Indian Journal of Clinical Biochemistry, 2004, 19 (1) 113-117

THE SIGNIFICANCE OF TROPONIN T AND CK-MB RELEASE IN C O R O N A R Y ARTERY

BYPASS SURGERY
Javad Mohiti*, Mostafa Behjati**, Moharnmad H. Soltani and All Babaei***

*Dept. of Biochemistry, **Afshar Primary Teaching Hospital, ***Dept. of Pharmacology, Shahid Sadoughi University
of Medical Science, Yazd, /ran.

ABSTRACT
Measurement of cardiac markers is an index of care standard in the assessment and diagnosis of
cardiovascualr disease. Two of the major cardiac markers are Creatine Kinase isoenzyme CK-MB
and Troponin T, which are extensively used in the diagnosis of heart disease. The release of
Troponin T and creatine kinase isoenzyme (CK-MB) was investigated in 50 coronary artery bypass
surgery patients. Measurement of plasma samples was carried out at five different time points,
namely before surgery, 1,6,12,24 hours after surgery. The results indicated that CK-MB level were
increased by a factor more than four times compared with the upper limit of baseline (befor surgery).
Troponin T concentration showed more than six fold over the upper limit of baseline (before surgert)
at 1,6,12,24 hours after surgery. In order to assess the significance of the length of the surgical
procedure on the release of Troponin T and CK-MB, the surgery patient were divided into two groups
according to the length of the surgical procedure: group I was selected on the basis that the surgical
procedure they underwent lasted above 90 minutes and group II with a surgical procedure below 90
minutes. Both Troponin T and CK-MB showed a significant increase in-group I compared to group
tl. To investigate the likelihood that this effect is party due to myocardial infarction during surgery, the
patients were divided into two groups: Group A with some sings of myocardial infarction on Q wave
of ECG and group B without any change. The results showed approximately a two-fold increase of
these markers in-group A compared to.group B. Since these markers reach into blood following
damage to myocardial their increase in patients with time course surgery of more than 90 minutes
and those with a probability of MI during operation, indicating that these patient fall into a high risk
group of repeat (MI) after surgery.

KEY WORDS
Creatine Kinase isoenzyme(CK-MB), TroponinT, Artery bypass surgery,

ABBREVIATIONS
Creatine Kinase isoenzyme(CK-MB), Cardiac Troponin T(CTNT).

INTRODUCTION

Cardiovascular disease is a major cause of death in
the wodd with coronary heart disease being the single
most important cause of death of middle-aged men
(1). Because of the frequency and severity of
cardiovascular disease, diagnosi~ must be rapid and
accurate. Diagnosis on an electrocardiogram is not
absolute criterion, particularly in the case of small
infarctions. Assays of plasma markers are thus of the
Author for Correspondence:
Dr. Javad Mohiti,
Dept. of Biochemistry,
Faculty of Medicine,
Yazd Universityof Medical Science, Yazd, IRAN.
Tel: +983518226128
Fax: +983518229500
Email: mohiti 99@yahoo.corn
importance to confirm the clinical hypothesis (2). They
measure intracellular cardiac tissue molecules
released into the circulation after the onset of
cardiovascular disease (3).
Cytoplasmic CK is a dimer composed of M and B
subunits that associate to form CK-MM, CK-MB and
CK-BB Isoenzymes. In patients having significant
myocardial disease, the CK-MB isoenzyme comprises
approximately 20% of the total CK in this tissue. Ck-
MB is diagnostically sensitive for myocardial injury (4).
Cardiac Troponin T and I are constituents of the
contractile proteins of all myofibrils including the
regulatory protein Troponin. This protein is a complex
of three protein subunits (troponin C, I and T). These
proteins are localized primarily in the myofibrils with a

