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CLINICAL CHEMISTRY
CHAPTER 10
ENZYMES
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Introduction

Enzymes are the chemical lubricants that make chemical reactions go nice
and easy

They help out with chemical reactions - but they dont get used up
themselves ( sort of like the oil in your car hopefully )

They are always proteins ! ( Remember proteins ? )

Theyre found in cells throughout the body. When these cells get sick the
enzymes in them tend to ooze out into the plasma

Want to diagnose heart attacks, liver disease, muscle disease, pancreatitis,
prostate cancer and bone disease? Enzymes can do that !

They are different because we measure them not in terms of how many
there are ( mg / dl , for example ) but in terms of their activity ( how well they
are lubricating chemical reactions
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KEY TERMS
Activation energy
Activators
Apoenzyme
Catalyst
Coenzyme
Cofactor
Enzyme
First Order Kinetics
Second Order Kinetics
Isoenzymes
Holoenzyme
International Unit (IU) of Enzyme
Activity
Kinetic Assay
2 - Point Assay
Substrate
Substrate Depletion
Zymogen
Prosthetic Group
Inhibitors
Competitive Inhibitors
Non - Competitive Inhibitors
Uncompetitive Inhibitors
Allosteric Site
Active Site
Michaelis - Menten Constant
Myocardial Infarction ( MI )
Congestive Heart Failure ( CHF )

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The Enzymes we will study
CPK
ALK
AST
ALT
GGT
LDH
AMY
LIP
ACP
SChE

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OBJECTIVES

Discuss the general structure and functions of enzymes

Define a unit of enzyme activity ( IU )

Discuss how temperature, pH and other factors effect enzyme activity

Explain first - order and zero - order enzyme kinetics and the special
techniques that are used to measure enzymes

Discuss the tissue sources, clinical significance and Normal Values of
the following

CPK, LDH, AST, ALT
ALK, GGT
AMYL, LIP
ACID PHOS, Cholinesterase
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General Properties and Definitions

Many chemical reactions cannot occur at 37 ( too cold )
Many chemical reactions require added heat energy
Biochemical reactions also require this energy , but proteins will
denature

So how do biochemical reactions ever happen ? They cheat !!!

Biochemical reactions can occur if there is a way to lower the
amount of energy it takes to make the reaction happen.

So how do biochemical reactions cheat ???
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Answer : They get a catalyst

Catalysts are substances that lessen the amount of energy required for
chemical reactions to occur

Catalysts are not used up in the reaction


Substrate Product


Enzymes are protein catalysts
Enzymes are required for the numerous metabolic processes of all cells

When cells are damaged, enzymes leak out into the plasma
The measurement of these enzymes are useful diagnostic tools

Enzyme
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Activation Energy for Chemical Reactions
Catalysts decrease the amount of energy required to activate chemical
reactions. Enzymes are protein catalysts.
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Enzyme Structure

Similar to protein structure, because all enzymes are proteins

1 Amino acid sequence
2 Interaction between 2 locations on the protein chain
3 Folding of chains ( 3D structure )
4 2 or more separate polypeptide chains


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Definitions

Active site

Physical location on the enzyme molecule which interacts with
the substrate molecule

Allosteric Site

Non active site , but which may interact with other
substances to change the overall enzyme 3D shappe

Isoenzymes

Structurally different enzymes ( proteins ) but which catalyze
the same chemical reactions
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Cofactor

A non protein substance required for normal enzyme activity
Cofactors maintain enzyme 3D structure ( critical for enzyme
function )

There are 2 types of cofactors

Activators ( Inorganic --- Magnesium , Calcium )

Coenzyme ( Organic - NADH )
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Holoenzyme

Enzyme + coenzyme ( prosthetic group ) = Active enzyme

Proenzyme ( Zymogen , Apoenzyme )

Enzyme coenzyme = Inactive enzyme
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Enzyme Structure and Substrate
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Classification and nomenclature

Enzyme kinetics

Chemical reactions occur spontaneously if the energy for
reactants is higher than products

The amount of energy required to stimulate molecules to break
their chemical bonds and form new bonds is the activation
energy

Increasing the temperature can generate the activation energy.
This a problem for living cells


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Enzymes lower the activation energy for chemical reactions

The enzyme substrate complex has a lower activation energy
than the substrate alone

Enzymes are usually specific as to which chemical reactions they
catalyze

E + S ES E + P
Enzyme +
Substrate
Enzyme Substrate
Complex
Enzyme + Product
The enzyme is not consumed or depleted by the chemical reaction
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Enzymes differ in their ability to react with different substrates

There are various enzyme specificities

Absolute : Catalyzes only 1 specific substrate

Group : Catalyzes reactions of a particular chemical group

Bond : Catalyzes reactions of particular chemical bonds

Stereoisomerism : Catalyzes reactions of steroisomers
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Factors that influence enzymatic factors

First Order Kinetics

Enzyme concentration exceeds substrate concentration
As substrate concentration increases , the reaction rate
increases
The reaction rate is proportional to substrate concentration

This is not a good place to measure enzyme activity
( The reaction rate is dependent on substrate , not enzyme )


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Zero Order Kinetics

Substrate concentration is in excess
Substrate saturates enzyme

All enzyme reacts with the excess substrate
The chemical reaction rate goes to maximum velocity
Reaction rate is dependent on enzyme activity ( conc . )

