Cardiac Biomarkers:

Definitions, Use and Utility

Herbert A. Hartman III, M.D.

Resident, Internal Medicine
University Hospitals/Case
Medical Center
PGY-3 Senior Talk
 Objectives
1) Present background scientific information concerning cardiac biomarkers including
current and historical markers

2) Present information about the medical use and utility of cardiac biomarkers

3) Identify CKMB and TI results in situations where false-positive and false-negative

possibilities should be entertained

4) Describe the associations between TI, CKMB and CK in patients with suspected
acute coronary syndrome as compared to patients with enzyme elevations in non-
ACS situations by using examples

5) Inform audience briefly about ongoing clinical trials regarding use of cardiac
biomarkers
 Definitions
A biomarker is a substance used as an indicator of a biologic
state. It is a characteristic that is objectively measured and
evaluated as an indicator of normal biologic processes,
pathogenic processes, or pharmacologic responses to a
therapeutic intervention.--Wikipedia

Cardiac markers are substances released from heart muscle

when it is damaged as a result of myocardial infarction.
--Wikipedia

Note: As will be discussed, it has been shown that cardiac

markers can be released from cardiac tissue as a result of
damage from processes other than MI
 Diagnosis of Acute Myocardial
Infarction
Triad of Chest pain, ECG manifestations and
elevations of biomarkers of cardiac injury
Chest Pain: highly variable and subjective
ECG: Objective ST or T-wave changes
Biomarker elevations: Objective data defining
ACS/AMI, Right?
sometimes
What biomarkers are good for:
Diagnosing AMI/ACS
Detecting myocardial damage whether due to AMI
or other cardiac process
Risk-stratifying patients
Commenting on Prognosis
In ACS, pre and post PCI/reperfusion therapy
CHF
Renal Disease
Stressing interns, confusing residents and worrying
cardiology fellows
Which Biomarkers?

CK (CPK)
CK-MB
Troponin-I/T
LD (LDH)
Myoglobin
ALT/AST
Others
 Creatine Kinase
Creatine kinase (CK/CPK) is an enzyme expressed in a number of tissues.
Function: it catalyses the conversion of creatine to phosphocreatine degrading ATP to ADP
(In cardiac as well as other tissues, phosphocreatine serves as an energy reservoir for the
rapid regeneration of ATP)

The CK enzyme consists of two subunits, B (brain type) or M (muscle type), Making three
different isoenzymes: CK-MM, CK-BB and CK-MB

CK-BB occurs mainly in tissues, rarely of any significance in the bloodstream

Skeletal muscle expresses CK-MM (98%) and low levels of CK-MB (1%)
Sensitive lab tests can pick up these low levels of CK-MB from skeletal muscle
The myocardium has CK-MM at 70% and CK-MB at ~30%

CK therefore, lacks specificity for cardiac damage and needs to be augmented with the
MB fraction and Relative Index (RI) to indicate true cardiac damage
 CK
Needs >two-fold increase with simultaneous increase in CK-MB to be
diagnostic for MI
May be problematic for use in patients with very little muscle mass
Increases 4-6 hours after onset of MI
Peak activity is at 18 to 24 hours
Usually has returned to baseline levels by 36 hours
False positive (for MI) CK elevation can be seen in:
Significant skeletal muscle injury
Significant CNS damage (Stroke/Trauma)
Occasionally from GI, renal, urologic disease

*elevations of CK secondary to non-cardiac causes have been noted to increase

following a flatter curve, rising and disappearing at a slower pace that a cardiac
source
 CK-MB
High specificity for cardiac tissue
Begins to rise 4-6 hours after onset of infarction
Peaks at about 12 hours
Returns to baseline at 24-36 hours
Can be used to indicate early re-infarction if level normalizes and then increases again
Lab test is for mass, not activity; mass assays are reported to be more sensitive.

False positive (for MI) CK-MB elevation can be seen in:

Significant skeletal muscle injury
*Cardiac injury for reason other than MI
Cardioversion, Defibrillation (ACLS CPR/ICD firing)
Blunt chest trauma (MVA/Sports injuries)
Cardiac AND non-cardiac surgical procedures
Cocaine abuse (vasospasm, tachycardia, perfusion/demand mismatch)
Non often elevated in myocarditis, unless severe
 Troponin

