Point of Care

Cardiac Markers

What? Why? Options?

Marcia L. Zucker, Ph.D.

Director of Clinical Support
Response Biomedical Corporation

Educational
Services

What are Cardiac Markers?

• Enzymes, proteins, and hormones

– associated with heart function, damage or
failure
• Some cardiac specific
– e.g., Troponin I
• Others also elevated due to skeletal muscle
damage
– e.g., Myoglobin

www.labtestsonline.org

What are Cardiac Markers?

• Laboratory Tests •Non-laboratory Tests
- Family History
Increasingly

– Cardiac Biomarkers
Invasive

• CK and CK-MB - Electrocardiogram

- Chest X-ray
• Troponin I or T - Stress test
• Myoglobin - Catheterization
• BNP or NT-proBNP - Echocardiogram
- Percutaneous
coronary intervention

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 Some Potential Cardiac Markers

Plaque Destabilization
MPO; ICAM-1; VCAM (myeloperoxidase; intercellular adhesion molecule 1; vascular adhesion molecule )
Plaque Rupture
sCD40L; PIGF; PAPP-A (sol CD40 ligand; placental growth factor; pregnancy-associated plasma protein A )
Acute Phase Reactants
CRP (C-reactive protein)
Ischemia
IMA; FFAu; Choline (ischemia-modified albumin; unbound free fatty acids)

Necrosis
Available CK-MB; Myoglobin; cTnI; cTnT
as POCT Myocardial Dysfunction
BNP; NT-ProBNP
Adapted from Apple, et. al., Clin Chem 2005: 51:810

Why Use Cardiac Markers?

• Tests used for diagnostic and prognostic purposes

– ordered when someone comes into the Emergency Room with:
• chest pain / pressure
• Indigestion / nausea
• shortness of breath
– to detect heart failure
– to detect acute coronary syndromes (ACS)
– to help determine prognosis following a myocardial infarction (MI)
– To help determine prognosis in patients with chronic congestive
heart failure (CHF)
www.labtestsonline.org

Evidence Based Practice Guidelines

• Cardiac Biomarker Guidelines

– Testing available on a continuous 24 hour basis, with a TAT
of < 60 minutes
• Optimally, 30 minutes.
– If cannot deliver TAT in < 60 minutes should consider POC
testing
– NACB (National Academy of Clinical Biochemists)

• AMI Guidelines
– Troponin at 0 and 6 – 12 hours after ED arrival
– Troponin (or CK-MB) at 0 & 8 – 12hrs post onset of
symptoms
– ESC (European Society of Cardiology); AHA (American Heart Assoc);
– ACEP Clinical Policies (Am College of Emergency Physicians)

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 Evidence Based Practice Guidelines

• CHF Guidelines
– BNP/ NT-proBNP performed as part of diagnosis
– Use as part of diagnosis. Level correlated to severity of HF.
– BNP or NT-proBNP useful in cases where HF diagnosis is
unclear
– BNP or NT-proBNP also useful to confirm symptomatic HF
– Useful in risk assessment post-MI
– ESC; NACB; ACC (Am College Cardiology); AHA

Why Use Cardiac Markers?

• Symptoms • Possible Diagnosis
– Chest pain – MI
– Dyspnea • Myocardial Infarction
• Breathing difficulty – CHF
– Wheezing / Coughing • Congestive heart failure
– Diaphoresis
– COPD
• Excessive sweating
• Coronary obstructive pulmonary
– Nausea / Vomiting disease
• Indigestion
– Pneumonia
– Fatigue, weakness
– Anxiety
– Need to sleep propped up
– Swelling of feet, ankles, or legs – Indigestion
– Abdominal pain and tenderness – Other
– Restlessness
– Fear of Impending Doom

AMI -Acute Myocardial Infarction

Acute disruption of OXYGENATED blood flow to heart

Prolonged blockage = cell damage and release of “markers”

Illustration from:
http://www.nlm.nih.gov/medlineplus/ency/imagepages/

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 Marker Release after AMI

path.upmc.edu/cases/case178/dx.html

Cardiac Troponins

cTnI = cardiac isoform of TnI

SPECIFIC to cardiac muscle

http://www.biology.eku.edu/RITCHISO/301notes3.htm
http://www.uic.edu/classes/phyb/phyb516/regulatoryproteinsu3.htm

Assessment of Risk

Antman, et. Al. N Engl J Med 1996;335:1342–9.

