SlideShare a Scribd company logo
1 of 49
BIOMARKERS OF CAD & MI:
RECENT ADVANCES
-Dr. Nilesh Chandra
OBJECTIVES:
 Brief Review of Existing biomarkers
 New Diagnostic Biomarkers
 New prognostic Biomarkers
 Biomarkers under research
DIAGNOSTIC MARKERS
 Serum Markers
 Fractional Flow Reserve
 Echocardiography
 Nuclear Imaging Studies
 Computed Tomography Scanning
 Electron Beam Computed Tomography
Scanning
DIAGNOSTIC MARKERS (CONTD.)
 Optical Coherence Tomography Imaging
 Magnetic Resonance Imaging
 Positron Emission Tomography
 Coronary Angiography
 Doppler Velocity Probes
 Ultrasonography
 Histology
SERUM MARKERS
 Troponins (I or T)
 Creatine kinase with MB isozymes
 Lactate dehydrogenase and lactate
dehydrogenase isozymes
 Serum aspartate aminotransferase
PROGNOSTIC MARKERS
 Biomarkers:
 Lipid Studies
 Copeptin
 H-FABP
 Urinary albumin-to-creatinine ratio
 Homocysteine
 Renin
 B-type natriuretic peptide
 CRP
LIPID STUDIES
 Total cholesterol level
 LDL cholesterol (LDL-C) level
 HDL cholesterol (HDL-C) level
 Triglyceride level
Specific lipid studies (if necessary) include the following:
 Small, dense LDL-C level
 Lipoprotein (a) level
 Apoprotein profile
 Direct measurement of LDL-C
C-terminal-provasopressin (Copeptin)
 The more stable surrogate of arginine vasopressin (AVP)
 Post AMI
 increase peripheral vasoconstrictor activity
 increase protein synthesis in myocytes
 vasoconstriction of coronary arteries
 Can rule out MI earlier in addition to a negative Troponin T test
 a copeptin level of < 14 pg/ml and a Trop T level of < 0.01
 an area under the curve (AUC) of receiver operating
characteristic curve (ROC) of 0.97 (negative predictive value
of 99.7%)
C-terminal-provasopressin (Copeptin) contd..
 Can rule out MI earlier in addition to a negative
Troponin T test
 a copeptin level of < 14 pg/ml and a Trop T level of < 0.01
 an area under the curve (AUC) of receiver operating
characteristic curve (ROC) of 0.97 (negative predictive value
of 99.7%)
 Effects are mediated via the V1 receptor
 These receptors are now targets for pharmacological
therapy.
Heart-Type Fatty Acid Binding Protein (H-FABP)
 A LMW protein involved in myocardial fatty-acid
metabolism
 Rapidly released early in myocardial infarction and
necrosis into the cytosol
 When added to Troponin for risk stratification
(Trop/H-FABP):(-)= H-FABP< 5.8 mcg/L
* -/- = zero mortality at six months
* -/+= 4.93-fold increase in risk of death
* +/+= 7.93-fold increase in risk of death
PROGNOSTIC BIOMARKERS
 1) Biomarkers of biomechanical stress:
 BNP/NTproBNP
 Mid-Regional pro-Atrial Natriuretic Peptide
(MRproANP
 Growth Differentiation Factor-15(GDF-15)
 ST2
 ET1/CTproET1
PROGNOSTIC BIOMARKERS (CONTD..)
 2) Biomarkers of neurohormonal pathway activation
 Mid-Regional-pro-Adrenomedullin (MRproADM)
 Copeptin
 3) Biomarkers of plaque instability and inflammation
 HsCRP (High-sensitivity C-reactive Protein)
 Myeloperoxidase (MPO)
 Pregnancy associated Plasma Protein A (PaPPA)
PROGNOSTIC BIOMARKERS (CONTD..)
 4) Other Novel biomarkers
 MMP9
 MMP2
 TIMP1
BNP/NTproBNP
 BNP: One of the best known biomarkers of
biomechanical stress
 Is released with the N-terminal portion of the pro-BNP
peptide (NTproBNP)
 Predicts in-hospital and 180-day death or heart failure
.
Mid-Regional pro-Atrial Natriuretic Peptide
(MRproANP)
 ANP has similar secretory profile post AMI as BNP.
 MRproANP fragment substantially more stable peptide
compared to N-ANP and ANP
 MRproANP is at least as good at predicting death and
heart failure as NTproBNP
Growth Differentiation Factor-15(GDF-15)
 A member of the Transforming Growth Factor Beta
cytokine superfamily
 Under episodes of stress like ischaemia and
reperfusion,its levels go up in cardiomyocytes.
 Provides prognostic information following an MI or ACS
ET1/CTproET1
 A potent vasoconstrictor peptide
 It activates ETA and ETB receptors
 Appears to be detrimental post-MI
 Plasma concentration of CTproET-1 peaks at Day 2
 Is increased in proportion to the severity of the
disease post AMI
 Independent of age, Killip class and past medical
history
Mid-Regional-pro-Adrenomedullin (MRproADM)
 Activity in the cardiovascular system is similar to that
of BNP
 Post AMI, increased MRproADM associated with
death, heart failure or both at one year, over and
above information gained from NTproBNP alone
 Combining the two markers increases the AUC of the
ROC from 0.77 and 0.79 to 0.84
HsCRP (High-sensitivity C-reactive Protein)
 CRP mediates atherothrombosis
 An elevated CRP associated with increased
cardiovascular risk
 Benefits of hsCRP testing to screen for ischaemic
heart disease is very clear, its use post-ACS or -MI is
less clear
 A new assay for Human Pentraxin 3 is now available
Myeloperoxidase (MPO)
 Myeloperoxidase has been found in atheromatous
plaques
 MPO in leucocytes may activate metalloproteinases
 MPO may inactivate plasminogen activator inhibitor
 Post-ACS, MPO levels higher than median predicted
future death and MI at one year
 MPO levels do not predict heart failure
Pregnancy associated Plasma Protein A (PaPPA)
 A proatherosclerotic metalloproteinase
 Is highly expressed in unstable plaques and their
extracellular matrices
 PaPPA > 2.9 mIU/L predicts a 4.6-fold increase in risk
of cardiovascular death, MI or revascularisation even
without a raised Troponin
NEWER TECHNOLOGIES: METABOLOMICS
 Components from branched-chain & aromatic amino
acid as independent cardiovascular risk factors:
 isoleucine, leucine, valine, tyrosine, and phenylalanine
 Lipids metabolites associated with cardiovascular
disease, shown to promote atherosclerosis:
 phosphatidylcholine-choline
 trimethylamine N-oxide
 betaine
GENETIC BIOMARKERS
 When one twin dies of CHD, the RR for the remaining
one is as high as 4-fold for dizygotes and 8-fold for
monozygotes
 Genome-wide association (GWA) studies for identifying
common SNPs that are associated with cardiovascular
disease
 Locus in the 9p21 region separately reported by 3
different groups
Chr SNP Risk allele
frequency
(%)
Odds ratio (95% CI)
per risk allele
Gene(s) of interest within or
near associated interval
6q26–
6q27
rs3798220 2 1.47 (1.35–1.60) LPA
rs10455872 7 1.68 (1.43–1.98) LPA
9p21 rs4977574 56 1.29 (1.25–1.34) CDKN2A-CDKN2B-ANRIL
21q22 rs9982601 13 1.20 (1.14–1.27) SLC5A3-MRPS6-KCNE2
1p13 rs646776 81 1.19 (1.13–1.26) CELSR2-PSRC1-SORT1
1p32 rs17114036 91 1.17 (1.13–1.22) PPAP2B
