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Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
Cardiac Biomarkers in ACS
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Cardiac Biomarkers in ACS

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Dr. Dasdo Antonius Sinaga, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com

Dr. Dasdo Antonius Sinaga, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com

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  • 1. Cardiac Biomarkers in Acute Coronary Syndrome Dasdo Antonius Sinaga Cardiologist
  • 2. 4 1 2 3 4 5 6 Presentation Working Dx ECG Cardiac Biomarker Final Dx UA NQMI QwMI No ST Elevation NSTEMI Ischemic Discomfort Acute Coronary Syndrome Unstable Angina Myocardial Infarction ST Elevation Modified from Libby. Circulation 2001;104:365, Hamm et al. The Lancet 2001;358:1533 and Davies. Heart 2000;83:361.
  • 3. Detection of a rise/fall of cardiac biomarkers (preferable Troponin) with at least one value above the 99th percentile upper reference limit, with at lest one of the following: Symptoms of ischemia New of presumed new significant ST-T Change or new Left Bundle Branch Block Development of pathological Q wave Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality Identification of an intracoronary thrombus by angiography or autopsy
  • 4. What is a BIOMARKER ? BIOMARKER = a traceable substance that is introduced into an organism as a means to EXAMINE ORGAN FUNCTION or other aspects of health. RENAL function Serum Ureum & Creatinine Glomerular Filtration Rate LIVER function Transaminase (SGOT-SGPT)
  • 5. MYOFILAMEN STRUCTURE
  • 6. Various possibilities during myocardial infarction: Release of structural proteins from the myocardium, including normal turnover of myocardial cells, Apoptosis, Cellular release of troponin degradation products, increased cellular wall permeability, Formation and release of membranous blebs, and Myocyte necrosis
  • 7. Cardiac-specific troponins should be used as the optimum biomarkers for the evaluation of patients with STEMI who have coexistent skeletal muscle injury. For patients with ST elevation on the 12-lead ECG and symptoms of STEMI, reperfusion therapy should be initiated as soon as possible and is not contingent on a biomarker assay. Biomarkers of Cardiac Damage III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII Alpert et al. J Am Coll Cardiol 2000;36:959. Wu et al. Clin Chem 1999;45:1104.
  • 8. 0 1 2 3 4 5 6 7 8 Cardiac troponin-no reperfusion Days After Onset of STEMI MultiplesoftheURL Upper reference limit 1 2 5 10 20 50 URL = 99th %tile of Reference Control Group 100 Cardiac troponin-reperfusion CKMB-no reperfusion CKMB-reperfusion Cardiac Biomarkers in MYOCARDIAL INFARCTION Alpert et al. J Am Coll Cardiol 2000;36:959. Wu et al. Clin Chem 1999;45:1104.
  • 9. Creatine kinase-MB A cytosolic carrier protein for high-energy phosphates, Has long been the standard marker for the diagnosis of MI. LESS sensitive and LESS specific for MI than the cardiac troponins. Low levels of CK-MB can be found in the blood of healthy persons Elevated levels occur with damage to skeletal muscle Tsung SH. Several conditions causing elevation of serum CK-MB and CK-BB. Am J Clin Pathol 1981;75:711–5
  • 10. TROPONIN The troponin complex consists of 3 subunits: Troponin T (TnT), Troponin I (TnI), Troponin C (TnC). Troponin C is expressed by both cardiac and skeletal muscle, whereas TnT and TnI are derived from heart- specific genes. Therefore, the term “cardiac troponins” in these guidelines refers specifically to either Troponin T or Troponin I. Mair J, et al. Equivalent early sensitivities of myoglobin, creatine kinase MB mass, creatine kinase isoform ratios, and cardiac troponins I and T for acute myocardial infarction. Clin Chem 1995;41:1266–72. Jaffe AS, Babuin L, Apple FS. Biomarkers in acute cardiac disease: the present and the future. J Am Coll Cardiol 2006;48:1–11.
  • 11. Cardiac troponin as a biomarker Highly sensitive and specific in detecting cell necrosis Because cTnT and cTnI generally are not detected in the blood of healthy persons, the cutoff value for elevated cTnT and cTnI levels may be set to SLIGHTLY ABOVE the upper limit of the performance characteristics of the assay for a normal healthy population. Mair J, et al. Equivalent early sensitivities of myoglobin, creatine kinase MB mass, creatine kinase isoform ratios, and cardiac troponins I and T for acute myocardial infarction. Clin Chem 1995;41:1266–72. Jaffe AS, Babuin L, Apple FS. Biomarkers in acute cardiac disease: the present and the future. J Am Coll Cardiol 2006;48:1–11.
  • 12. HIGH SENSITIVITY TROPONIN Novel testing devices: 5- to 10-fold more sensitive than existing troponin assays. Earlier detection of myocardial infarction relative to the time of presentation Detect a higher percentage of emergency department chest pain patients who are at risk for short-term major adverse cardiac events. However, use of a high-sensitivity troponin assay will also result in detection of more patients who have cardiac necrosis due to a non-ischemic etiology,