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 CHF - Congestive Heart Failure

A complication of AMI

or an acute exacerbation of chronic heart failure

Illustration from:
http://www.sciosinc.com/img/heartfailure_image.gif

B-type natriuretic peptides

NTproBNP BNP and

stress
NTproBNP
proBNP
levels
BNP increase as
the severity
Reduced
of heart
stress failure
Increased
worsens
diuresis

CHF Diagnosis
Natriuretic peptide testing improves diagnostic
accuracy over clinical judgment alone

Januzzi et. al., Am J Cardiol 2005;95:948–954

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 Why Point of Care?

Clinical Laboratory Process

Identify need Obtain Order Process Order

Receive sample Transport Obtain sample

Analyze Report Interpret Treat

Point-of-Care Process

Identify need Obtain Order Process Order

Obtain sample

Analyze Interpret Treat

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 POCT Cardiac Markers
• Myoglobin
A – Released from damaged muscle; Not cardiac specific
• CKMB
M – Released from damaged muscle; MB cardiac specific
I • Cardiac Troponins (T and I)
– Released from damaged muscle; Very cardiac specific

A/C • B-Type Natriuretic Peptides

C – Proteins produced during myocyte stress (CHF)
H – BNP (vasoactive peptide)
F – NT-proBNP (“inactive” fragment)

ELISA Technology

http://www.jp.amershambiosciences.com/newsletter/biodirect_mail/sinote/image/11_01s.jpg

• http://biosystemdevelopment.com/site_graphics/elisa.jpg

IFA and ELISA Technology

• IFA – immunofluorescence assay

• ELISA – enzyme linked immunosorbent assay

i. Sample is incubated with antigen.

ii. Secondary antibodies labeled with an enzyme or fluorescent tag bind Ab/Ag complex.
iii. Bound secondary antibodies can be detected using the marker.
i. The label used can be a fluorescent molecule, colloidal gold or an enzyme which induces a
color change or current when the substrate is added.

Adapted from
http://www.biobest.co.uk/diagnostics/elisa.html

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 What Systems are Available?

• RAMP Reader
– Response Biomedical Corporation
– TnI, Myo, CK-MB, NT-proBNP*
– EDTA whole blood sample
– Internal electronic QC (IQC)
– Two levels wet control with each test
– External wet QC available
– Lot card with each box
• Reader stores up to 50 lots
– Single slot Reader
• New Reader with up to 6 slots for Q4 2007

*Under FDA review

RAMP Technology

Ratio of internal standard and detection zone fluorescence converted to

result

What Systems are Available?

• Biosite Triage
– Biosite Corporation
– TnI, Myo, CK-MB, d-dimer, BNP in panels
• D-dimer and BNP available alone
– EDTA whole blood or plasma
– Meter specific QC simulator
– “On-board” control with each test
– External wet QC available
– Lot card with each box
• Stores 20 lot codes
– Single slot instrument

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 Biosite Triage Technology

• Sample Port filters out blood cells

and particulates.
• Sample flows through the device,
encounters “zones” where the
analyte binds to analyte-specific
antibodies.
• Meters detect the labeled, bound
analyte in each assay zone.
• Meter measures fluorescence at the
control zones and assay zones.
• The results are displayed.

What Systems are Available?

• i-STAT
– Abbott POC (Now GE)
– TnI, CK-MB, BNP
– TNI, CK-MB – heparinized whole blood or plasma
– BNP - EDTA whole blood or plasma
– External electronic simulator
– Internal control with each test
– Do not move analyzer during testing
– External wet QC available
– Calibration download from PC 3x per year
• QC ranges available online
– Single slot instrument

i-STAT Technology

•Antibody – antigen complex is

captured onto the surface of the
electrochemical sensor.
•Enzyme bound to the
antibody/antigen/antibody sandwich
cleaves the substrate releasing an
electrochemically detectable
product.
•The electrochemical
(amperometric) sensor measures
and reports analyte concentration.

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 What Systems are Available?

• Roche Cardiac Reader

– Roche Diagnostics
– TnT, Myo, NT-proBNP, d-dimer
– Heparinized whole blood sample
– External electronic QC (2 separate tests)
– External lyophilized QC available
– Lot card with each box
• Stores 15 lot codes
– Insert test before drawing sample
– Single slot Reader

Roche Cardiac Reader Technology

http://www.imtek.de/anwendungen/content/upload/vorlesung/2006/2_capillary-systems.pdf

What Systems are Available?

• Stratus CS
– Dade-Behring Inc.
– TnI, Myo, CK-MB, NT-proBNP, d-dimer
– Heparinized whole blood or plasma
• 2.7mL minimum
– Internal electronic QC (System Check)
– External wet QC available
– Barcoded calibration on testpak
• Calibration updated on site per lot
• Stores 3 lots per testpak
– One rotor and up to 4 testpaks per sample

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 Stratus CS Technology

• Solid-phase Radial Partition Immunoassay (RPIA)

technology.
– STARBURST dendrimers bind antibody to the
center portion of a square piece of glass fiber paper
in the reagent TestPak.
• System spins sample and transfers plasma the
paper.
• Conjugate reagent is pipetted onto the reaction
zone of the paper.
• The reaction rate is measured by front surface
fluorescence and converted to result.