10q11 rs1746048 84 1.17 (1.11–1.24) CXCL12
2q33 rs6725887 14 1.17 (1.11–1.23) WDR12
3q22 rs9818870 15 1.15 (1.11–1.19) MRAS
1p32 rs11206510 81 1.15 (1.10–1.21) PCSK9
19p13 rs1122608 75 1.15 (1.10–1.20) LDLR
1q41 rs17465637 72 1.14 (1.10–1.19) MIA3
11q23 rs964184 13 1.13 (1.10–1.16) ZNF259, APOA5-A4-C3-A1
12q24 rs3184504 40 1.13 (1.08–1.18) SH2B3
6p24 rs12526453 65 1.12 (1.08–1.17) PHACTR1
Endogenous Bioactive Peptides
 Adiponectin, an adipocytokine
 Heregulin-β1 (neuregulin-1 type I), a neuron growth
factor
 Glucagon-like peptide-1 (GLP-1), an incretin hormone
 Salusin-α
Effects of new novel peptides on the cardiovascular
system.
Adiponectin Heregulin-β1 GLP-1 Salusin-α
VSMC
proliferation
↓ ↓ ↓ ↑
eNOS ↑ ↑ ↑ →
Cardiomyocyte
protection
+ + + +
Anti-inflammation + + + NE
Anti-oxidation + + + NE
Effects of new novel peptides on macrophage foam
cell formation.
Adiponectin Heregulin-β1 GLP-1 Salusin-α
Foam cell
formation
↓ ↓ ↓ ↓
ACAT1 ↓ ↓ ↓ ↓
SR-A ↓ ↓ → →
ABCA1 ↑ ↑ → →
Comparisons of circulating heregulin-β1 and salusin-α levels
between CAD and non-CAD subjects
MECHANISMS IN MI
Markers and stage of appearance
Summary
 Existing biomarkers for CAD & MI diagnosis,
prognosis and their limitations
 Biomarkers undergoing clinical trials
 Newer potential biochemical markers under
research
References
 Harrison’s Principles of Internal Medicine; 17th Edition
 Daniel Chan, Leong L Ng ;Biomarkers in acute myocardial infarction; BMC
Med. 2010; 8: 34.
 Ramachandran S. Vasan;Biomarkers of Cardiovascular Disease: Molecular
Basis and Practical Considerations; Circulation. 2006; 113: 2335-2362
 Yin Ge,Thomas J. Wang;Circulating, imaging, and genetic biomarkers in
cardiovascular risk prediction;Trends Cardiovasc Med. 2011 May; 21(4):
105–112
 Takuya Watanabe, Kengo Sato, Fumiko Itoh, Kohei Wakabayashi, Masayoshi
Shichiri, Tsutomu Hirano; Endogenous Bioactive Peptides as Potential
Biomarkers for Atherosclerotic Coronary Heart Disease;Sensors (Basel).
2012; 12(4): 4974–4985
THANK YOU
Killip Classification:
 Killip class I includes individuals with no clinical signs of heart failure.
 Killip class II includes individuals with rales or crackles in the lungs, an
S3, and elevated jugular venous pressure.
 Killip class III describes individuals with frank acute pulmonary edema.
 Killip class IV describes individuals in cardiogenic shock or hypotension
(measured as systolic blood pressure lower than 90 mmHg), and
evidence of peripheral vasoconstriction (oliguria, cyanosis or sweating).
 Within a 95% confidence interval the patient outcome was as follows:
 Killip class I: 81/250 patients;32% (27–38%).Mortality rate 6%.
 Killip class II: 96/250 patients;38% (32–44%).Mortality rate 17%.
 Killip class III: 26/250 patients;10% (6.6–14%).Mortality rate 38%.
 Killip class IV: 47/250 patients;19% (14–24%).Mortality rate 67%.
FRACTIONAL FLOW RESERVE
 An index of functional severity of coronary
artery stenosis.
 Based on the observation that myocardial
perfusion is entirely pressure dependent during
maximal hyperemia.
 Represents the fraction of the normal maximal
coronary flow that can be achieved in an artery
in which flow is restricted by a coronary
stenosis.
ECHOCARDIOGRAPHY
 Transthoracic echocardiography helps to assess LVF, wall-
motion abnormalities.
 Transesophageal echocardiography used for assessing
possible aortic dissection.
 Stress echocardiography used to evaluate
hemodynamically significant stenoses.
 Treadmill echocardiography stress testing and dobutamine
echocardiography stress testing provide equivalent
predictive values.
NUCLEAR IMAGING STUDIES
 Useful in assessing patients for
hemodynamically significant coronary artery
stenoses:
 Treadmill nuclear stress test
 Dipyridamole (Persantine)
 Adenosine nuclear stress test
 Dobutamine nuclear stress test.
COMPUTED TOMOGRAPHY SCANNING
 Allow excellent visualization of the coronary arteries:
 Multidetector computed tomography (MDCT) scanning
 Low-dose CT attenuation correction (CTAC)
 hybrid positron emission tomography (PET)/CT
 single-photon emission computed tomography (SPECT)
 CT myocardial perfusion imaging (MPI)
ELECTRON BEAM COMPUTED TOMOGRAPHY
SCANNING
 Method of evaluating calcium content in the coronary
arteries.
 Used as a screening test in asymptomatic patients
 Used as a diagnostic test for obstructive CAD in
symptomatic patients
OPTICAL COHERENCE TOMOGRAPHY IMAGING
 Catheter-based, high-resolution intravascular imaging
 Remarkable resolutionin the range of 10-20 µm.
 Acquisition rates are near video speed
 OCT imaging uses light
MAGNETIC RESONANCE IMAGING
 Used to gain information noninvasively about blood
vessel wall structure and to characterize plaque
composition
POSITRON EMISSION TOMOGRAPHY
 Radiation exposure 4- to 5-fold lower with PET.
 PET offers better spatial and temporal resolution and
shorter imaging time.
CORONARY ANGIOGRAPHY
 In vivo assessment
 The criterion standard for detecting significant flow-
limiting stenoses that may be revascularized through
percutaneous or surgical intervention of the coronary
arteries
 Limitation: only the vessel space occupied by blood is
visualized.
DOPPLER VELOCITY PROBES
 Based on the principle of the Doppler effect
 Use miniaturized crystals fixed to the tip of catheters
 Allows measurement of selective coronary artery flow
velocity
RELATIVE CORONARY FLOW RESERVE
 Calculated as follows: ([rCFR] = CFR target/CFR
reference).
 Correlates with stress myocardial perfusion imaging
results
 Provides additional information regarding the status of
the microcirculation in patients with CAD
ULTRASONOGRAPHY
 Aids in evaluating brachial artery reactivity and
carotid artery intima media thickness:
 Brachial Artery Reactivity
 Carotid artery intima-media thickness
 Intravascular Ultrasonography
HISTOLOGY
 A system devised by Stary et al.
 classifies atherosclerotic lesions according to
their histologic composition and structure.
 Type I to type VIII lesions
ST2
 an IL1-receptor-like protein
 elevated when heart is under mechanical
stress
 seems to have a cardioprotective role
 ST2 predicts cardiovascular death following
ACS
 correlates somewhat with NTproBNP
Copeptin
 Predicts mortality or heart failure at 60 days
post AMI
 Relationship of copeptin to LV dysfunction
persists for a prolonged period after the acute
event
 Provides complementary prognostic
information to NTproBNP

