Biochemical Markers: AMI

Case Scenarios
Case No.1

A 75-year-old man was hospitalized with lower left lobe

pneumonia. He was given an intramuscular injection of thiamine
in the buttock on 28/04.

The next day the patient had an hypotensive episode associated

with sweating and lower chest pain; an ECG was suggestive of an
MI.

Date

29/04

30/04

Unit

Reference Range

Time

10:30

12:10

LD

356

390

U/L

180-360

CK

1359

619

U/L

Male: 46-171

Plasma

FM: 34-145
CK-MB

31

14

MB%

2.3

2.3

U/L

(<15)
<3.9%

QUESTIONS
What is your diagnosis on the basis of: History
Cardiac Enzymes pattern
Comment on the pattern of cardiac markers

Case No.1

Discussion
The enzyme results for this patient are not suggestive of an
AMI for the following reasons:
The total CK value is very high so soon after the onset of MIlike symptoms
In MI, the total LD activity does not rise on day 2.
MB% of total CK activity indicates a non-cardiac source
(typical AMI >3.9%)

Answer
The rise in total CK is probably due to muscle bruising
around the injection site.

Case No.2
A 57-years-old man was admitted to the coronary care unit
after a 6-h history of central chest pain; the ECG on
admission indicated an MI.
Admission and subsequent biochemical monitoring yielded
the following results:
Date

02/09

03/09

04/04

05/09

Time

16:30

05:00

06:00

06:00

234

2976

876

205

Ref Range

Plasma
CK

Male: 46171
FM: 34-145

AST

55

186

235

115

Male: <35
FM: <31

LD

242

608

653

677

180-360 U/L

CK-MB

27

197

48

12

<15U/L

MB%

6.2

5.1

<3.9 %

Question
What is the diagnosis
Comment on the activity of cardiac enzymes in making the
diagnosis.

Case No.2
Discussion
With the typical clinical history and ECG trace, the plasma
activities of Cardiac Enzymes are superfluous to making
the diagnosis.
The typical temporal pattern is seen, with total CK activity
rising, peaking and declining first, followed by AST and LD
still more than two fold elevated after 3 days
The pattern of appearance of these enzymes is due to:
Relative concentration of enzymes in cardiac tissue
Relative size of enzymes, with the smallest molecules
escaping from the damaged cells first, e.g., CK: 85KDa,
AST: 120kDa, LD: 140kDa
Extent of blood perfusion around damaged tissue
Relative rate of clearance from plasma
There is no diagnostic value to estimating CK activity
within=4h of chest pain onset, or 3 days have elapsed since
pain began.
Typical peak total CK activities in AMI are of the order of
1500-2000 U/L, rarely reaching 5000 U/L in case of massive
infarction.

Case No. 3
A 62-year-old man was admitted to the coronary care within
3h of the onset of severe chest pain. He was diagnosed as
having an inferior MI and commenced on thrombolytic
therapy using streptokinase.
After the management his blood sample was sent for cardiac
enzymes
Date

20/07

21/07

21/07

22/07

Time

12:30

00:40

06:30

06:30

2840

629

Ref Range

Plasma
CK

39

3950

Male: 46171
FM: 34-145

LD

148

1135

1090

997

180-360U/L

Question
Comment on the Cardiac enzymes activity
CK
LD

Case No. 3
Discussion
Thrombolytic therapy within approximately 6h of coronary
artery occlusion has a good chance of re-establishing
patency and reperfusion of the affected region of cardiac
tissue.
Studies have shown that when reperfusion has been
established, as shown by angiogram, there is a much earlier
and higher peak of plasma activity of both total CK and MB
activity.
This washout effect is thought to be at least partly due to
cell membrane damage caused by radicals formed on the
reavailability of oxygen.
Some studies suggest that at least a doubling of MB activity
over 90 min after thrombolytic therapy commences,
indicates successful reperfusion.

Case No. 4
A 63-year-old male patient in the coronary care unit had a cardiac
arrest followed by defibrillation during 11/08. Evidence of an AMI
was sought by carrying out cardiac enzymes.
Date

12/08

13/08

14/08

Ref Range

Time

07:30

07:30

07:30

LD

351

328

282

180-360U/L

CK

3736

3570

1930

Male: 46-171

Plasma

FM: 34-145
CK-MB

44

48

32

<15U/L

MB%

1.4

1.6

2.0

<3.9

Question
What is your diagnosis?
Comment on LD an CK activity pattern

Case No. 4
Discussion
Although the B isoenzyme activity is raised (normally below
15 U/L), the results are not suggestive of an MI because:
The LD activity is falling along with that of total CK,
rather than rising after the apparent CK peak.
Although the B activity is raised, the percentage of total
is low, suggesting the source is skeletal muscle.

Case No.5
A 69-year-old man had a cardiac arrest on 24/7 during
hospitalization for severe angina. He was defibrillated three
times, after which he was ventilated and treated for cerebral
anoxia.
An ECG suggested that an MI occurred about the time of the
arrest; supporting evidence from enzyme changes was
sought.
Date

24/07

24/07

25/07

25/07

25/07

Time

10:30

16:10

07:00

15:00

22:00

LD

2583

5250

9000

4990

CK

144

209

799

1360

1430

MB

24

44

84

60

45

MB%

21

10.5

4.4

3.4

Plasma

Case No.5
Discussion
LD:
It can be seen that peak LD activity appear before that
of total CK.

The rate of LD decline from 9000U/L indicates a t of

around 10h, which suggests that liver isoenzyme is
responsible and may have been released by the effect
of cardioversion and poor hepatic perfusion at the same
time.

CK-Total
It can be seen that peak MB activity occurs before that
of total CK.
The percentage MB for the first two samples is too high
to be typical of MI, and is more suggestive of BB.
The rapid decline in apparent MB activity to 60U/L
suggests that the high level initially is probably due to
BB isoenzyme (plasma half life = 3hours), which have
been released following the documented brain anoxia.
The last two samples have a proportion of MB suggestive of
an MI.

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Case No. 6
A 60-years old patient reported to the emergency with acute
chest pain and sweating for last 3-4 hours. Laboratory
investigations show:Serum:
a. Total CK = 360 u/L (Ref Range Male: 46-171 FM: 34-145)
b. Troponin T = 7.5 ng/ml (Ref: < 0.08 ng/ml)
Give your diagnosis?
Name two biochemical investigations which you would like to
perform to support your diagnosis at this stage of the
attack?

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Case No. 6
Key
Acute myocardial infarction
CK-MB and Myolobin

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Case No. 7
A 40 years old farmer was admitted to the hospital with chest
pain which had developed during the afternoon. He gave history
of spending 4 hours digging in his fields. There were no specific
signs of myocardial infarction on the ECG. He was kept in acute
coronay unit for 48 hours. How you interpret his lab results.
Parameters

On admission

48hrs later References

Serum

300 U/L

80 U/L

28 195 U/L

Total CK
CK-MB

10 U/L

5 U/L

25 U/L

Total Cholesterol

4.5 mmol/L

4 mmol/L

<5.2 mmol/L

Triglyceride

5 mmol/L

1.01

< 1.6mmol/L

mmol/L

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Case No. 7
Answer
Although Creatinine kinase (CK-NAC) activity is increased
but normal CK-MB shows no cardiac injury. Total cholesterol
levels and LDL-cholesterol can be measured in non-fasting
individuals and recent food intake affects total cholesterol
concentration less than 1.5%. However, serum triglyceride
can increase markedly after eating.

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