detect pathologic elevations in all
patients with infarct
 Elevated levels can persist in blood for weeks; the
cardiac specificity of troponins thus make them the
ideal marker for retrospective diagnosis of
infarction
 CK-MB
22

 High specificity for cardiac tissue

 The preferred marker for cardiac injury for many
years
 Begins to rise 4-6 hours after infarction but can take
up to 12 hours to become elevated in all patients
with infarction
 Elevations return to baseline within 36-48 hours, in
contrast to troponins
 CK-MB is the marker of choice for diagnosis of
reinfarction after CABG because of rapid washout
 CK and CK-MB
23
 CK-MB: Shortcomings
24

 Concomitant skeletal muscle damage can confuse

the issue of diagnosis:
 CPR and defibrillation
 Cardiac and non-cardiac procedures

 Blunt chest trauma

 Cocaine abuse
 CK:CK-MB Ratio
25

 Proposed to improve specificity for use in diagnosis

of AMI
 Ratios 2.5-5 have been proposed
 Significantly reduces sensitivity in patients with both
skeletal muscle and cardiac injury
 Also known to be misleading in the setting of
hypothyroidism, renal failure, and chronic skeletal
muscle diseases
 Myoglobin
26

 Heme protein rapidly released from damaged

muscle
 Elevations can be seen as early as one hour post-
infarct
 Much less cardiac specific; meant to be used as a
marker protein for early diagnosis in conjunction
with troponins
 27

NATRIURETIC PEPTIDES
 Natriuretic Peptides
28

 Present in two forms, atrial (ANP) and brain (BNP)

 Both ANP and BNP have diuretic, natriuretic and
hypotensive effects
 Both inhibit the renin-angiotensin system and renal
sympathetic activity
 BNP is released from the cardiac ventricles in
response to volume expansion and wall stress
 BNP Assay
29

 Approved by the FDA for diagnosis of cardiac

causes of dysnpea
 Currently measured via a rapid, bedside
immunofluorescence assay taking 10 minutes
 Especially useful in ruling out heart failure as a
cause of dyspnea given its excellent negative
predictive value
 BNP
30

 Came to market in 2000 based on data from many

studies, primarily the Breathing Not Properly (BNP)
study
 Prospective study of 1586 patients presenting to
the ER with acute dyspnea
 The predictive value of BNP much superior to
previous standards including radiographic, clinical
exam, or Framingham Criteria
 BNP
31

 BNP has also shown utility as a prognostic marker in

acute coronary syndrome
 It is associated with increased risk of death at 10
months as concentration at 40 hours post-infarct
increased
 Also associated with increased risk for new or
recurrent MI
 32

PROGNOSTIC MARKERS AND

MARKERS OF RISK
STRATIFICATION
 Prognostic Markers and Markers of Risk
Stratification
33

 C-reactive protein
 Myeloperoxidase
 Homocysteine
 Glomerular filtration rate
 C-Reactive Protein
34

 Multiple roles in cardiovascular disease have been

examined
 Screening for cardiovascular risk in otherwise “healthy”
men and women
 Predictive value of CRP levels for disease severity in
pre-existing CAD
 Prognostic value in ACS
 C-Reactive Protein
35

 Pentameric structure consisting of five 23-kDa

identical subunits
 Produced primarily in hepatocytes
 Plasma levels can increase rapidly to 1000x
baseline levels in response to acute inflammation
 “Positive acute phase reactant”
 C-Reactive Protein
36

 Binds to multiple ligands, including many found in

bacterial cell walls

 Once ligand-bound, CRP can:

 Activate the classical compliment pathway
 Stimulate phagocytosis

 Bind to immunoglobulin receptors

 C-Reactive Protein:
Risk Factor or Risk Marker?
37

 CRP previously known to be a marker of high risk in

cardiovascular disease
 More recent data may implicate CRP as an actual
mediator of atherogenesis
 Multiple hypotheses for the mechanism of CRP-
mediated atherogenesis:
dysfunction via ↑ NO synthesis
 Endothelial
 ↑LDL deposition in plaque by CRP-stimulated
macrophages
 CRP and CV Risk
38

 Elevated levels predictive of:

 Long-term risk of first MI
 Ischemic stroke

 All-cause mortality
 Myeloperoxidase
39

 Released by activated leukocytes at elevated levels

in vulnerable plaques
 Predicts cardiac risk independently of other markers
of inflammation
 May be useful in triage of ACS (levels elevate in the
1st two hours)
 Also identifies patients at increased risk of CV event
in the 6 months following a negative troponin
NEJM 349: 1595-1604
 Homocysteine
40

 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, or smoking
 Homocysteine
41

 Homocysteine implicated directly in vascular injury

including:
 Intimalthickening
 Disruption of elastic lamina
 Smooth muscle hypertrophy
 Platelet aggregation

 Vascular injury induced by leukocyte recruitment,

foam cell formation, and inhibition of NO synthesis
 Homocysteine
42

 Elevated levels appear to be an independent risk

factor, though less important than the classic CV risk
factors
 Screening recommended in patients with premature
CV disease (or unexplained DVT) and absence of
other risk factors
 Treatment includes supplementation with folate, B6
and B12
 Glomerular Filtration Rate
43

 The relationship between chronic kidney disease

and cardiovascular risk is longstanding
 Is this the result of multiple comorbid conditions
(such as diabetes and hypertension), or is there an
independent relationship?
 Glomerular Filtration Rate
44

 Recent studies have sought to identify whether

creatinine clearance itself is inversely related to
increased cardiovascular risk, independent of
comorbid conditions
 Glomerular Filtration Rate
45

 Go, et al performed a cohort analysis of 1.12

million adults in California with CKD that were not
yet dialysis-dependent
 Their hypothesis was that GFR was an independent
predictor of cardiovascular morbidity and mortality
 They noted a strong independent association
between the two

NEJM 351: 1296-1305

 Glomerular Filtration Rate
46

 Reduced GFR has been associated with:

 Increased inflammatory factors
 Abnormal lipoprotein levels

 Elevated plasma homocysteine

 Anemia

 Arterial stiffness

 Endothelial dysfunction
 Questions and Thanks
47