Creatine Kinase

A. Definition

B. Indications/ Contraindications
Exercise and muscle trauma (contact sports, traffic accidents, intramuscular injections, surgery,
convulsions, wasp or bee stings, and burns) can elevate serum creatine kinase values.

 Monitor:
o Muscle damage
 Diagnose:
o Acute Myocardial Infarction(MI)
o Ischemia
o Muscular Dystrophy
 Evaluate success of treatment

https://www.nrsng.com/creatine-kinase-ck/

Myoglobin

 Muscle pain
 Dark-colored urine
 Fever
 Fatigue
 Nausea and vomiting
 Belly pain

https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=m
yoglobin_blood

Heavy drinking and certain medicines can affect your results.

 Fraser, Marianne, MSN, RN

 Haldeman-Englert, Chad, MD

2017

What are the Clinical Indications for performing the

Myoglobin Blood Test?
Following are the clinical indications for performing a Myoglobin Blood Test:

 Diagnosing and assessing the severity of a recent heart attack, which is marked by:
 o Chest pain or discomfort
o Radiating pain to the jaw and face
o Heartburn and indigestion
 Assessing the severity of muscular trauma and muscle diseases

C. Equipment used/ Procedure

Sample required: Blood

Process: Insertion of needle into a vein (arm).
Preparation required: None.However, the healthcare provider should be informed about any
medications used before the test, since some medications may interfere with the test
results.
http://www.dovemed.com/common-procedures/procedures-laboratory/creatine-kinase-mb-
test/

CK - MB is done using Spectrophotometric method on a Blood sample.

https://www.practo.com/tests/creatine-kinase-mb-fraction-spectrophotometric-method-
blood/p

Myoglobin

A blood sample is needed.

First, your provider will use an antiseptic to clean the area for the needlestick.
Common locations are the inside of the elbow and the back of the hand. Then,
your doctor will stick you with the needle and begin to draw blood.

An elastic band is tied around the arm in order to slow the flow of blood. The
blood is drawn into a tube that is connected to the needle and sent to the
laboratory for analysis. The elastic band is then released, and a cotton ball or
gauze is used to apply pressure to the site of entry.

D. Nursing Responsibilities (Pre-test, During, Post-test)

Prior to taking the blood sample, the nurse should inform the patient about the test(s) to be performed
and the preparation for the test. You should:
 1. define and explain the test
2. state the specific purpose of the test
3. explain the procedure
4. discuss test preparation, procedure, and posttest care

Some of the more common tests require no special preparation. However, some blood chemistry tests will
have specific requirements such as dietary restrictions or medication restrictions. For some tests, such as
hormones, stress should be avoided prior to the test. Be sure to inform the patient of any special
preparation prior to the venipuncture and any posttest care needed.

Myoglobin

You should also inform providers about any drug and alcohol use. Heavy
alcohol consumption and the use of certain drugs can cause muscle injury,
which also increases myoglobin levels.

Medically Reviewed by Steven Kim, MDon January 19, 2016 — Written by Darla Burke

E. Possible Complications

 Muscle damage
 Rhabdomyolysis
 Muscular Dystrophy
 Heart attack
 Exercise
 Kennedy’s Disease
 Stroke

https://www.nrsng.com/creatine-kinase-ck/

MYOGLOBIN

Higher results may also be caused by:

 Kidney failure
 Shock
 Electrical shock
 Malignant hyperthermia, an inherited condition in which your body temperature rises rapidly
and your muscles contract when you have general anesthesia
Lower results may mean you have:

 Rheumatoid arthritis
 Myasthenia gravis
 Antibodies to myoglobin in your blood
These include bleeding, infection, bruising, and feeling lightheaded. When the
needle pricks your arm or hand, you may feel a slight sting or pain. Afterward, the
site may be sore.
 Fraser, Marianne, MSN, RN
 Haldeman-Englert, Chad, MD

F. Normal Values

 Early pregnancy
 Small stature

https://www.nrsng.com/creatine-kinase-ck/

G. Significant Results/Interpretations

H. Drug study (If any)

I. Validity of the Test

CK-MB mass has been reported to be useful for the diagnosis of myocardial infarction, re-
infarction, and the sizing of infarction.