More Related Content

What's hot

Biomarkers in heart failure
Biomarkers in heart failureBiomarkers in heart failure
Biomarkers in heart failureHimanshu Rana
 
High sensitivity troponins
High sensitivity troponinsHigh sensitivity troponins
High sensitivity troponinsSCGH ED CME
 
DYSLIPIDEMIA AND RESIDUAL RISK
DYSLIPIDEMIA  AND  RESIDUAL RISKDYSLIPIDEMIA  AND  RESIDUAL RISK
DYSLIPIDEMIA AND RESIDUAL RISKSYEDRAZA56411
 
Webinar cardiac biomarkers
Webinar cardiac biomarkersWebinar cardiac biomarkers
Webinar cardiac biomarkersS G CHAKRAVARTHY
 
Lipid lowering trials ppt
Lipid lowering trials pptLipid lowering trials ppt
Lipid lowering trials pptNavin Agrawal
 
What’s new in Lipidology, Lessons from “recent guidelines“
What’s new in Lipidology, Lessons from “recent guidelines“What’s new in Lipidology, Lessons from “recent guidelines“
What’s new in Lipidology, Lessons from “recent guidelines“Arindam Pande
 
the novel biomarker in diabetes.
the novel biomarker in diabetes.the novel biomarker in diabetes.
the novel biomarker in diabetes.Dr. Raju Niraula
 
Imaging techniques for myocardial hibernation
Imaging techniques for myocardial hibernationImaging techniques for myocardial hibernation
Imaging techniques for myocardial hibernationMichael Katz
 
coronary microvascular dysfunction
coronary microvascular dysfunctioncoronary microvascular dysfunction
coronary microvascular dysfunctionmagdy elmasry
 
High Sensitivity Troponin
High Sensitivity TroponinHigh Sensitivity Troponin
High Sensitivity TroponinMatt Sanderson
 
Focused bedside Echocardiography
Focused bedside EchocardiographyFocused bedside Echocardiography
Focused bedside EchocardiographyAhmedElBorae1
 
Troponin elevation is not always acss
Troponin elevation is not always acssTroponin elevation is not always acss
Troponin elevation is not always acssaymanabdelaziz
 
Role of raas inhibition in management of hypertension
Role of raas inhibition in management of hypertensionRole of raas inhibition in management of hypertension
Role of raas inhibition in management of hypertensionKyaw Win
 
Assessment of myocardial viability
Assessment of myocardial viabilityAssessment of myocardial viability
Assessment of myocardial viabilityDrBayazid
 

What's hot (20)

Biomarkers in heart failure
Biomarkers in heart failureBiomarkers in heart failure
Biomarkers in heart failure
 
High sensitivity troponins
High sensitivity troponinsHigh sensitivity troponins
High sensitivity troponins
 
cardiac biomarker
cardiac biomarkercardiac biomarker
cardiac biomarker
 
DYSLIPIDEMIA AND RESIDUAL RISK
DYSLIPIDEMIA  AND  RESIDUAL RISKDYSLIPIDEMIA  AND  RESIDUAL RISK
DYSLIPIDEMIA AND RESIDUAL RISK
 
Webinar cardiac biomarkers
Webinar cardiac biomarkersWebinar cardiac biomarkers
Webinar cardiac biomarkers
 
Cardiac biomarkers in chf
Cardiac biomarkers in chfCardiac biomarkers in chf
Cardiac biomarkers in chf
 
Lipid lowering trials ppt
Lipid lowering trials pptLipid lowering trials ppt
Lipid lowering trials ppt
 
What’s new in Lipidology, Lessons from “recent guidelines“
What’s new in Lipidology, Lessons from “recent guidelines“What’s new in Lipidology, Lessons from “recent guidelines“
What’s new in Lipidology, Lessons from “recent guidelines“
 
the novel biomarker in diabetes.
the novel biomarker in diabetes.the novel biomarker in diabetes.
the novel biomarker in diabetes.
 