Troponin is a complex of three regulatory proteins that is integral to non-

smooth muscle contraction in skeletal as well as cardiac muscle
Troponin is attached to the tropomyosin sitting in the groove between actin
filaments in muscle tissue
Troponin has three subunits, TnC, TnT, and TnI
Troponin-C binds to calcium ions to produce a conformational change in TnI
Troponin-T binds to tropomyosin, interlocking them to form a troponin-
tropomyosin complex
Troponin-I binds to actin in thin myofilaments to hold the troponin-
tropomyosin complex in place
Thus far, studies have failed to find a source of Troponin-I outside the heart, but
have found some Troponin-T in skeletal muscle
Because of its increased specificity, our lab uses Troponin-I
 More about Troponin
Laboratory range definition:
Cutoff is set at 99th percentile of a normal
reference population, variation of less than 10%
Since troponin levels are virtually undetectable
in normal subjects, this 99th percentile
corresponds to <0.06
-heparin in sample can result in lowered values
 Troponin Use
Troponin-I levels begin to rise 2-3 hours after onset of MI
and roughly 80% of patients with AMI will have positive
values at 3 hours
Elevations in Troponin-I and Troponin-T can persist for up
to 10 days after MI
Therefore it has good utility for retrospectively diagnosing
AMI
Remember, CK-MB returns to baseline by 48 hours
Troponin release can also be precipitated by other
conditions that cause myocardial damage
Troponin Influence on Prognosis
Since normal people have virtually nil levels of
troponin in serum, it is thought that detectable
levels indicate chronic disease even if not acute
myocardial damage
Degree of elevation of Troponin value can give
prognostic information
Some data suggest that the 72-96 hour peak TI value
correlates with infarct size. This is not necessarily true
with other biomarkers
 Lab Details
Run in chemistry section of UH lab on sample of patient serum
Red top tube (you may need to draw for yourself someday)

Type of chemistry reaction:

CK/CK-MB: Radioimmunoassay
Troponin: Immunoassay

An immunoassay is a biochemical test that measures the concentration of a

substance in serum or urine, using the reaction of a specific antibody (often
monoclonal Ab) or antibodies to bind to its antigen. To determine a numerical
result (as in cardiac biomarkers), the response of the fluid being measured
must be compared to standards of a known concentration. One of the most
common methods is to label either the antigen or the antibody with an enzyme
(EIA), radioisotope (RIA), magnetic labels (MIA) or fluorescence.
 Other Biomarkers
LD (LDH)
Used in the past along with aminotransferases to diagnose AMI. LD is non-specific for cardiac
tissue, which contains LD-1. However, pancreas, kidney, stomach tissue and red cells also contain
LD-1. In the setting of AMI, LD rises at about 10 hours, peaks at 24-48 hours, and remains
elevated for up to 8 days.
Myoglobin
Ubiquitous small-size heme protein released from all damaged tissues. Increases often occur more
rapidly than TI and CK. Not utilized often for AMI/cardiac damage assessment because of its very
rapid metabolism (short plasma half-life) causing short burst increases that are difficult to assess
clinically, as well as its lack of specificity for cardiac tissue.
ALT/AST
Used as surrogate markers of cellular damage in the past. Very non-specific so not used for
assessment of myocardial damage any longer
H-FABP
Heart-type fatty acid binding protein
Kinetically similar to myoglobin but more specific to cardiac tissue which contains a greater
percentage of this protein than skeletal muscle
May also have role in prediction- prognosis in patients with NSTEMI
Current studies ongoing to further evaluate its utility
 UH Laboratory
CK (U/L) Normal Range: 0-215

CKMB (ng/mL)
RELATIVE INDEX- RI (%MB OF CK)
CKMB <7 and RI <4% :Negative
CKMB <7 and RI >4% :Equivocal
CKMB >=7 and RI <4% :Equivocal
CKMB >=7 and RI >4% :Positive

TROPONIN I
LESS THAN 0.07 NG/ML: NEGATIVE
0.07 - 0.5 NG/ML: CONSISTENT WITH POSSIBLE CARDIAC DAMAGE AND POSSIBLE
INCREASED CLINICAL RISK.
>0.5 NG/ML: CONSISTENT WITH CARDIAC DAMAGE, INCREASED CLINICAL RISK
AND MYOCARDIAL INFARCTION.
 Timing Summary