©2013 Abbott Point of Care Inc

J. Latest update on the study

Serial CK-MB determination in the ED can help identify AMI patients with initial nondiagnostic
ECGs. Use of serial CK-MB analysis may facilitate optimal in-hospital disposition and help guide
therapeutic interventions in patients with suspected AMI despite a nondiagnostic ECG. [Gibler
WB, Young GP, Hedges JR, Lewis LM, Smith MS, Carleton SC, Aghababian R, Jorden RO, Allison EJ
Jr, Otten E J, Makens PK, Hamilton C, The Emergency Medicine Cardiac Research Group: Acute
myocardial infarction in chest pain patients with nondiagnostic

Myoglobin
Following is the specimen collection process for Myoglobin Blood Test:
Sample required: Blood
Process of obtaining blood sample in adults:
  A band is wrapped around the arm, 3-4 inches above the collection site (superficial
vein that lies within the elbow pit)
 The site is cleaned with 70% alcohol in an outward spiral, away from the zone of
needle insertion
 The needle cap is removed and is held in line with the vein, pulling the skin tight
 With a small and quick thrust, the vein is penetrated using the needle
 The required amount of blood sample is collected by pulling the plunger of the
syringe out slowly
 The wrap band is removed, gauze is placed on the collection site, and the needle is
removed
 The blood is immediately transferred into the blood container, which has the
appropriate preservative/clot activator/anti-coagulant
 The syringe and the needle are disposed into the appropriate “sharp container” for
safe and hygienic disposal

Preparation required: No special preparation is needed prior to the test.

What is the Significance of the Myoglobin Blood Test Result?

The significance of the Myoglobin Blood Test is explained:

 Increased myoglobin levels may indicate:Recent heart attack

o Rapid atrophy, possibly due to:
o Muscle-wasting disease
o Viral infection
o Recent muscle trauma

 Decreased myoglobin levels may indicate:

o Myasthenia gravis
o Polymyositis (presence of antibodies to myoglobin)
o Rheumatoid arthritis
 Lab Tests Online (2012, January 30). Retrieved November 12, 2014 from
http://labtestsonline.org/understanding/analytes/myoglobin/
 Martini, F., Nath, J. L., & Bartholomew, E. F. (2012). Fundamentals of anatomy &
physiology (9th ed.). San Francisco: Benjamin Cummings.
 Schnell, Z. B., Van, L. A., & Kranpitz, T. R. (2003). Davis's Comprehensive
handbook of laboratory and diagnostic tests: With nursing implications. Philadelphia:
F.A. Davis.

Definition
The troponin test measures the levels of certain proteins called troponin T and troponin I in the blood. These proteins
are released when the heart muscle has been damaged, such as a heart attack. The more damage there is to the
heart, the greater the amount of troponin T and I there will be in the blood.

Alternative Names
TroponinI; TnI; TroponinT; TnT; Cardiac-specific troponin I; Cardiac-specific troponin T; cTnl; cTnT
 How the test is performed
A blood sample is needed. For information on how this is done, see: Venipuncture

How to prepare for the test

Usually, no special preparation is necessary.

How the test will feel

When the needle is inserted to draw blood, you may feel moderate pain, or only a prick or stinging sensation.
Afterward, there may be some throbbing.

Why the test is performed

The most common reason to perform this test is to determine if chest pain is due to a heart attack. Your doctor will
order this test if you have chest pain and signs of a heart attack. The test is usually repeated two more times over the
next 12 to 16 hours.

Your doctor may also order this test if you have angina that is getting worse, but no signs of a heart attack.

The troponin test may also be done to help detect and evaluate other causes of heart injury.

The test may be done along with other cardiac marker tests, such as CPK isoenzymes or myoglobin.

Normal Values
Cardiac troponin levels are normally so low they cannot be detected with most blood tests.

Your test results are usually considered normal if the results are:
 Troponin I : less than 10 Â µg/L
 Troponin T : 0†“ 0.1  µg/L
Normal troponin levels 12 hours after chest pain has started mean a heart attack is unlikely.

The examples above are common measurements for results of these tests. Normal value ranges may vary slightly
among different laboratories. Some labs use different measurements or test different samples. Talk to your doctor
about the meaning of your specific test results.

What abnormal results mean

An increase in the troponin level, even a slight one, usually means there has been some damage to the heart.
Significantly high levels of troponin are a sign that a heart attack has occurred.

Most patients who have had a heart attack have increased troponin levels within 6 hours. After 12 hours almost
everyone who has had a heart attack will have raised levels.

Troponin levels may remain high for 1 to 2 weeks after a heart attack.