Imaging techniques for myocardial hibernation
Imaging techniques for myocardial hibernationImaging techniques for myocardial hibernation
Imaging techniques for myocardial hibernation
 
coronary microvascular dysfunction
coronary microvascular dysfunctioncoronary microvascular dysfunction
coronary microvascular dysfunction
 
High Sensitivity Troponin
High Sensitivity TroponinHigh Sensitivity Troponin
High Sensitivity Troponin
 
Echo in IHD
Echo in IHDEcho in IHD
Echo in IHD
 
Focused bedside Echocardiography
Focused bedside EchocardiographyFocused bedside Echocardiography
Focused bedside Echocardiography
 
Troponin elevation is not always acss
Troponin elevation is not always acssTroponin elevation is not always acss
Troponin elevation is not always acss
 
Ecg
EcgEcg
Ecg
 
Role of raas inhibition in management of hypertension
Role of raas inhibition in management of hypertensionRole of raas inhibition in management of hypertension
Role of raas inhibition in management of hypertension
 
Assessment of myocardial viability
Assessment of myocardial viabilityAssessment of myocardial viability
Assessment of myocardial viability
 
Biomarkers in diabetes
Biomarkers in diabetesBiomarkers in diabetes
Biomarkers in diabetes
 
NT-ProBNP
NT-ProBNPNT-ProBNP
NT-ProBNP
 

Viewers also liked

Acs – new biomarkers & role of newer anticoagulants
Acs – new biomarkers & role of newer anticoagulantsAcs – new biomarkers & role of newer anticoagulants
Acs – new biomarkers & role of newer anticoagulantsArindam Pande
 
Hemoglobinopathy
HemoglobinopathyHemoglobinopathy
Hemoglobinopathyvlmawia
 
Cardiac troponin (Dr.Vishal)
Cardiac troponin (Dr.Vishal)Cardiac troponin (Dr.Vishal)
Cardiac troponin (Dr.Vishal)drvishalpatel
 
Kidney disorders, Laboratory Investigation and Renal Function Tests
Kidney disorders, Laboratory Investigation and Renal Function TestsKidney disorders, Laboratory Investigation and Renal Function Tests
Kidney disorders, Laboratory Investigation and Renal Function TestsMadhukar Vedantham
 
Chemical Mediators of inflammation
Chemical Mediators of inflammationChemical Mediators of inflammation
Chemical Mediators of inflammationOmair Riaz
 
Common presentation and investigation of Kidney diseases
Common presentation and investigation of Kidney diseasesCommon presentation and investigation of Kidney diseases
Common presentation and investigation of Kidney diseasesEzmeer Emiral
 
Renal Diagnostic Tests OR Investigations
Renal Diagnostic Tests OR InvestigationsRenal Diagnostic Tests OR Investigations
Renal Diagnostic Tests OR InvestigationsChandima007
 
Cardiac biomarkers
Cardiac biomarkersCardiac biomarkers
Cardiac biomarkersJai Kanth
 
Fluid & Electrolytes Balance
Fluid & Electrolytes  BalanceFluid & Electrolytes  Balance
Fluid & Electrolytes Balancemohammed indanan
 
Quality Control in a Medical Testing Laboratory
Quality Control in a Medical Testing LaboratoryQuality Control in a Medical Testing Laboratory
Quality Control in a Medical Testing LaboratoryDr. Bikash Kumar Chaudhury
 
Quality control in clinical biochemistry
Quality control in clinical biochemistryQuality control in clinical biochemistry
Quality control in clinical biochemistryAshok Katta
 
Respiratory burst by Phagocytosis
Respiratory burst by PhagocytosisRespiratory burst by Phagocytosis
Respiratory burst by PhagocytosisRamesh Pothuraju
 
Quality control in the medical laboratory
Quality control in the medical laboratoryQuality control in the medical laboratory
Quality control in the medical laboratoryAdnan Jaran
 

Viewers also liked (20)

Acs – new biomarkers & role of newer anticoagulants
Acs – new biomarkers & role of newer anticoagulantsAcs – new biomarkers & role of newer anticoagulants
Acs – new biomarkers & role of newer anticoagulants
 
Hemoglobinopathy
HemoglobinopathyHemoglobinopathy
Hemoglobinopathy
 
Cardiac troponin (Dr.Vishal)
Cardiac troponin (Dr.Vishal)Cardiac troponin (Dr.Vishal)
Cardiac troponin (Dr.Vishal)
 
Biomarkers in acs dr.i.tammi raju
Biomarkers in acs dr.i.tammi rajuBiomarkers in acs dr.i.tammi raju
Biomarkers in acs dr.i.tammi raju
 
Cardiac Biomarkers
Cardiac BiomarkersCardiac Biomarkers
Cardiac Biomarkers
 
Kidney disorders, Laboratory Investigation and Renal Function Tests
Kidney disorders, Laboratory Investigation and Renal Function TestsKidney disorders, Laboratory Investigation and Renal Function Tests
Kidney disorders, Laboratory Investigation and Renal Function Tests
 
Chemical Mediators of inflammation
Chemical Mediators of inflammationChemical Mediators of inflammation
Chemical Mediators of inflammation
 
Common presentation and investigation of Kidney diseases
Common presentation and investigation of Kidney diseasesCommon presentation and investigation of Kidney diseases
Common presentation and investigation of Kidney diseases
 
Biomarkers
BiomarkersBiomarkers
Biomarkers
 
Renal Diagnostic Tests OR Investigations
Renal Diagnostic Tests OR InvestigationsRenal Diagnostic Tests OR Investigations
Renal Diagnostic Tests OR Investigations
 
Chemical mediators of inflammation
Chemical mediators of inflammationChemical mediators of inflammation
Chemical mediators of inflammation
 
Inflammation
InflammationInflammation
Inflammation
 
Inflammation
Inflammation Inflammation
Inflammation
 
Cardiac biomarkers
Cardiac biomarkersCardiac biomarkers
Cardiac biomarkers
 
Fluid & Electrolytes Balance
Fluid & Electrolytes  BalanceFluid & Electrolytes  Balance
Fluid & Electrolytes Balance
 
Quality Control in a Medical Testing Laboratory
Quality Control in a Medical Testing LaboratoryQuality Control in a Medical Testing Laboratory
Quality Control in a Medical Testing Laboratory
 
Quality control in clinical biochemistry
Quality control in clinical biochemistryQuality control in clinical biochemistry
Quality control in clinical biochemistry
 
