A presentation on cardiac profile tests for MBBS ,BDS ,BIOTECHNOLOGY & B Pharm students for self study.

1. Cardiac Profile Tests(Biochemical )
DR ROHINI C SANE

2. Cardiac Profile Tests
IHD –ISCHAEMIC HEART DISEASE: CORONARY BLOOD SUPPLY TO THE
MYOCARDIUM IS INADEQUATE AS COMPARED TO ITS DEMAND
1. THE MOST COMMON CAUSE is ATHEROSCLEROSIS
2. CONGENITAL ANAMOLIES OF THE CORONARY ARTERIES
3. CORONARY EMBOLI OF VARIOUS NATURE FROM DIFFIRENT SOURCES
(A ) Vegetation of bacterial endocarditis
(B ) Atheromatous plague from major coronary artery
(C) Diminished blood supply due paroxysmal tachycardia
(D) Severe anemia ,CO2 poisoning ,decrease oxygen supply to
myocardium

3. IHD –ISCHAEMIC HEART DISEASE
Clinical manifestation
I .Arrhythmias /autonomous disturbance
II. Angina pectoris
a. Clinical syndrome
b. Sudden attacks of chest pain of short duration
Precipitation factors
1.Physical exertion
2. Stress
3. Trachycardia
4. Heavy meals
5. Exposure to cold
6. Administration of insulin/T3,T4

4. Coronary atheroma
Coronary atheroma :lipid deposit within intimal coat of coronary arteries
↓
Narrowing of lumen
↓
Diminished blood supply to myocardium
↓
Formation of thrombus in coronary arteries
↓
Complete occlusion
↓
Infarction /necrosis

5. ATHEROSCLEROSIS

7. The modifiable risk factors of Cardiac diseases
1. Hyper lipidemia
2. Diabetes Mellitus
3. Smoking
4. Hypertension
5. Stress
6. Obesity
7. Heavy Physical activity
8. Diet high content of saturated fat & cholesterol

8. The non-modifiable risk factors of cardiac diseases
1. Heredity: individuals more susceptible to premature atherosclerosis
2. Age : after middle age increase incidence of atherosclerosis
3. Sex : male > women risk of atherosclerosis

9. CLASSIFICATION OF CARDIAC PROFILE TESTS
GROUP I : DIABETIS MELLITUS - DISTRUBED CARBOHYDRATE
METABOLISM ATHEROGENIC RISK FACTORS  PRE RENAL CONDITIONS
GROUP II : CARDIAC RISK EVALUTION TESTS
GROUP III: CARDIAC INJURY PANEL TESTS

10. CLASSIFICATION OF CARDIAC PROFILE TESTS
• GROUP I :
1. Blood Glucose
2. Blood Urea Nitrogen ( BUN )
3. Serum creatinine
4. Serum Electrolytes

11. CLASSIFICATION OF CARDIAC PROFILE TESTS
GROUP II :CARDIAC RISK EVALUTION TESTS
1. Serum Total Cholesterol
2. Serum HDL cholesterol
3. Serum TOTAL/HDL cholesterol
4. Serum VLDL /LDL cholesterol
5. Serum Triglyceride

12. CLASSIFICATION OF CARDIAC PROFILE TESTS
GROUP III: CARDIAC INJURY PANEL TESTS
1. Serum Creatine Phospho Kinase ( CPK )
2. Serum Glutamate Oxaloacetate Transferase ( SGPT )
3. Serum Lactate Dehydrogenase ( LDH )
4. Serum Hydro Butyrate Dehydrogenase ( SHBD )

13. GROUP III: CARDIAC INJURY PANEL TESTS
1. To assess severity of heart disease
2. To follow trend of the disease
3. To determine post operative disease
4. ECG do not permit clear diagnosis
↓
20% infarct are silent are silent
( elderly Diabetes Mellitus /Hypertension patients )
5. CPK, LDH ,SGOT, SHBD levels in serum  for diagnosis & prognosis
6.Concentration of CPK,LDH ,SGOT ,SHBD α size of infarct