Increased troponin levels may also be due to:

 Abnormally fast heart beat
 High blood pressure in lung arteries (pulmonary hypertension)
 Blockage of a lung artery by a blood clot, fat, or tumor cells (pulmonary embolus)
 Congestive heart failure
 Coronary artery spasm
 Inflammation of the heart muscle usually due to a virus (myocarditis)
 Strenuous exercise (for example, due to marathons or triathlons)
 Trauma that injures the heart such as a car accident
 Weakening of the heart muscle (cardiomyopathy)
Increased troponin levels may also result from certain medical procedures such as:
 Cardiac angioplasty/stenting
 Heart defibrillation or electrical cardioversion (purposeful shocking of the heart by medical personnel)
 Open heart surgery
 Radiofrequency ablation of the heart

What the risks are

There is very little risk involved with having your blood taken. Veins and arteries vary in size from one patient to
another and from one side of the body to the other. Taking blood from some people may be more difficult than from
others.

Other risks associated with having blood drawn are slight but may include:
 Excessive bleeding
 Fainting or feeling light-headed
 Hematoma (blood accumulating under the skin)
 Infection (a slight risk any time the skin is broken)
 AndersonJL. ST segment elevation acute myocardial infarction and complications of myocardial infarction.
In: Goldman L, Schafer AI, eds.Cecil Medicine. 24th ed.Philadelphia,PA: Saunders Elsevier; 2011:chap 73.
 Kushner FG, et al. 2009 Focused Updates:ACC/AHA Guidelines for the Management of Patients With ST-
Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and
ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007
Focused Update).Circulation. 2009;120:2271-2306.
 Patil H, Vaidya O and Bogart D. A review of causes and systemic approach to cardiac troponin
elevation.Clin Cardiol. 2011 Dec;34(12):723-8.
 Sabatine MS, Cannon CC. Approach to the patient with chest pain. In: Bonow RO, Mann DL, Zipes DP,
Libby P, eds.Bonow: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine.9th ed. Saunders;
2011:chap 53.

Increased troponin levels may also be due to:

 Abnormally fast heart beat

 High blood pressure in lung arteries (pulmonary hypertension)

 Blockage of a lung artery by a blood clot, fat, or tumor cells (pulmonary embolus)
 Congestive heart failure

 Coronary artery spasm

 Inflammation of the heart muscle usually due to a virus (myocarditis)
 Prolonged exercise (for example, due to marathons or triathlons)

 Trauma that injures the heart, such as a car accident

 Weakening of the heart muscle (cardiomyopathy)

 Long-term kidney disease

Increased troponin levels may also result from certain medical procedures such as:

 Cardiac angioplasty/stenting

 Heart defibrillation or electrical cardioversion (purposeful shocking of the heart by medical personnel to
correct an abnormal heart rhythm)
 Open heart surgery

 Radiofrequency ablation of the heart

Updated by: Michael A. Chen, MD, PhD, Associate Professor of Medicine, Division of Cardiology,
Harborview Medical Center, University of Washington Medical School, Seattle, WA. Also reviewed
by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

he myoglobin test, which provides rapid results, may be substituted in early

diagnosis of myocardial infarction for the plasma myoglobin assay which is
unsuitable for emergency analysis.

Clinica Chimica Acta

Volume 153, Issue 1, 29 November 1985, Pages 1-8

Study of a myoglobin test in patients hospitalized for

suspected myocardial infarction
Author links open overlay panelFrancineMainardaBernardMassoubreaHervéLeMarécbYvesMadeca
Show more

The data obtained in the present studies confirm and extend our preliminary findings using myoglobin
radioimmunoassay in patients with acute myocardial infarction (Stone et al., 1975). Patients with acute
infarcts have serum myoglobin levels which are about ten times higher on average than those found in
normal individuals. This profound rise in serum myoglobin concentration is maximal

Was tested that Myoglobin diagnostic test is effective for early diagnosis for MI
We believe larger studies specifically designed to revise the diagnostic
criteria of AMI are urgently required with the advent of novel cardiac
markers. Our concern is that whether this newly introduced cardiac
troponins analysis definitely improves the diagnosis of acute myocardial
infarction or inadvertently leads to over-diagnosis of acute myocardial
infarction with potential impact on health economic issues.

Editor,

Hillis and Fox overviewed the advantages of cardiac

troponins in the assessment of patients with acute chest pain. The authors
have pointed out that whilst there is increased sensitivity of the
available tests for myocardial necrosis with the advent of cardiac
troponin thus allowing early risk stratification, traditional
classification of acute coronary syndromes into unstable angina, non-Q
wave acute myocardial infarction and Q wave infarction has become limited
in accuracy and validity.1,2 However, the article did not address the
urgent need to revise the criteria for the diagnosis of acute myocardial
infarction with the introduction of the novel markers of myocardial
injury.