TEST ONSET PEAK DURATION

CK/CK-MB 3-12 hours 18-24 hours 36-48 hours
Troponins 3-12 hours 18-24 hours Up to 10 days
Myoglobin 1-4 hours 6-7 hours 24 hours
LDH 6-12 hours 24-48 hours 6-8 days
 Elevated cardiac biomarkers in
non-ACS situations
The ACC/AHA task force states that clinical evidence of
myocardial ischemia is necessary in addition to
biochemical evidence because biochemical markers can be
elevated in numerous other physiologic scenarios
Some as previously described with CK and TI
Others: sepsis, hypovolemia, atrial fibrillation, PE, HF,
myocarditis, myocardial contusion, renal failure and
tachycardia
In patients with low pre-test probability of CHD or ACS,
increased cardiac biomarkers may skew analysis and
diagnosis causing tunnel vision
Elevated cardiac biomarkers in non-ACS
situations
Situations of prolonged myocyte ischemia--cell membrane breaks down releasing
myofibril cell components into the bloodstream
Tachy/bradyarrhythmias (reduced diastolic coronary filling time),
prolonged/profound hypotension, HF-acute and chronic, pulmonary hypertension
CPR/Cardiac contusion
Electrical Cardioversion/ICD firing
PE, pericarditis, myocarditis
Sepsis (SIRS)-- secondary both to hypotension as well as direct effects of
inflammatory mediators and myocardial oxygen demand-supply mismatch)
Apical Ballooning syndrome-- Takotsubo Cardiomyopathy
Chemotherapy, e.g. Adriamycin, Herceptin
Toxins, cocaine
Extreme exertion--Marathons, ultramarathons, Military basic training
LVH--leads to subendocardial ischemia by increased O2 demand from increased mass
HF--discussed separately
 Biomarkers in Renal Failure
CAD is highly prevalent in patients with end-stage renal disease and patients
on dialysis.
HTN and DM are very prevalent in this population
ESRD itself as well as dialysis change normal homeostatic mechanisms
for lipids, calcium and electrolytes
Like HF patients, it has been found that ESRD patients nay have low
levels of troponin elevations chronically without evidence of myocardial
damage, although the mechanism and significance are not known.
Possible reasons parallel those for HF:
significant LVH, endothelial dysfunction, loss of cardiomyocyte
membrane integrity and possibly impaired renal excretion
 Biomarkers in Renal Failure
Increasing evidence suggests that chronically elevated troponin
levels indicate a worse long-term prognosis for cardiovascular
outcomes in this patient population
False positives have been reported with use of troponin-T in
ESRD patients but not as much with troponin-I
CK: plasma concentrations are elevated in 30-70% of dialysis
patients at baseline, likely secondary to skeletal myopathy,
intramuscular injections and reduced clearance
CK-MB: 30-50% of dialysis patients exhibit an elevation in the
MB fraction >5% without evidence of myocardial ischemia
Therefore, the most specific marker for suspected AMI in ESRD
patients is Troponin-I with an appropriate sequential rise
 Biomarkers in Heart Failure
It has been reported that small elevations in TI are chronically found in patients
with heart failure, without current symptoms of ischemia
In these studies, the presence of TI remained an independent predictor of death
On the same note, a positive TI in a hospitalized patient with ADHF is
associated with a higher in-hospital mortality 8% vs. 2.7% P<0.001 (data from
Peacock et al. reference at end)
The presumed mechanism of cardiac troponin release in HF is from
myocardial strain-volume and pressure overload of both ventricles causing
excessive wall tension leading to decreased subendocardial myocyte
perfusion.
There is a correlation of elevated BNP and TI release
myocyte death- continued wall tension and other mediator stimulation
(sympathetic stimulation, increased renin-AII system, inflammatory
cytokines) is thought to lead to progressive myocyte apoptosis and cardiac
dysfunction
 Case 1
62 yo male with PMH of HTN x20 years, DM II x
10 years presents with 2 hours of mid-sternal chest
pain radiating to left arm and jaw, with associated
SOB and diaphoresis. He was given O2, ASA
325mg and SL NTG en-route by EMS. Upon
arrival to ED his CP is 5/10, somewhat relieved by
the nitro, His ECG shows TWI in v2-v6. BP
150/100, P115, R18, 96% 2L NC
 Case 1 Discussion
What is your pre-test probability for ACS
before you get cardiac biomarkers in this
patient?
Which biomarkers to you think will be
positive at this time? In 12 hours?
Will you wait for the biomarker results to
start treatment for ACS?
 Timing Revisited