15. SERUM LACTATE DEHYDROGENASE (LDH )
• Principle of estimation : Decrease in UV Absorbance at 340 nm as LDH catalyzed
reaction progresses
• LACTATE + NAD + PYRUVATE + NADH + H +
• NORMAL SERUM LEVELS OF LDH = 125- 290 U/ L
• OCCURRENCE : HEART ,LIVER ,SKELETAL MUSCLES ,ERYTHROCYTES IDH ,AMI 
LDH1 > LDH2 ( FLIPPED PATTERN )
• PHYSIOLOGICAL CONDITION : LDH1 < LDH2
ISOENZYME NORMAL RANGE ( % ) UNITS /L (SERUM )
LDH 1 20 – 30 100
LDH 2 32 – 40 115
LDH 3 17 – 23 65
LDH 4 03 - 13 40
LDH 5 04- 12 35

16. Cardiac biomarker :Iso-enzymes of Lactate dehydrogenase (LDH )
ENZYME HALF LIFE
LDH 1 8 DAYS
LDH 6. 8 DAYS
CPK -MB 2 DAYS
SGOT 4 DAYS
AREA UNDER CURVE ,SLOPE OF INITIAL RISE α INFARCT

17. Iso enzymes of Lactate dehydrogenase

19. Iso enzymes of Lactate dehydrogenase
LDH1 LDH5
Optimum
condition
AEROBIC ANAEROBIC
Km high low
Affinity for
pyruvate
low high
Synthesis of
lactate
Not favored Favored

20. SERUM APARTATE AMINO TRANSFERASE (AST )
SERUM GLUTAMATE OXALO ACETATE (SGOT )
1. NORMAL RANGE : 6 – 25 IU/L
2. STARTS INCREASING WITHIN 6 -12 HRS AFTER CHEST PAIN
3. PEAK HRS  24- 48 HRS
4. Less specific indication of myocardial infarction as it occurrence liver,
muscle ,hemolytic diseases
5. Prolonged Myocardial Ischemic ,Congestive Heart Failure increase in
SGOT ( AST )
6. Increase in SGOT ( AST ) < Increase in CPK (TOTAL )
7. HALF LIFE is of small duration & returns to normal within 4-6 days

21. Serum Creatinine phosphor kinase (CPK )
1. Normal ( CPK- MB ) is 6% OF Total CPK activity
2. CPK /GOT ratio < 10 myocardial infarction
3. CPK /GOT ratio > 10 muscular damage
4. Silent myocardial infarction
5. Pain free infarcts Diabetes Mellitus ,Hypertension ,impaired
peripheral arterial blood flow
6. ECG /Other findings
III ANGINA PECTORIS
a) Increase in CPK activity
b) Increase in arrhythmias
c) Congestive cardiac failure

22. Iso enzymes of Creatinine phosphokinase (CPK)

23. Creatinine phosphokinase (CPK)-cardiac marker

24. Serum Creatine phosphor kinase (CPK )
CPK MM / CPK TOTAL increased observed in
1. myocardial infarction
2. muscular dystrophy
3. Polymyositis
4. Motor neuron disorders
5. acute cerebrovascular accidents
Normal range CPK Total
Men : 20-50 IU
Women : 10-37 IU
PRINCIPLE OF ESTIMATION OF CPK (COLORIMETRIC ):
CREATINE –P + ADP+ CPK  CREATINE + ATP
CREATINE + DI ACETYL + α NAPTHOL - alkaline pHcolor complex
( absorbance at 520 nm , green filter )

25. Serum Creatine Phospho kinase (CPK )
Precautions for estimation of CPK
(1)Patients undergone strenuous exercise before blood collection –
erroneous high levels of CPK
(2)Minor tissue trauma- erroneous high levels of CPK
(3)Sample should be kept in refrigerator until test carried out
(4) Cardiac markers (follow time course after onset of AMI )

26. MYOGLOBIN (MB )
MYOGLOBIN (MB )
1. oxygen binding protein in skeletal muscle & cardiac muscles
2. Low molecular weight : cytosolic location
3. Appearance in circulation after muscle injury
4. Myoglobin –monoclonal antibody for estimation by RIA /
ELIZA/chemiluminescence
5. Temporal pattern of serum myoglobin & Creatine kinase -2 patients
with myocardial infarction

