8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
1/27
CARDIAC TROPONINARDIAC TROPONINASSAY-UTILITY INSSAY-UTILITY INDIAGNOSIS OFIAGNOSIS OF ACUTECORONARY SYNDROME
By
Dr.Anup Bhandari
JR 1 ,Department of Pathology,
S.R.T.R.M.C.Ambajogai
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
2/27
Definitionefinition
Abiomarkeriomarker is a substance usedas an indicator of a biologic state.
It is a characteristic that isobjectively measured and
evaluated as an indicator of
normal biologic processes,
pathogenic processes, or
pharmacologic responses to a
therapeutic intervention.
--Wiki edia
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
3/27
NEEDEEDBIOMARKERIOMARKERSTUDY INTUDY IN
ACUTECUTECORONARYORONARYSYNDROMEYNDROME?
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
4/27
I t s bec ause;t s bec ause; neither the clinicalneither the clinical
presentation nor the ECGpresentation nor the ECGhad adequate clinicalhad adequate clinical
sensitivity and specificitysensitivity and specificityfor detecting MI without thefor detecting MI without theuse of biomarkersuse of biomarkers
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
5/27
CONFOUNDING FACTORSONFOUNDING FACTORS For ECGor EC G preexisting ST-segment
elevation because of
ventricularaneurysm or by Q
waves
pacemaker rhythm
or preexisting or newly
developed bundle
branch blocks (BBB).
For clinicalor clinicalpresentationresentation
Gastroesophageal
disease
Pericarditis, pleuritis
Chest wall syndromes
Pulmonary embolism
Aortic aneurism
Herpes zoster
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
6/27
What biomarkers arehat biomarkers aregood f orood f or
DiagnosingAMI/ACS
Detecting myocardial damagewhether due to AMI orother cardiac process
Risk-stratifyingpatients
Commenting onPrognosis
In ACS, pre and post PCI/reperfusion therapy
Renal Disease Stressing interns, confusing residents and worrying
cardiology fellows
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
7/27
WhichhichBiomarkers?iomarkers? CK (CPK)
CK-MB
Troponin-I/T
LD (LDH)
Myoglobin
ALT/AST
Others
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
8/27
CARDIAC ENZYMESARDIAC ENZYMES(BIOMARKERS)BIOMARKERS)
Most cardiac specific
TestTest Normal RangeNormal Range
CK or CPKCK or CPK
CreatinineCreatininePhosphokinasePhosphokinase
Normal 25-170 U/LNormal 25-170 U/L
CK-MBCK-MB < 5% MB< 5% MB
MyoglobinMyoglobin Normal < 85 ng/mlNormal < 85 ng/ml
LDHLDH(Lactate(Lactatedehydrogenase)dehydrogenase)
Normal 100-200 U/LNormal 100-200 U/LLDH-1 -5LDH-1 -5LDH- 1 is found primarily inLDH- 1 is found primarily inheart muscle and red bloodheart muscle and red bloodcells.cells.
TroponinTroponincTnTcTnT
Normal < 0.01ng/mlNormal < 0.01ng/mlMay be elevated by CRFMay be elevated by CRF
Troponin ITroponin IcTnIcTnI
Normal < 0.1 ng/mlNormal < 0.1 ng/mlNot elevated by CRFNot elevated by CRF
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
9/27
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
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
10/27
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
11/27
Diagnosis f Acutegnos s cuteMyocardialyocardialInfarctionnfarction Typical rise and gradual fall (troponin) or
more rapid rise and fall (CK-MB)of
biochemical markers of myocardial
necrosis with at least one of the following:
ischemic symptoms;
development of pathologic Q waves on the
ECG;
ECG changes indicative of ischemia (STsegment elevation or depression);
coronary artery intervention (e.g., coronary
angioplasty)
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
12/27
TROPONINROPONIN
Troponin is a complex of three regulatoryproteins 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
three subunits, TnC, TnT, and TnI Troponin-C (calcium ions)
Troponin-T (tropomyosin)
Troponin-I (actin)
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
13/27
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
14/27
MORE ABOUTORE ABOUTTROPONINROPONIN Laboratory range definitionaboratory 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 percentilecorresponds to
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
15/27
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
16/27
Troponi n Useroponin Use
Therefore it has good utility for retrospectively
diagnosing AMI
Remember, CK-MB returns to baseline by 4 8 h o u r s8 h o u r s
Troponin
EarlyRise(hrs)
Peak(Hrs)
Duration(Days)
Specficity Sensitivity
Tn T 3-4 10-24 10-24 80% >98%
Tn I 4-6 1-24 4-7 95% >98%
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
17/27
Troponin Influenceroponin Influenceon Prognosisn Prognosis
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
18/27
Other than M.I .ther than M.I .c ondi ti onsondi ti ons C ardiac conditions-ardiac conditions- heart failure, myocarditis and pericarditis,
cardiomyopathy, cardiac contusion, defibrillation and
internal or external cardioversion,cardiac procedures
Non- cardiac conditions-on- cardiac conditions- critical illnesses such as sepsis, Several toxins and
venoms, Carbon monoxide poisoning , primary pulmonary
hypertension, pulmonary embolism and acute
exacerbations of chronic obstructive pulmonary disease
(COPD), Seizures, end-stage renal disease, Strenuous
endurance exercise
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
19/27
Lab Detailsab D etai l s
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
20/27
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
21/27
An immunoassay is a biochemical test that
measures the concentration of a substance inserum 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
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
22/27
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
23/27
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
24/27
New molecules beingew molecules beingstudi ed;tudi ed;
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
25/27
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
26/27
Edge over other biomarkers
improved time dependent sensitivity and
improved specificity
first peak value 40 times the detection limit VsCK-MB only 6-9 times
prognostic value of troponin in unstable
angina,reperfusion therapy
Corelates with infarct size
Reducing false positives
8/6/2019 Copy of Cardiac Troponin Assay-utility in Early Detection of Acs
27/27
Thanky
ou!
Thanky
ou!