Renal Function Test
Renal Function TestRenal Function Test
Renal Function Test
 
Respiratory burst by Phagocytosis
Respiratory burst by PhagocytosisRespiratory burst by Phagocytosis
Respiratory burst by Phagocytosis
 
Quality control in the medical laboratory
Quality control in the medical laboratoryQuality control in the medical laboratory
Quality control in the medical laboratory
 

Similar to Biomarkers of cad & mi presentation

Biomarkers in Coronary Artery Disease
Biomarkers in Coronary Artery Disease Biomarkers in Coronary Artery Disease
Biomarkers in Coronary Artery Disease Han Naung Tun
 
Marc Penn, MD, PhD, FACC - Trials and Tribulations of Assessing CVD Risk in ...
Marc Penn,  MD, PhD, FACC - Trials and Tribulations of Assessing CVD Risk in ...Marc Penn,  MD, PhD, FACC - Trials and Tribulations of Assessing CVD Risk in ...
Marc Penn, MD, PhD, FACC - Trials and Tribulations of Assessing CVD Risk in ...Cleveland HeartLab, Inc.
 
Bio-Markers of Heart Failure (Dr.LIKHIT T)
Bio-Markers of Heart Failure (Dr.LIKHIT T)Bio-Markers of Heart Failure (Dr.LIKHIT T)
Bio-Markers of Heart Failure (Dr.LIKHIT T)Likhit T
 
Poster 27 biochimie
Poster 27 biochimiePoster 27 biochimie
Poster 27 biochimieJIB Congress
 
Inflammationandatherosclerosis 191217191540 (2)
Inflammationandatherosclerosis 191217191540 (2)Inflammationandatherosclerosis 191217191540 (2)
Inflammationandatherosclerosis 191217191540 (2)Jonathan Bishinsky, FRCPC
 
Inflammation and atherosclerosis
Inflammation and atherosclerosisInflammation and atherosclerosis
Inflammation and atherosclerosisDIPAK PATADE
 
Heart Failure biomarkers
Heart Failure biomarkersHeart Failure biomarkers
Heart Failure biomarkersdrucsamal
 
dkNET Webinar: Leveraging Computational Strategies to Identify Type 1 Diabete...
dkNET Webinar: Leveraging Computational Strategies to Identify Type 1 Diabete...dkNET Webinar: Leveraging Computational Strategies to Identify Type 1 Diabete...
dkNET Webinar: Leveraging Computational Strategies to Identify Type 1 Diabete...dkNET
 
stroke biomarkers a new era with diagnostic promise.pptx
stroke biomarkers a new era with diagnostic promise.pptxstroke biomarkers a new era with diagnostic promise.pptx
stroke biomarkers a new era with diagnostic promise.pptxMoustafa Rezk
 
Translational Genomics and Prostate Cancer: Meet the NGS Experts Series Part 2
Translational Genomics and Prostate Cancer: Meet the NGS Experts Series Part 2Translational Genomics and Prostate Cancer: Meet the NGS Experts Series Part 2
Translational Genomics and Prostate Cancer: Meet the NGS Experts Series Part 2QIAGEN
 
Newer biomarkers in heart failure
Newer biomarkers in heart failure Newer biomarkers in heart failure
Newer biomarkers in heart failure lotusheart7
 
Cardiac profile tests(biochemical )
Cardiac profile tests(biochemical )Cardiac profile tests(biochemical )
Cardiac profile tests(biochemical )rohini sane
 
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...JohnJulie1
 
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...AnonIshanvi
 

Similar to Biomarkers of cad & mi presentation (20)

Biomarkers in Coronary Artery Disease
Biomarkers in Coronary Artery Disease Biomarkers in Coronary Artery Disease
Biomarkers in Coronary Artery Disease
 
Biomarkers in acute coronary syndrome
Biomarkers in acute coronary syndromeBiomarkers in acute coronary syndrome
Biomarkers in acute coronary syndrome
 
Fuster aha-2005-dallas-biomarkers,
Fuster  aha-2005-dallas-biomarkers,Fuster  aha-2005-dallas-biomarkers,
Fuster aha-2005-dallas-biomarkers,
 
Marc Penn, MD, PhD, FACC - Trials and Tribulations of Assessing CVD Risk in ...
Marc Penn,  MD, PhD, FACC - Trials and Tribulations of Assessing CVD Risk in ...Marc Penn,  MD, PhD, FACC - Trials and Tribulations of Assessing CVD Risk in ...
Marc Penn, MD, PhD, FACC - Trials and Tribulations of Assessing CVD Risk in ...
 
Bio-Markers of Heart Failure (Dr.LIKHIT T)
Bio-Markers of Heart Failure (Dr.LIKHIT T)Bio-Markers of Heart Failure (Dr.LIKHIT T)
Bio-Markers of Heart Failure (Dr.LIKHIT T)
 
BIOMARKERS IN HF.pptx
BIOMARKERS IN HF.pptxBIOMARKERS IN HF.pptx
BIOMARKERS IN HF.pptx
 
Poster 27 biochimie
Poster 27 biochimiePoster 27 biochimie
Poster 27 biochimie
 
Inflammationandatherosclerosis 191217191540 (2)
Inflammationandatherosclerosis 191217191540 (2)Inflammationandatherosclerosis 191217191540 (2)
Inflammationandatherosclerosis 191217191540 (2)
 
Inflammation and atherosclerosis
Inflammation and atherosclerosisInflammation and atherosclerosis
Inflammation and atherosclerosis
 
Heart Failure biomarkers
Heart Failure biomarkersHeart Failure biomarkers
Heart Failure biomarkers
 
dkNET Webinar: Leveraging Computational Strategies to Identify Type 1 Diabete...
dkNET Webinar: Leveraging Computational Strategies to Identify Type 1 Diabete...dkNET Webinar: Leveraging Computational Strategies to Identify Type 1 Diabete...
dkNET Webinar: Leveraging Computational Strategies to Identify Type 1 Diabete...
 