Point of Care, (2002) Cardiac Symposium 1: 54-7

POC System Selection

• Menu
– All have markers for MI and CHF
– Qualitative systems exist, beyond these quantitative systems
• Yes, you can use different markers in lab and POC
– TnI vs TnT
– BNP vs NT-proBNP
– Requires different ranges and cut-offs
• Predefined panels vs site selected paneling
– Will results be supressed?
– Sequential vs concurrent panels
– Timing of testing
– Billing for serial testing
• Lock-out for non-validated assays?

Performance - Accuracy

• Correlation to the lab

– CORRELATE DOES NOT MEAN MATCH
– Especially for Troponin I
• Evaluate
Clinical Agreement
– Positive = positive
– Negative = negative

ACEP Clinical Policies, Ann Emerg Med. 2006;48:270-301

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 Accuracy
•Both systems showed excellent correlation across full range (R >0.95)

•False Positives
•False Negatives
Adapted from Wu, et. al. Clinica Chimica Acta 346: (2004) 211-219

Accuracy

• Clinical Agreement
– False positive
• Delayed release from ED
• Potential for unnecessary tests
– False negative
• Potential release from ED of patient with MI
Suffered an apparent heart attack the day after being sent home by an
emergency room physician at xxxxxx Medical Center in Lafayette.
The paramedic, who gave xxxxx oxygen and aspirin and then used an
electrocardiogram machine to examine the heart's electrical function,
agreed it was a heart attack. The doctor in the emergency room
disagreed with the paramedic. After running more tests, he sent xxx
home nearly five hours later, saying xxx just had anxiety. The patient
10/24/2006 was advised to follow up with his doctors but to return if his chest
pain became worse.
xxxx, was dead the next day, one of thousands who perish each year
when their heart attacks are undetected by doctors.

Clinical cut-offs

• Comparison to lab
– Troponin I and BNP different on every system
– Troponin T and NT-proBNP - closer match across systems
• All licensed by Roche
• All must meet Roche specifications
– Current recommendations to set cut-of values at 99th percentile

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 Performance - Precision

• Measured as CV (%) for replicate sample testing

– Different for whole blood and controls
• Generally higher for controls
– Use controls recommended by manufacturer
• Matrix effects differ for each reagent
• “Current scientific data suggest that such use of EQAS results is not
always feasible because of matrix effects, which exist with many external
control materials. These processed materials (including quality control and
calibrating materials) sometimes do not behave like the fresh specimens
routinely analyzed in the laboratory. Biases not generally seen with fresh
biological fluids are frequently seen with EQAS, control, and calibrator
materials. Because of these matrix effects, evaluating laboratory
performance for accuracy of testing using PT can lead to inaccurate
conclusions and, potentially, inappropriate regulatory sanctions. Any
conclusions from the study are limited to the specific variables of the
processed samples, e.g., manufactured batch, sources of analytes used
to supplement the sample, types of stabilizers that might be present, etc.”
– CLSI guideline, EP-14-A Evaluation of Matrix Effects.

Precision

• CV is generally higher for lower concentrations

Replicate 1 2 3 4 5 6 7 8 9 10
Level 1 0.10 0.15 0.08 0.12 0.14 0.09 0.07 0.11 0.13 0.11
Level 2 3.4 4.1 4.5 3.5 3.6 3.8 4.2 4.4 4.1 3.5

Range Mean SD CV
Level 1 0.07 0.11 0.026 23.5%
Level 2 1.10 3.9 0.40 10.3%

•Low CV does not mean values all match

Cost – Effectiveness of POC

• Acute Coronary Syndromes

– POC TnI reduced cost per admission by 25%
• Replaced lab TnI in ED
– Apple et. al. Clin Chim Acta. 370:191-5 (2006)

• Heart Failure
– POC BNP reduced healthcare costs by 14%
• Used as primary screen in ED
– Aspromonte, et. al. Clin Chem 52:1802–1808 (2006)

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 Conclusions

• POC cardiac markers are recommended if lab

results not available in <30 minutes
– Variety of choices for system
• POC markers can be equal to lab in accuracy
– Not all systems are equal
– Individual site correlations required
– May need different cut-off POC vs lab
• Cost effective
– Reduction in length of stay
– Reduction in more invasive diagnostic procedures

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