Indian Journal of Clinical Biochemistry, 2004 113

Indian Journal of Clinical Biochemistry, 2004, 19 (1) 113-117
small farction in the cytoplasm. On injury, Troponins Effect of length operation on the blood markers
are released into the blood circulation. Troponin T is a
cardiac-specific marker which, numerous studies have The surgery patients had a mean length operation of
shown it to be highly sensitive in the detection of MI 5- 80 minutes, therefor, to investigate the time course
6 hours after the onset of chest pain(5). Release of surgery on the release of blood markers, patients
myocardial proteins occurs in all cardiac surgery were divided into two groups. Group I patients who
patients (4.5). After surgery, these markers reach the had time course operation more than 90 minutes(15
circulation quickly through the patient's blood vessels. patients) and group II less than 90 minutes (35
In pedoperative myocardial infarction, these markers patients). CK-MB and Tropinin T were measured in
are released more slowly, as with typical myocardial each individual time in two groups (before operation
infarction (8,9). The time course of markers is the best 1,6,1Z and 24 hours after operadial). The results thus
criterion for detecling myocardial infarction in this
se~ng. I~ ~ n autopsy-conb-ol~ed study, a CK-MB greater Fig.t: Time course o f release of CK-MB into the
than 133 IU/L at 15 hours after surgery had a sensitivity circulation after artery bypass surgery. (the x-axis,
of 60% and a specificity of 100% for pedoperation show activityof CK-MB which is expressed in IU/L)
myocardial infarction (13,14). Our aim was to evaluate
the clinical value of cardiac Troponin T and CK-MB as
a marker in assessing myocardial cell damage in the
patient undergoing open heart surgery. Various
contractile proteins were possible candidates, but we
selected the blood markers CK-MB and Troponin T
because these markers have high sensitivity and are
used extensively for the diagnosis of MI (10,11).

MATERIALS AND METHODS

Materials
The CK-MB (Immunoassay kit) and CK(NAC-ACT Kit)
were obtained from RANDOX, England. Troponin T
ELISA kit was obtained from DRG.instruments GmbH,
Germany
obtained indicale that CK-MB levels in group I increased
Methods
from the baseline value of 17.5 lUlL to mean values
Fifty patients(19 femate and 31male) who underwent 65, 60, 67 and 59 IU/L respectively after surgery,
CABG surgery with one or two vein, were selected. A whereas in group II this increased to mean values 36,
senal blood samples(before operation 1,6, 12 and 24 38, 35 and 37 IU/L respectively (Fig.3). The levels of
hours after operation )were taken. CK-MB was
measured by Autoanalyzer ModehALCYON 300 base Fig,2: Time course of release of CTNT into
on RANDOX Parameter(13). Troponin T was also circulation after artery bypass surgery.
separately measured by an ELISA sandawich (the x-axis, show CTNT which is expressed in
method(14). microgeram/liter).

RESULTS

Increase of blood markers after operation

Five blood samples of each surgical patients (before

surgery 1.6,12 and 24 hours after surgery) were taken
and the Troponin T and CK-MB were obtained by the
above methods. The results indicated that CK-MB
increased from a baseline of 17 lU/L to mean values
87, 77, 74 and 75 lUlL after operation respectively
(Fig.l). As expected, serum Treponin T increased from
a baseline 1.1 I~g/L to mean values 6.3, 6.4, 10.5 and
12 pgtL after operation respectively (Fig.2). Similar
resutts were obtained for CK (Results not shown).

Indian Journal of Clinical Biochemistry, 2004 114

Indian Journal of Clinical Biochemistry, 2004, 19 (1) 113-117
Troponin T also increased from t~e baseline value of Fig.4. The release of CTNT with time course of
1.1 iJg/L to mean values10.5, 12, 13.2 and 17 i~g/L surgery more than 90 minutes (square) and less
respectively in group I after surgery, while it reached to than 90 minutes (triangle). (P<0.05)
mean values of 5.7, 6.3, 6.7 and 7.5 I~glL in group II
(Fig.4).

Likelihood of the effect of myocardial infarction during

surgical operation on the release of blood markers
Since in artery bypass surgery, the heart muscle of
surgical bypass patients' acts under the control of a
pump, clinical evidence showed that some surgical
patients had myocardial infarction during surgery.
Therefore, to assess the possibility that myocardial
infarction has an effect on the release of Troponin T
and CK-MB, fifty patients undenNent on operation were
divided into two groups: group A with some clinical
sings of myocardial infarction on a Q-wave of an
ECG(12 patients) and group B with no sings of

Fig.3. The levels of CK-MB released with time

course of surgery more than 90 mins (square),
and less than 90 minutes (triangle). (p<0.05)
Fig.5. The release of CK-MB with Likelihood of MI
during the artery bypass surgery with some sign
of Ml(square) and without sign of Ml(triangle).
(p<0.05)

myocardial infarction(38 patients). The results indicate

that the serum CK-MB levels increased to mean values
of 52, 57, 64 and 53 IU/L in group A respectively and it
reached to mean values 30, 34, 31, and 32 lUlL in
group B after surgery (Fig.5). Troponin T levels also of laboratory t e c h n i q u e s , c o m m e n c i n g with
increased to mean values 10.2, 11.5, 14 and 18 iglL m e a s u r e m e n t of aspartate t r a n s a m i n a s e and
respectively in group A after surgery and it reached to progressing to measurement of creatine kinase (CK)
mean values 5, 5.8, 6.3 and 8 ig/L in group B after and its MB isoenzyme (CK-MB) and Troponins I and
surgery(Fig. 6). T(11,13).