ACC UPDATE 2018
ACC UPDATE 2018ACC UPDATE 2018
ACC UPDATE 2018
 
stroke biomarkers a new era with diagnostic promise.pptx
stroke biomarkers a new era with diagnostic promise.pptxstroke biomarkers a new era with diagnostic promise.pptx
stroke biomarkers a new era with diagnostic promise.pptx
 
Translational Genomics and Prostate Cancer: Meet the NGS Experts Series Part 2
Translational Genomics and Prostate Cancer: Meet the NGS Experts Series Part 2Translational Genomics and Prostate Cancer: Meet the NGS Experts Series Part 2
Translational Genomics and Prostate Cancer: Meet the NGS Experts Series Part 2
 
Newer biomarkers in heart failure
Newer biomarkers in heart failure Newer biomarkers in heart failure
Newer biomarkers in heart failure
 
Acs ppt
Acs pptAcs ppt
Acs ppt
 
Acs ppt
Acs pptAcs ppt
Acs ppt
 
Cardiac profile tests(biochemical )
Cardiac profile tests(biochemical )Cardiac profile tests(biochemical )
Cardiac profile tests(biochemical )
 
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
 
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
Deadenylase Expression in Small Cell Lung Cancer Related To Clinical Characte...
 

More from Nilesh Chandra

More from Nilesh Chandra (8)

Techniques used for separation in proteomics
Techniques used for separation in proteomicsTechniques used for separation in proteomics
Techniques used for separation in proteomics
 
Vit d
Vit dVit d
Vit d
 
Glycoproteins
GlycoproteinsGlycoproteins
Glycoproteins
 
Epigenetics final
Epigenetics finalEpigenetics final
Epigenetics final
 
Csf seminar
Csf seminarCsf seminar
Csf seminar
 
Apoptosis seminar f
Apoptosis seminar fApoptosis seminar f
Apoptosis seminar f
 
Ab diversity
Ab diversityAb diversity
Ab diversity
 
Mechanism of tissue graft rejection
Mechanism of tissue graft rejectionMechanism of tissue graft rejection
Mechanism of tissue graft rejection
 

Recently uploaded

epilepsy and status epilepticus for undergraduate.pptx
epilepsy and status epilepticus  for undergraduate.pptxepilepsy and status epilepticus  for undergraduate.pptx
epilepsy and status epilepticus for undergraduate.pptxMohamed Rizk Khodair
 
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowKolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowNehru place Escorts
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceNehru place Escorts
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Timevijaych2041
 
Hematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsHematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsMedicoseAcademics
 
call girls in munirka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in munirka  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in munirka  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in munirka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
SWD (Short wave diathermy)- Physiotherapy.ppt
SWD (Short wave diathermy)- Physiotherapy.pptSWD (Short wave diathermy)- Physiotherapy.ppt
SWD (Short wave diathermy)- Physiotherapy.pptMumux Mirani
 
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Measurement of Radiation and Dosimetric Procedure.pptx
Measurement of Radiation and Dosimetric Procedure.pptxMeasurement of Radiation and Dosimetric Procedure.pptx
Measurement of Radiation and Dosimetric Procedure.pptxDr. Dheeraj Kumar
 
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...narwatsonia7
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknownarwatsonia7
 
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...Nehru place Escorts
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxbkling
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingNehru place Escorts
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbaisonalikaur4
 
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi NcrDelhi Call Girls
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...rajnisinghkjn
 
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...saminamagar
 
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original PhotosBook Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photosnarwatsonia7
 

Recently uploaded (20)

epilepsy and status epilepticus for undergraduate.pptx
epilepsy and status epilepticus  for undergraduate.pptxepilepsy and status epilepticus  for undergraduate.pptx
epilepsy and status epilepticus for undergraduate.pptx
 
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowKolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
 
Hematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsHematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes Functions
 
call girls in munirka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in munirka  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in munirka  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in munirka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
SWD (Short wave diathermy)- Physiotherapy.ppt
SWD (Short wave diathermy)- Physiotherapy.pptSWD (Short wave diathermy)- Physiotherapy.ppt
SWD (Short wave diathermy)- Physiotherapy.ppt
 
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
 
Measurement of Radiation and Dosimetric Procedure.pptx
Measurement of Radiation and Dosimetric Procedure.pptxMeasurement of Radiation and Dosimetric Procedure.pptx
Measurement of Radiation and Dosimetric Procedure.pptx
 
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
High Profile Call Girls Kodigehalli - 7001305949 Escorts Service with Real Ph...
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
 
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
Call Girls Service in Virugambakkam - 7001305949 | 24x7 Service Available Nea...
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptx
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
 
Epilepsy
EpilepsyEpilepsy
Epilepsy
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
 
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
 
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
 
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original PhotosBook Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
 