28. MYOGLOBIN (MB )as a cardiac marker
CLINICAL INTERPRETATION of Serum Myoglobin
1. Increase in serum levels after myocardial infarction as early as 1 hr
(necrosis )
2. Peak values  4-12hrs
3. Myoglobin remain high 0-4hrs
4. Time period :in which CPK -2 & CARDIAC TROPONIN IS VERY SHORT .
Disadvantages of Myoglobin as cardiac marker :
1. non specific eg myoglobin increases in any form of muscle damage
2. Methods not tissue specific ( muscle /cardiac )
3. Muscle injury  increase in myoglobin misdiagnosis of AMI

29. CARDIAC TROPONINS
I. Troponin : “contractile ”proteins of myofibrils regulatory proteins
a) Troponin C ( the calcium binding component )
b) Troponin I ( the inhibitory component )
c) Troponin T (Tropomyosin binding component )
II. Component of cardiac muscles
III. Longer Half Time –Insoluble Troponin released from infarcted
heart muscle therefore circulatory levels remain high .
IV .Rise in serum Troponin continues for longer than enzymes

30. Comparison between cardiac Troponin I & Troponin T
Human cardiac Troponin I Human cardiac Troponin T
30 AMINO ACIDS 11 AMINO ACIDS
CARDIAC MARKERS ---SPECIFIC &SENSITIVE MUSCLUAR DYSTROPHY
CHRONIC RENAL FAILURE
POLYMYOSITIS
2 ISOFORMS—GENETIC ORIGIN
INCREASE OBSERVED AFTER AMI—CPK –MB&
CPK -TOTAL

31. TROPONINS ( MARKER OF MYOCARDIAL INFARCTION )
TROPONINS TYPE PROPERTY
TROPONINS C CALCIUM BINDING
TROPONINS I ACTINO MYCIN INHIBITORY ATPase
TROPONINS T TROPOMYOSIN BINDING ELEMENT

33. Cardiac Troponin I &T
Clinical interpretation :cardiac troponin ( C Tn I & C Tn T )
1. Longer half life insoluble troponin released from infarcted heart muscles
within 4 to 8 hrs after onset of symptoms
2. Troponin I &C increase significantly after AMI
3. Increase in serum levels of Troponin I &C synchronizes CPK –MB & CPK –
TOTAL
4. circulatory levels are maintained for 4-5 days
5. Half life of C Tn I & C Tn T is 5- 10days
6. peak values of C Tn T observed at 72 -100 hrs.
7. peak values of C Tn I observed at 24 -48 hrs.
8. low levels & undetectable serum levels are observed in individuals
without cardiac disease( no false + ve or –ve values for C Tn I )

34. Comparison of cardiac markers
1. Increase in CPK -2 in conditions individuals without cardiac disease
Therefore better risk assessment than CPK –MM .
2. CPK -2 (CPK –MB ) increase in muscle injury
3. ( C Tn I & C Tn T ) don't increase in muscle injury
4. C Tn T excellent marker for AMI VERSES muscle injury when
concomitant.
5. C Tn T increases in sepsis, drug induced toxicities ,chronic diseases
,malignancies ,hematological disorder ,non cardiac surgery
6. C Tn I sensitive & specific for AMI

35. Biochemical Cardiac Markers
CARDIAC
MARKER
ABNORMAL
ACTIVITY
DETECTABLE IN
( hrs )
PEAK VALUE OF
ABNORMALITY (hrs)
DURATION OF
ABNORMALITY
( DAYS )
1 CPK ( TOTAL) 3-8 HRS 10-24 3-4
2 CPK -MB 3-8 HRS 10-24 2-3
3 LDH ( TOTAL ) 8-12HRS 72-144 8-14
4 SGOT ( AST ) 6TO 12HRS ( 24-48 4-6
5 MYOGLOBIN 1TO 3HRS 6-9 1
6 TROPONIN I
( C –T n I )
3-8 HRS 24-48 3-5
7 TROPONIN T
( C –Tn T )
3-8 HRS 72-100 5-10