  • 13. MYOGLOBIN Myoglobin, a low-molecular-weight heme protein Found in both cardiac and skeletal muscle not cardiac specific But it is released more rapidly from infarcted myocardium than are CK-MB and Troponin Can be detected as early as 2 hours after the onset of myocardial necrosis. However, the clinical value of serial determinations of myoglobin for the diagnosis of MI is limited by its brief duration of elevation of less than 24 h. Eggers KM, Oldgren J, Nordenskjold A, Lindahl B. Diagnostic value of serial measurement of cardiac markers in patients with chest pain: limited value of adding myoglobin to troponin I for exclusion of myocardial infarction. Am Heart J 2004;148:574–81.
  • 14. ONSET of RELEASE of BIOMARKER
  • 15. ADVANTAGES DISADVANTAGES CARDIAC TROPONIN • Highly sensitive & spesific • Detection of Myocardial infarction until 2 weeks Low sensitivity in early hour of infarction (> 6 hours) CKMB Detect Early Infarction (4- 6 hours) Loss of spesificity in muscle disease or injury MYOGLOBIN Early Detection of MI (2-4 hours) • Loss of spesificity in muscle disease or injury • Quickly rapid to normal value
  • 16. Cardiac Troponin in Patients with Kidney Disease In good kidney function, Troponin T and Troponin I give equivalent information In RENAL dysfunction, TROPONIN I assessment appears to have a specific role. Among patients with end-stage renal disease and no clinical evidence of acute myocardial necrosis, 15% to 53% show increased cTnT, fewer than 10% have increased cTnI; Freda BJ, Tang WH, Van Lente F, Peacock WF, Francis GS. Cardiac troponins in renal insufficiency: review and clinical implications. J Am Coll Cardiol 2002;40:2065–71.
  • 17. Dialysis increases Troponin T, but but decreases cTnI. The exact reasons: NOT CLEAR. An elevation of Troponin in patients with renal insufficiency is associated with a higher risk of morbidity REGARDLESS of the presence of cardiac symptoms or documented CAD. Freda BJ, Tang WH, Van Lente F, Peacock WF, Francis GS. Cardiac troponins in renal insufficiency: review and clinical implications. J Am Coll Cardiol 2002;40:2065–71.
  • 18. PROGNOSTIC VALUE James SK, Lindahl B, Armstrong P, et al. A rapid troponin I assay is not optimal for determination of troponin status and prediction of subsequent cardiac events at suspicion of unstable coronary syndromes. Int J Cardiol 2004;93:113–20
  • 19. HIGH SENSITIVITY TROPONIN Novel testing devices: 5- to 10-fold more sensitive than existing troponin assays. Earlier detection of myocardial infarction relative to the time of presentation Detect a higher percentage of emergency department chest pain patients who are at risk for short-term major adverse cardiac events. However, use of a high-sensitivity troponin assay will also result in detection of more patients who have cardiac necrosis due to a non-ischemic etiology,
  • 20. ROLE OF SERIAL MEASUREMENT Blood samples for the measurement of Troponin should be drawn on first assessment Repeated 3-6 h later. The second sample is required if: Further ischemic episodes occur, or Timing of the initial symptoms is unclear To establish the diagnosis of MI, a rise and/or fall in values with at least one value above the cut-off level is required.
  • 21. For example, patients with renal failure or HF can have significant chronic elevations in cTn. These elevations can be marked, as seen in many patients with MI, but do not change acutely no myocardial infarction But if the serial troponin measurement shows significantly higher troponin level Evidence of myocardial infarction
  • 22. Case 1: What would you do? Man, 55 years old Risk factors: smoker, hypertension Complaint: CHEST PAIN since 3 hours prior to admission CKMB: 20 (cuf off: 24) Troponin T low (Cut off 0.03)
  • 23. Case 2: What would you do? Woman, 50 years old Risk factors: Diabetes mellitus for 10 years Complaint: CHEST PAIN since 2 hours prior to admission Waiting for biomarker results?
  • 24. Case 2: What would you do? Man, 45 years old Risk factors: Diabetes mellitus for 10 years, smoker No spesific complaint. ECG found during routine medical check up
  • 25. SUMMARY Diagnosis of myocardial infarction includes Detection of a rise/fall of cardiac biomarkers (preferable Troponin) with at least one value above the 99th percentile upper reference limit. Several types of cardiac biomarkers/enzymes can be utilized, namely Troponin, creatine kinase, and myoglobin. Troponin is the most spesific biomarker in diagnosing myocardial infarction. ONSET of chest pain and biomarker level must be considered in establishing diagnosis of MI.
  • 26. THANK YOU

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