Biomarkers of cad & mi presentation

  • 1. BIOMARKERS OF CAD & MI: RECENT ADVANCES -Dr. Nilesh Chandra
  • 2. OBJECTIVES:  Brief Review of Existing biomarkers  New Diagnostic Biomarkers  New prognostic Biomarkers  Biomarkers under research
  • 3. DIAGNOSTIC MARKERS  Serum Markers  Fractional Flow Reserve  Echocardiography  Nuclear Imaging Studies  Computed Tomography Scanning  Electron Beam Computed Tomography Scanning
  • 4. DIAGNOSTIC MARKERS (CONTD.)  Optical Coherence Tomography Imaging  Magnetic Resonance Imaging  Positron Emission Tomography  Coronary Angiography  Doppler Velocity Probes  Ultrasonography  Histology
  • 5. SERUM MARKERS  Troponins (I or T)  Creatine kinase with MB isozymes  Lactate dehydrogenase and lactate dehydrogenase isozymes  Serum aspartate aminotransferase
  • 6. PROGNOSTIC MARKERS  Biomarkers:  Lipid Studies  Copeptin  H-FABP  Urinary albumin-to-creatinine ratio  Homocysteine  Renin  B-type natriuretic peptide  CRP
  • 7. LIPID STUDIES  Total cholesterol level  LDL cholesterol (LDL-C) level  HDL cholesterol (HDL-C) level  Triglyceride level Specific lipid studies (if necessary) include the following:  Small, dense LDL-C level  Lipoprotein (a) level  Apoprotein profile  Direct measurement of LDL-C
  • 8. C-terminal-provasopressin (Copeptin)  The more stable surrogate of arginine vasopressin (AVP)  Post AMI  increase peripheral vasoconstrictor activity  increase protein synthesis in myocytes  vasoconstriction of coronary arteries  Can rule out MI earlier in addition to a negative Troponin T test  a copeptin level of < 14 pg/ml and a Trop T level of < 0.01  an area under the curve (AUC) of receiver operating characteristic curve (ROC) of 0.97 (negative predictive value of 99.7%)
  • 9. C-terminal-provasopressin (Copeptin) contd..  Can rule out MI earlier in addition to a negative Troponin T test  a copeptin level of < 14 pg/ml and a Trop T level of < 0.01  an area under the curve (AUC) of receiver operating characteristic curve (ROC) of 0.97 (negative predictive value of 99.7%)  Effects are mediated via the V1 receptor  These receptors are now targets for pharmacological therapy.
  • 10. Heart-Type Fatty Acid Binding Protein (H-FABP)  A LMW protein involved in myocardial fatty-acid metabolism  Rapidly released early in myocardial infarction and necrosis into the cytosol  When added to Troponin for risk stratification (Trop/H-FABP):(-)= H-FABP< 5.8 mcg/L * -/- = zero mortality at six months * -/+= 4.93-fold increase in risk of death * +/+= 7.93-fold increase in risk of death
  • 11. PROGNOSTIC BIOMARKERS  1) Biomarkers of biomechanical stress:  BNP/NTproBNP  Mid-Regional pro-Atrial Natriuretic Peptide (MRproANP  Growth Differentiation Factor-15(GDF-15)  ST2  ET1/CTproET1
  • 12. PROGNOSTIC BIOMARKERS (CONTD..)  2) Biomarkers of neurohormonal pathway activation  Mid-Regional-pro-Adrenomedullin (MRproADM)  Copeptin  3) Biomarkers of plaque instability and inflammation  HsCRP (High-sensitivity C-reactive Protein)  Myeloperoxidase (MPO)  Pregnancy associated Plasma Protein A (PaPPA)
  • 13. PROGNOSTIC BIOMARKERS (CONTD..)  4) Other Novel biomarkers  MMP9  MMP2  TIMP1
  • 14. BNP/NTproBNP  BNP: One of the best known biomarkers of biomechanical stress  Is released with the N-terminal portion of the pro-BNP peptide (NTproBNP)  Predicts in-hospital and 180-day death or heart failure .
  • 15. Mid-Regional pro-Atrial Natriuretic Peptide (MRproANP)  ANP has similar secretory profile post AMI as BNP.  MRproANP fragment substantially more stable peptide compared to N-ANP and ANP  MRproANP is at least as good at predicting death and heart failure as NTproBNP
  • 16. Growth Differentiation Factor-15(GDF-15)  A member of the Transforming Growth Factor Beta cytokine superfamily  Under episodes of stress like ischaemia and reperfusion,its levels go up in cardiomyocytes.  Provides prognostic information following an MI or ACS
  • 17. ET1/CTproET1  A potent vasoconstrictor peptide  It activates ETA and ETB receptors  Appears to be detrimental post-MI  Plasma concentration of CTproET-1 peaks at Day 2  Is increased in proportion to the severity of the disease post AMI  Independent of age, Killip class and past medical history
  • 18. Mid-Regional-pro-Adrenomedullin (MRproADM)  Activity in the cardiovascular system is similar to that of BNP  Post AMI, increased MRproADM associated with death, heart failure or both at one year, over and above information gained from NTproBNP alone  Combining the two markers increases the AUC of the ROC from 0.77 and 0.79 to 0.84
  • 19. HsCRP (High-sensitivity C-reactive Protein)  CRP mediates atherothrombosis  An elevated CRP associated with increased cardiovascular risk  Benefits of hsCRP testing to screen for ischaemic heart disease is very clear, its use post-ACS or -MI is less clear  A new assay for Human Pentraxin 3 is now available
  • 20. Myeloperoxidase (MPO)  Myeloperoxidase has been found in atheromatous plaques  MPO in leucocytes may activate metalloproteinases  MPO may inactivate plasminogen activator inhibitor  Post-ACS, MPO levels higher than median predicted future death and MI at one year  MPO levels do not predict heart failure
  • 21. Pregnancy associated Plasma Protein A (PaPPA)  A proatherosclerotic metalloproteinase  Is highly expressed in unstable plaques and their extracellular matrices  PaPPA > 2.9 mIU/L predicts a 4.6-fold increase in risk of cardiovascular death, MI or revascularisation even without a raised Troponin
  • 22. NEWER TECHNOLOGIES: METABOLOMICS  Components from branched-chain & aromatic amino acid as independent cardiovascular risk factors:  isoleucine, leucine, valine, tyrosine, and phenylalanine  Lipids metabolites associated with cardiovascular disease, shown to promote atherosclerosis:  phosphatidylcholine-choline  trimethylamine N-oxide  betaine
  • 23. GENETIC BIOMARKERS  When one twin dies of CHD, the RR for the remaining one is as high as 4-fold for dizygotes and 8-fold for monozygotes  Genome-wide association (GWA) studies for identifying common SNPs that are associated with cardiovascular disease  Locus in the 9p21 region separately reported by 3 different groups