DISCUSSION We assessed coronary artery bypass surgery patients

Coronary heart disease is the largest killer in developed
country (16). It has been predicted that cardiovascular
disease will be the most important cause of mortality
in Iran.
For assessment of coronary artery surgery, the choice
of cardiac enzyme has been dictated by the evolution
by measuring the levels of Troponin T and CK-MB pre-
and post-operatively. We observed a variation in the
levels of these markers in the blood, which is probably
dependent on the surgic~t factors, with a mean value
of 9.15+2.5 ig/L for Troponin T and 78+6.5 lUlL for CK-
MB after surgery (Figs 1,2).(17,18). It has been shown
that biological markers are released differently, as with
a typical myocardial infarction. Several reports indicate

Indian Journa/ of C/inica/ Biochemistry, 2004 115

Indian Journal of Clinical Biochemistry, 2004, 19 (1) 113-117
Fig.6 The release of CTNT with likelihood of MI
during the artery bypass surgery with some sign of
MI (square) and without sign of MI (triangle).
(P<0.05)
that CK-MB and Troponin T increase significant at 12
and 24 hours versus baseline and the end of surgery
(21,22). The results of study by Yamamato and co-
workers indicate that these markers increase in blood
30-40 times higher than cut- off value in a open-heart
operation (9.10,15,23).
Our results indicate that patients with longer operation
time had raised levels of the cardiac markers Troponin
T and CK-MB in blood. (Compare patients with
operation time of more than 90 minutes (CK-MB:
61.25+4.2, CTNT: 13.17+2.77) to patients with less
than 90 minutes of operative time (Ck-MB: 34.5+1.3,
CTNT: 6.55t0.75) (Figs 3,4). These results agree with
other studies in assessing the time course operation
on the raise of these markers in blood. (19, 20). Since
the sensitivity of Troponin T is about 0.01 g of heart cell
and CK-MB is about 0.1 g, also the specificity of these
markers are 100% after 6 hours following MI, therefore
our results suggest that patients in group I should be
twice at risk of myocardial damage than those of group
II (1,12.13). Result of Chen's work in assessing
Troponin T as a marker myocardial cell damage in the
patients undergoing open heart surgery showed that
Troponin T can used as a routine indicator for
myocardial protection(25).
A direct correlation was observed between the group
of patients that had some signs of myocardial infarction
dudng operation and the increase of these markers in
blood. The group of patients that had some signs of
myocardial infarcUon(group A) during operation showed
CK-MB levels raised three and half times after
operation (Mean:56+5.4) higher than those normal
control prior to surgery, whereas it raised
twice(Mean:31.7:1:1.7) higher than normal control prior
to surgery in group B (Fig .5). Troponin T levels were 12
times (Mean:13.4+3.4) higher than normal prior to
/ndian Journal of Clinica/ Biochemistry, 2004
surgery in group A after operation, whereas it raised to
near six times(Mean: 6.1 +1.2) higher normal control in
group B (Figs 5,6). Costa and co-workers (17) showed
that, in a population comprising 496 patients with
multivessel coronary disease assigned to CABG in
the Artedal Revasculadzation Therapies Study (ARTS),
CK-MB levels were prospectively measured at 6, 12,
and 18 hours after the operation, thirty-day and 1-year
clinical follow-ups were performed. The results indicate
that patients with increased cardiac markers after
operation were at increased risk of both death and
repeat infarction. Troponin T and ~CK-MB assays
considered the "gold standard" for MI diagnosis with a
high sensitivity (24), therefore the patients that had MI
during the operation, probably are a higher risk group
for MI after operation. This suggests that these patients
should go for a follow-up with an assay for these
markers at least for one year (14,12,13,15).
ACKNOWLEDGMENT
The authors thank Dr. Amar Chiter, Sussex University,
UK for critically reading this manuscript.
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