36. Homocystein as a cardiac marker
Homocystein is formed during biosynthetic pathway of cysteine from
Methionine.

39. Cardiac profile tests –Homocysteine
Normal range : < 15 micro –moles /l (serum )
Inborn error in metabolism of Homocystein: increase serum
Homocystein ( paediatric ) > 100 micro –moles /l
Free Homocysteine S S Free Homocysteine
PROTEINS ← Disulphide bridge ( )
Dimer formation decrease metabolism ( therefore increase in
serum Homocystein  increase risk of atherosclerosis
Molecular basis CHD :damage to lining of blood vessels ( vascular
endothelium )
Increase serum Homocystein in growth of vascular muscles

44. Causes of Homocysteinuria
Genetic causes
• Genetic mutation within a gene coding cystathione beta synthetase
• Homocystein + Cystathione beta synthase  Cystathione
Non genetic causes
Deficiency of
pyridoxal phosphate ( vitamin B6 )
Folic acid (tetra hydro folate )
Vitamin B12 ( CYANOCOBALAMINE )
HOMOCYSTEIN + (VITAMINES B6, B12 ,FA )  METHIONINE
Treatment –Dietary supplementation of (VITAMINES B6, B12 ,FA ) till
Serum Homocysteine decreases

45. Cardiac profile tests –Homocysteine
• INCREASE IN SERUM HOMOCYSTEIN  Homocysteinemia -
coronary arterial disease
Molecular basis of coronary arterial disease (CAD )respect to
Homocysteinemia
1.damage cell lining of blood vessels
2. increase growth of smooth muscles
3. Homocystein alters anti coagulant properties of endothelial cells to
pro coagulant
4. dysfunction of vascular endothelium
5. damaged vascular endothelium  Atherosclerosis & CAD
Methods of estimation of Homocysteine  Gas chromatography, HPLC
, immune assays ,Chemiluminescence

46. Cardiac profile tests --C reactive protein ( CRP )
1. ACUTE PHASE PROTEIN (APP ) –MOST SENSITIVE APPS
Significant increase observed in
a) Inflammatory diseases
b) After injury
c) inflammation
d) Myocardial infarctions
e) Tumors
2.NORMAL RANGE : 0.05 TO 0.20mg /L (SERUM )
Increase in Serum CRP indicates high risk of cardio vascular events
20 times increase in CRP ( > 10 mg ) suggestive of AMI

47. Cardiac Profile Tests- Serum Hydroxyl Butyrate Dehydogenase(SHBD )
Principle of estimation of SHBD :
Alpha oxo butyrate + NADH2 +SHBD ( p H 7.4 ,phosphate buffer ) alpha hydroxyl butyrate +
NAD +
SOLUTION 1 : PHOSPHATE BUFFER PREPARATION : (STABLE AT 2-8 ◦ C )
13. 97 gm K2 HPO4
2.69 gm KH2PO4
SOLUTION 2 : (0.0045 mmols/ i e 0.017 gm/dl in 2.5 ml of distilled water )
• Wave length for measurement : 340 nm ,cuvette 1 cm
Procedure : 3 ml 0f solution 1 + 0.1 ml of solution2 + sample 0.1 ml mix well ,note
extinction at 340nm at 1,2,3 minutes intervals
• Determine mean absorbance & change of absorbance (∆ A / minutes )
Calculation :
• Concentration of Alpha SHBD ( IU ) = 5079 X ∆ A / minutes
• If ∆ A > 0.1 dilute sample 1: 10 with phosphate buffer

48. Cardiac profile tests- Serum Hydroxyl Butyrate Dehydogenase
Serum SHBD increases significantly in Acute myocardial infarction
(AMI)
NORMAL RANGE OF SERUM SHBD:
• at 25◦ C  55 -140 IU
• at 30 ◦ C  65 -165 IU
• at 37 ◦ C  72 -182 IU

49. Cardiac profile tests- Apo proteins (Apo lipoproteins )
Functions of Apo proteins (Apo lipoproteins )
1. Structural components of lipoproteins
2. Recognize the membrane surface receptors
3. Activate enzymes involved in lipoprotein metabolism
APOPROTEINS SUBGROUPS
APO A A-I, AII , AIII
APO B B100 ,B 48
APO C C I, CII,CIII
APO D
APO E