  • 24. Chr SNP Risk allele frequency (%) Odds ratio (95% CI) per risk allele Gene(s) of interest within or near associated interval 6q26– 6q27 rs3798220 2 1.47 (1.35–1.60) LPA rs10455872 7 1.68 (1.43–1.98) LPA 9p21 rs4977574 56 1.29 (1.25–1.34) CDKN2A-CDKN2B-ANRIL 21q22 rs9982601 13 1.20 (1.14–1.27) SLC5A3-MRPS6-KCNE2 1p13 rs646776 81 1.19 (1.13–1.26) CELSR2-PSRC1-SORT1 1p32 rs17114036 91 1.17 (1.13–1.22) PPAP2B 10q11 rs1746048 84 1.17 (1.11–1.24) CXCL12 2q33 rs6725887 14 1.17 (1.11–1.23) WDR12 3q22 rs9818870 15 1.15 (1.11–1.19) MRAS 1p32 rs11206510 81 1.15 (1.10–1.21) PCSK9 19p13 rs1122608 75 1.15 (1.10–1.20) LDLR 1q41 rs17465637 72 1.14 (1.10–1.19) MIA3 11q23 rs964184 13 1.13 (1.10–1.16) ZNF259, APOA5-A4-C3-A1 12q24 rs3184504 40 1.13 (1.08–1.18) SH2B3 6p24 rs12526453 65 1.12 (1.08–1.17) PHACTR1
  • 25. Endogenous Bioactive Peptides  Adiponectin, an adipocytokine  Heregulin-β1 (neuregulin-1 type I), a neuron growth factor  Glucagon-like peptide-1 (GLP-1), an incretin hormone  Salusin-α
  • 26. Effects of new novel peptides on the cardiovascular system. Adiponectin Heregulin-β1 GLP-1 Salusin-α VSMC proliferation ↓ ↓ ↓ ↑ eNOS ↑ ↑ ↑ → Cardiomyocyte protection + + + + Anti-inflammation + + + NE Anti-oxidation + + + NE
  • 27. Effects of new novel peptides on macrophage foam cell formation. Adiponectin Heregulin-β1 GLP-1 Salusin-α Foam cell formation ↓ ↓ ↓ ↓ ACAT1 ↓ ↓ ↓ ↓ SR-A ↓ ↓ → → ABCA1 ↑ ↑ → →
  • 28. Comparisons of circulating heregulin-β1 and salusin-α levels between CAD and non-CAD subjects
  • 30. Markers and stage of appearance
  • 31. Summary  Existing biomarkers for CAD & MI diagnosis, prognosis and their limitations  Biomarkers undergoing clinical trials  Newer potential biochemical markers under research
  • 32. References  Harrison’s Principles of Internal Medicine; 17th Edition  Daniel Chan, Leong L Ng ;Biomarkers in acute myocardial infarction; BMC Med. 2010; 8: 34.  Ramachandran S. Vasan;Biomarkers of Cardiovascular Disease: Molecular Basis and Practical Considerations; Circulation. 2006; 113: 2335-2362  Yin Ge,Thomas J. Wang;Circulating, imaging, and genetic biomarkers in cardiovascular risk prediction;Trends Cardiovasc Med. 2011 May; 21(4): 105–112  Takuya Watanabe, Kengo Sato, Fumiko Itoh, Kohei Wakabayashi, Masayoshi Shichiri, Tsutomu Hirano; Endogenous Bioactive Peptides as Potential Biomarkers for Atherosclerotic Coronary Heart Disease;Sensors (Basel). 2012; 12(4): 4974–4985
  • 34. Killip Classification:  Killip class I includes individuals with no clinical signs of heart failure.  Killip class II includes individuals with rales or crackles in the lungs, an S3, and elevated jugular venous pressure.  Killip class III describes individuals with frank acute pulmonary edema.  Killip class IV describes individuals in cardiogenic shock or hypotension (measured as systolic blood pressure lower than 90 mmHg), and evidence of peripheral vasoconstriction (oliguria, cyanosis or sweating).  Within a 95% confidence interval the patient outcome was as follows:  Killip class I: 81/250 patients;32% (27–38%).Mortality rate 6%.  Killip class II: 96/250 patients;38% (32–44%).Mortality rate 17%.  Killip class III: 26/250 patients;10% (6.6–14%).Mortality rate 38%.  Killip class IV: 47/250 patients;19% (14–24%).Mortality rate 67%.
  • 35. FRACTIONAL FLOW RESERVE  An index of functional severity of coronary artery stenosis.  Based on the observation that myocardial perfusion is entirely pressure dependent during maximal hyperemia.  Represents the fraction of the normal maximal coronary flow that can be achieved in an artery in which flow is restricted by a coronary stenosis.
  • 36. ECHOCARDIOGRAPHY  Transthoracic echocardiography helps to assess LVF, wall- motion abnormalities.  Transesophageal echocardiography used for assessing possible aortic dissection.  Stress echocardiography used to evaluate hemodynamically significant stenoses.  Treadmill echocardiography stress testing and dobutamine echocardiography stress testing provide equivalent predictive values.
  • 37. NUCLEAR IMAGING STUDIES  Useful in assessing patients for hemodynamically significant coronary artery stenoses:  Treadmill nuclear stress test  Dipyridamole (Persantine)  Adenosine nuclear stress test  Dobutamine nuclear stress test.
  • 38. COMPUTED TOMOGRAPHY SCANNING  Allow excellent visualization of the coronary arteries:  Multidetector computed tomography (MDCT) scanning  Low-dose CT attenuation correction (CTAC)  hybrid positron emission tomography (PET)/CT  single-photon emission computed tomography (SPECT)  CT myocardial perfusion imaging (MPI)
  • 39. ELECTRON BEAM COMPUTED TOMOGRAPHY SCANNING  Method of evaluating calcium content in the coronary arteries.  Used as a screening test in asymptomatic patients  Used as a diagnostic test for obstructive CAD in symptomatic patients
  • 40. OPTICAL COHERENCE TOMOGRAPHY IMAGING  Catheter-based, high-resolution intravascular imaging  Remarkable resolutionin the range of 10-20 µm.  Acquisition rates are near video speed  OCT imaging uses light
  • 41. MAGNETIC RESONANCE IMAGING  Used to gain information noninvasively about blood vessel wall structure and to characterize plaque composition
  • 42. POSITRON EMISSION TOMOGRAPHY  Radiation exposure 4- to 5-fold lower with PET.  PET offers better spatial and temporal resolution and shorter imaging time.
  • 43. CORONARY ANGIOGRAPHY  In vivo assessment  The criterion standard for detecting significant flow- limiting stenoses that may be revascularized through percutaneous or surgical intervention of the coronary arteries  Limitation: only the vessel space occupied by blood is visualized.
  • 44. DOPPLER VELOCITY PROBES  Based on the principle of the Doppler effect  Use miniaturized crystals fixed to the tip of catheters  Allows measurement of selective coronary artery flow velocity
  • 45. RELATIVE CORONARY FLOW RESERVE  Calculated as follows: ([rCFR] = CFR target/CFR reference).  Correlates with stress myocardial perfusion imaging results  Provides additional information regarding the status of the microcirculation in patients with CAD
  • 46. ULTRASONOGRAPHY  Aids in evaluating brachial artery reactivity and carotid artery intima media thickness:  Brachial Artery Reactivity  Carotid artery intima-media thickness  Intravascular Ultrasonography
  • 47. HISTOLOGY  A system devised by Stary et al.  classifies atherosclerotic lesions according to their histologic composition and structure.  Type I to type VIII lesions
  • 48. ST2  an IL1-receptor-like protein  elevated when heart is under mechanical stress  seems to have a cardioprotective role  ST2 predicts cardiovascular death following ACS  correlates somewhat with NTproBNP
  • 49. Copeptin  Predicts mortality or heart failure at 60 days post AMI  Relationship of copeptin to LV dysfunction persists for a prolonged period after the acute event  Provides complementary prognostic information to NTproBNP