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Cardiac Markers

• Cardiac markers are proteins expressed commonly or exclusively

by myocardial cells and released into the circulating blood upon
cell necrosis
• They are known as troponin I, troponin T, myoglobin and CK-MB.
• These cardiac markers play an essential role in the global risk
assessment and treatment of patients presenting with an acute
coronary syndrome (ACS).
Learning outcomes
• Important characteristics that a
cardiac biomarker must have
• List different types of cardiac
markers used for diagnosis of
acute coronary syndrome
• Differentiate cardiac markers in
terms of marker release patterns,
sensitivity and specificity
• Describe importance of cardiac
markers in patient managemant
Cardiac Troponins
 Troponin is a contractile protein that normally is not found in
serum. It is released only when myocardial necrosis occurs.
 Cardiac troponins T and I are highly sensitive and specific for
cardiac damage. Troponin I and T are of equal clinical value.
 Serum levels increase within 3-12 hours from the onset of
chest pain, peak at 24-48 hours, and return to baseline over 5-
14 days.
 Troponin levels may not be detectable for six hours after the
onset of myocardial cell injury. The most sensitive early marker
for myocardial infarction is myoglobin. (stranious exercise)
• Troponin levels should be measured at presentation and
again 10-12 hours after the onset of symptoms.
• Elevated troponin levels can occur in patients without an
ACS and are associated with adverse outcomes in many
other clinical situations, including congestive heart failure,
sepsis, acute pulmonary embolism and chronic kidney
ack disease. Other cardiac causes include myocarditis and aortic
Prognostic value
of Troponin

• In addition to its use in the

diagnosis of MI, an elevated
troponin level can identify
patients at high risk for
adverse cardiac events.
• Data from a meta-analysis
indicated that an elevated
troponin level in patients
without ST-segment
elevation is associated with
a nearly 4-fold increase in
the cardiac mortality rate

CKMB level comes down faster

Creatine kinase Myoglobin
• Myocardial muscle creatine
kinase (CK-MB) is found
• Myoglobin is found in
mainly in the heart. cardiac and skeletal
• CK-MB levels increase
within 3-12 hours of onset of • It is released more
chest pain, reach peak rapidly from infarcted
values within 24 hours, and myocardium than
return to baseline after 48- troponin and CK-MB and
72 hours. may be detected as
• Sensitivity and specificity early as 2 hours after
are not as high as for an acute myocardial
troponin levels. infarction.
• However, its release kinetics • Myoglobin has high
can assist in diagnosing sensitivity but poor
reinfarction if levels rise after specificity. It may be
initially declining
days to comes down useful for the early
acute MI. Faster than troponin
detection of myocardial
But sensitivity not that high
Cleared fast by liver

Severity of damge

Remained DROP
Emerging Markers
Criteria for novel biomarkers
• Novel biomarkers have to clear a high hurdle to be
adopted in clinical practice. Numerous experts have
proposed criteria or features for evaluating the utility of
cardiac biomarkers.

 •Does the biomarker measure a specific pathology with
known reference limits and high myocardial specificity?
 •Can the marker be measured with high accuracy, precision,
and reproducibility?
 •Does the biomarker have high sensitivity and specificity?
 •Are results available with high throughput and short
turnaround time?
 •Can the biomarker be measured at reasonable cost?
 •Have pre-analytical issues been evaluated and are
measurable—is the marker stable?
Incremental Value
 Has a linear relationship Patient Impact
between a change in the
marker and a change in  •Does a change in the marker alter
pathology been patient management?
demonstrated in multiple  •Is there evidence that biomarker-
studies? guided triage or monitoring improves
 •Is the marker superior care?
to existing tests in  •Does the marker aide in selecting
predicting risk, therapy, stratifying risk, monitoring
diagnosing disease response to therapy or disease
earlier, or correlating progression, detecting sub-clinical
with disease? disease?
 •Have the decision limits
been validated in more  •Will knowledge of the test result
than one study? bring better patient understanding of
their disease or risk?
 •Has the marker been
 •Will knowledge of the test result
evaluated in diverse prompt healthier patient behaviors?