52. Cardiac profile tests- Apoproteins (Apolipoproteins )
CLINCAL SIGNIFICANCE OF APOLIPROTEINS :
1. To assess hyper lipedemias with /without increase in LDL CHOLESTROL
2. APO PROTEIN B100 –To assess prognostic value after lipid lowering drug therapy
3. Management of AMI patients  decrease risk of re infarction
APOPROTEIN TYPE NORMAL RANGE ( PLASMA) Comments
Apoprotein A 100-120 mg/dl
Apoprotein A1 < 120mg /dl increase risk of CAD
> 160mg /dl Protective
Apoprotein B 100-120 mg/dl
Apoprotein B100 100-120 mg/dl >120 mg /dl HIGH RISK CAD
>100 mg /dl moderate RISK CAD
Increase in Apoprotein B100 ,decrease
Apoprotein B100 suggestive high risk of CAD
HDL cholestrol 130-160mg/dl
LDL cholesterol 130-160mg/dl

53. Cardiac profile tests- Apoproteins (Apolipoproteins )
APOPROTEIN TYPE MOLECULAR WEIGHT COMPONENT OF FUNCTIONS
1. APOPROTEIN A1 28016 HDL &
CHYLOMICRONS
LECITHIN CHOESTEROL ACYL TANSFERASE (LCAT)
ACTIVATOR
2. APOPROTEIN AII 17414 HDL &
CHYLOMICRONS
SECOND MOST COMMON APOPROTEIN OF HDL
3. APOPROTEIN AIII 46465 HDL &
CHYLOMICRONS
TRANSFER OF APOPROTEIN BETWEEN HDL &
CHYLOMICRONS
4. APOPROTEIN B48 264000 CHYLOMICRONS NECESSARY FOR ASSESSBLY & SECRETION OF
CHYLOMICRONS FROM SMALL INTESTINE
5. APOPROTEIN B100 512000 VLDL,IDL,LDL NECESSARY FOR ASSESSBLY & SECRETION OF VLDL
FROM LIVER
6. APOPROTEIN CI 7600 VLDL, HDL POSSIBLE LECITHIN CHOESTEROL ACYL TANSFERASE
(LCAT) ACTIVATOR
7. APOPROTEIN CII 8900 ALL MAJOR
LIPOPROTEINS
LECITHIN CHOESTEROL ACYL TANSFERASE (LCAT)
ACTIVATOR
8. APOPROTEIN CIII 8800 ALL MAJOR
LIPOPROTEINS
ACTIVATOR OF LIPOOPROTEIN LIPASE

54. Cardiac profile tests- Apoproteins (Apolipoproteins )
APOPROTEIN TYPE MOLECULAR WEIGHT COMPONENT OF FUNCTIONS
9. APOPROTEIN D 22000 MAINLY HDL INVOLVED IN REVERSED CHOLESTEROL
TRANSPORT OR ESTERIFIED
CHOLESTEROL TO VLDL
10. APOPROTEIN E 34145 ALL MAJOR
LIPOPROTEINS
LIGAND FOR BINDING OF SEVERAL
LIPOPROTEINS TO LDL RECEPTORS

55. Cardiac profile tests-ABNORMAL FORM OF LIPOPROTEIN A ( LP a )
1. Variant of LDL
2. Synthesized in liver
3. LDL –S-S – APO B 100 ( with disulphide bridge )
4. Interfere with action of plasminogen ( clot resolution ---fibri lysis )
5. Normal concentration in plasma = < 0.30 gm /l ( <30mg/dl)*
6. High levels of LPa increases in coronary heart disease therefore forms
cardio vascular risk factor
7. *Normal range racial specific, vary with ethnic group
8. Lipoprotein levels of African Americans > Caucasians ( more risk for CAD )

56. Cardiac profile tests-LIPOPROTEINS /ABNORMAL FORM OF LIPOPROTEIN A ( LP a )
Methods of estimation of LIPOPROTEIN A ( LP a ) :
a) Immuno Turbidometric
b) Immuno Nephalometric
c) Radiometric
d) Elisa
e) RIA