TEST ONSET PEAK DURATION

CK/CK-MB 3-12 hours 18-24 hours 36-48 hours
Troponins 3-12 hours 18-24 hours Up to 10 days
Myoglobin 1-4 hours 6-7 hours 24 hours
LDH 6-12 hours 24-48 hours 6-8 days
 Case 2
55 yo female with no significant PMH but positive
FHx for early MI in her brother at 48 years, and her
father at 56 years, presents with mid-epigastric pain
episodes lasting 1hr each, off and on for the last 24
hours after her labor Day BBQ (1st episode 24hrs
ago), and she thinks her right arm is tingly. The last
episode was 2 hours ago, but the pain is gone now.
The ED gave her 1 nitropaste, 81mg asa x4 and
Lovenox 1mg/kg, as well as Zofran and Morphine.
Her ECG shows TWI in lead II. Pulse is 100. Other
VS WNL.
 Case 2 Discussion
What is your pre-test probability of ACS in
this patient and how are you going to utilize
your blood tests?
Obviously the ED physician felt this was
likely to be ACS, do you agree?
If her troponin comes back as 0.07 with a
normal CK and CK-MB what will you do?
 UH Laboratory
CK (U/L) Normal Range: 0-215

CKMB (ng/mL)
RELATIVE INDEX- RI (%MB OF CK)
CKMB <7 and RI <4% :Negative
CKMB <7 and RI >4% :Equivocal
CKMB >=7 and RI <4% :Equivocal
CKMB >=7 and RI >4% :Positive

TROPONIN I
LESS THAN 0.07 NG/ML: NEGATIVE
0.07 - 0.5 NG/ML: CONSISTENT WITH POSSIBLE CARDIAC DAMAGE AND
POSSIBLE INCREASED CLINICAL RISK.
>0.5 NG/ML: CONSISTENT WITH CARDIAC DAMAGE, INCREASED CLINICAL
RISK AND MYOCARDIAL INFARCTION.
 Case 3

73 yo AAM presents to clinic for routine HF

check. By office scale he has gained 10# since last
visit 2 months ago. He admits to sleeping upright
and has1block DOE. He denies angina/chest pain.
In-office ECG is notable for strain pattern. He is
diagnosed with HF exacerbation and direct
admitted. AMI panel is drawn and CK is 250, MB
is 8, TI is 1. BNP is 3500. 2nd TI is 1.2 and 3rd is
1.1. He is hypertensive but stable.
 Case 3 Discussion
What is the likely explanation for this
patients elevated cardiac biomarkers?
How do you plan to manage this patient
from here? Does he need to be in the
CICU? Does he need further enzyme
studies?
 Case 4
44 yo AAF with ESRD secondary to HTN
on dialysis (HD x 7 years) presents with
chest pain at dialysis. Her end-HD BP was
190/100 and she reports a headache. ECG
shows Q-waves in the inferior leads but no
acute changes. She got her flu shot at
dialysis today. You draw AMI panel and CK
is 300, MB 15, RI 4% and TI is 1.13
 Case 4 Discussion
If her serial enzymes stay at the same levels what
is her general Cardiovascular prognosis?
Given the story, what other findings do you expect
on her ECG?
What is the likely physiological mechanism for
her elevated CK? Her TI?
She refuses cath. What is the best, simplest way to
attenuate her cardiovascular mortality?
 References
1) Zethelius, B. et al. Use of multiple Biomarkers to Improve
the Prediction of Death from Cardiovascular Causes. NEJM
2008;358;2107-16.
2) Peacock, F. et al. Cardiac Troponin and Outcome in Acute
Heart Failure. NEJM 2008;358:2117-26.
3) Brunwald, E. Biomarkers in Heart Failure. NEJM
2008;358:2148-59
4) Foy, A and Weitz, H. When to Suspect a false-positive
cardiac troponin. Resident and Staff Physician
2008;54(4):32-36.
5) Jaffe, A. Troponins, creatine kinase, and CK isoforms as
biomarkers of cardiac injury. Up-To-Date. 2008.
6) Henrich, W. Serum cardiac enzymes in patients with renal
failure. Up-To-Date. 2008.
7) Gibson, C. Elevated serum cardiac troponin concentration in
the absence of an acute coronary syndrome. Up-To-Date.
2008.
 Cardiac Biomarkers: Definitions, Use and Utility
Objectives:

1) Present background scientific information concerning cardiac biomarkers including

current and historical markers

2) Present information about the medical use and utility of cardiac biomarkers

3) Identify CKMB and TI results in situations where false-positive and false-negative

possibilities should be entertained

4) Describe the associations between TI, CKMB and CK in patients with suspected
acute coronary syndrome as compared to patients with enzyme elevations in non-
ACS situations by using examples

5) Inform audience briefly about ongoing clinical trials regarding use of cardiac
biomarkers