According to the current WHO criteria, diagnosis of acute myocardial

infarction (AMI) requires the presence of two or more of the three
following findings: (1) clinical history of typical chest pain >30
minutes in duration, (2) evidence of ischaemic electrocardiographic
changes (ST-segment depression, ST-segment elevation, T-wave inversion),
and (3) a rise of peak total creatine kinase(TCK) of more than twice upper
limit of normal.3

In 237 consecutive patients with suspected acute coronary syndromes

admitted over the period of a month, cardiac troponin I(cTnI), creatine
kinase MB mass(CK-MB mass) and TCK were measured at 12-24 hour of
admission. TCK values were also checked on admission as well as on day 1,2
and 3. Bayer Immuno 1 method was used for measuring Cardiac toponin
I(cTnI).4 Values above 0.8 mg/L were regarded as indicative of
underlying AMI and level of 0.1 to 0.8 m/L as indicative high risk
unstable angina with underlying minute myocardial necrosis based on
manufacturer's recommendation supported by previous studies. 4,5

Out of 237 patients presenting with chest pain, 98(41.3%) had abnormal
cTnI result of more than 0.1 mg/L independent of ECG changes. Of these,
20(8.4%) had 12-24 hour levels between 0.1 to 0.8 mg/L indicating high-
risk unstable angina and 78(32.9%) patients had levels of more than 0.9
mg/L indicating underlying AMI. In patients with normal cTnI(<_0.1 mg="mg" l="l" and="and"
in="in" patients="patients" with="with" ctni="ctni" level="level" within="within"
unstable="unstable" angina="angina" range="range" _0.1="_0.1" to="to" _0.8="_0.8" the="the"
peak="peak" tck="tck" levels="levels" remained="remained" below="below" twice="twice"
upper="upper" limit="limit" of="of" normal="normal" supporting="supporting"
validity="validity" test.="test." however="however" _23="_23" _9.7="_9.7"
although="although" _12-24="_12-24" hr="hr" was="was" higher="higher" than="than"
suggesting="suggesting" underlying="underlying" ami="ami" values="values" never="never"
reached="reached" normal.="normal." p="p"/>Our data suggest that the number of patients who
meet enzyme criteria for
AMI will rise sharply if cTnI completely replaces TCK as a marker of
myocardial injury consistent with increased sensitivity of the test.

We believe larger studies specifically designed to revise the diagnostic

criteria of AMI are urgently required with the advent of novel cardiac
markers. Our concern is that whether this newly introduced cardiac
troponins analysis definitely improves the diagnosis of acute myocardial
infarction or inadvertently leads to over-diagnosis of acute myocardial
infarction with potential impact on health economic issues.

References:

1.Graham S Hillis, Keith A A Fox . Cardiac troponins in chest pain.

British Medical Journal 1999;319; 1451-1452.

2.Hamm CW, Goldmann BU, Heeschen C, et al. Emergency room triage of

patients with acute chest pain by means of rapid testing for cardiac
troponin T or troponin I. N Engl J Med 1997; 337: 648-53.

3.Tunstall-Pedoe H, Kuulasmaa K, Amougel P, et al. Myocardial

infarction and coronary deaths in the World Health Organization MONICA
Project. Circulation 1994; 90: 583-612.

4.Bayer Immuno 1Ô System method manual; Publication No. DA4-1234M97;

1997

5.Duncan M, Smith L, Rosium T, Downing R, Plapp FV. Evaluation of

cardiac troponin I on Bayer's Immuno 1 Analyzer. Clinical Chemistry 1998;
vol 44(S6): A118

Htut Kyaw Win, Staff Physician, Coronary Care Unit

Shaila Garg, Cardiology Research Registrar

Steve Butler, Consultant Biochemist

Michael Brack, Consultant Physician/ Cardiologist

Anoop Chauhan, Consultant Cardiologist

 Regional Cardiac Centre, Victoria Hospital, Whinney Heys Road,
Blackpool,
Lancashire
FY3 8NR,
United Kingdom

Correspondence to:
Dr Htut Kyaw Win,
Staff Physician (CCU).

Competing interests: No competing interests

13 December 1999
Htut Kyaw Win

The assessment of patients with chest pain is a difficult skill, informed by clinical judgment. Cardiac
troponins can, however, help in this process—not merely in the application of diagnostic labels but as a
means to estimate risk and guide management.

Hospitalization data has higher validity and hence can be used to identify MI, but the accuracy of MI as a
cause-of-death on death certificates is suboptimal, and more studies are needed on the validity of ICD-10
codes. When using administrative data for research purposes, authors should recognize these factors
and avoid using vital statistics data if hospitalization data is not available to confirm deaths from MI.

 Natalie McCormick,
 Diane Lacaille,
 Vidula Bhole,
 J. Antonio Avina-Zubieta





 Published: March 28, 2014

 https://doi.org/10.1371/journal.pone.0092286