Enzymes are not measured in terms of concentration , but
activity

Zero Order conditions are suited for enzyme measurement
because this is where the reaction rate is dependent on the
enzymes ability to catalyze a chemical reaction
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Relationship between substrate concentration and
the reaction rate in a enzymatic reaction
Substrate concentration
Reaction
Rate
Zero Order conditions
First Order Conditions
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Enzyme concentration

Enzymes are not measured in terms of concentration
Enzymes are measured is terms of their activity
Enzyme activity = The rate at which an enzyme catalyzes a
chemical reaction
Increased activity is proportional to increased concentration

Activity is measured under Zero Order conditions because this is
where the reaction rate is dependent on the work ( activity ) of the
enzyme



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MICHAELIS-MENTEN CONSTANT (K
m
)

Numerical constant for each enzyme and substrate under defined
conditions

Expresses a relationship between the reaction rate and substrate
concentration

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pH ( acidity )

Enzymes are proteins and subject to changes in 3D structure from
pH changes
pH must be carefully controlled in enzymatic reactions

Temperature

Reactions rates vary dramatically with temperature changes
Reactions rates may double per 10 C increase in temperature
Temperature must be defined and regulated for enzymatic reactions
37 C is the common standardized temperature
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Cofactors ( non-protein substances needed for enzymatic activity )

Activators ( Ca
+2
, Fe
+2
, Mg
+2
, Mn
+2
, Zn
+2 )

Coenzymes ( Vitamins and nucleotide phosphates )

Increased coenzyme concentration increases reaction rate
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Inhibitors ( Substances that decrease enzyme reaction rates )

Competitive Inhibitors

Substances that bind at the enzymes active site
Competes with substrate for the active site
Addition of additional substrate increases the reaction rate

Non Competitive Inhibitors

Substances that bind at an enzymes non active site
Enzymes 3D shape is altered, decreasing enzyme activity
Addition of additional substrate has no effect on reaction rate

Uncompetitive Inhibitors

Substances that bind with enzyme substrate complex
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Effects of inhibitors on K
m


Competitive Inhibitors increase K
m


Non-competitive Inhibitors have no effect on K
m

( maximum velocity is not possible )


Un-competitive Inhibitors decrease K
m


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Measuring enzyme activity

Enzymes are not directly measured
Enzymes are commonly measured in terms of their catalytic activity

We dont measure the molecule
We measure how much work it performs
Its catalytic activity
The rate at which it catalyzes the conversion of substrate to product

The enzymatic activity is a reflection of its concentration
Activity is proportional to concentration
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Photometric measurement of activity

E + S ES E + P

Enzyme activity can be tested by measuring

Increase of product
Decrease of substrate
Decrease of co-enzyme
Increase of altered co-enzyme

If substrate and co-enzyme are in excess concentration, the
reaction rate is controlled by the enzyme activity.
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Coupled enzyme reactions

Some enzyme testing utilizes other enzymatic reactions in a
sequence of reactions.

These other accessory enzymes are not being measured.

Auxillary enzymes are used as reagents and added in excess so they do
not become rate limiting factors in the overall process.

All enzymatic reactions in a coupled assay must be performed at zero
order kinetics.
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Example of a coupled assay

S
1
+ E
1
S
1
E
1
E
1
+ P
1
( RXN 1)
P
1
+ E
2
P
1
E
2
E
2
+ P
2
( RXN 2 )
P
2
+ E
3
P
2
E
3
E
3
+ P
3
( RXN 3)

E
1
= Enzyme we want to measure ( patient )
E
2
= Auxiliary enzyme ( reagent )
E
3
= Indicator enzyme ( reagent )

There are 3 reactions with 3 different enzymes
P
1
becomes the substrate for reaction rxn 2
P
2
becomes the substrate for reaction rxn 3
We end up measuring reaction 3, but its reaction rate is
determined by reaction rate of rxn 1
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Enzymatic reactions are measured in terms of the rate at which
substrate is converted into product. This can be done in 2 different
ways.

Fixed Time Assay ( 2 Point )

Zero Order Kinetics
Substrate concentration is measured at set timed intervals to
determine enzyme activity

A slight delay from the beginning of the reaction to maximum
velocity is the lag phase

These times intervals may not be short enough to detect sudden
changes
Extreme elevations in enzyme activity may deplete the substrate
between measured intervals - Substrate Depletion
Substrate depletion causes falsely decreased activity results.
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Two Point Enzyme Methodology
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Multipoint Continuous Monitoring ( Kinetic Assay )

Continuous measurements of substrate product concentration
are recorded by the spectrophotometer of an automated
analyzer

Substrate depletion is detected because the analyzer is always
looking and will see any sudden dramatic changes
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Multipoint Enzyme Method
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Comparison of 2 Point and Multipoint Enzyme Techniques
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Enzyme Activity can be measured as a function of the change of absorbance
values over a period of time
Remember that enzymes are measured in terms of activity
How much work is getting done? How fast are chemical reactions taking place?

A large change in absorbance per unit of time indicates that the reaction was
occurring at a rapid rate, meaning that enzyme activity is high
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Calculation of enzyme activity

Remember, its not concentration its activity
Enzymes are measured in terms of how fast they convert substrate into
product
Activity is a measurement of how fast they work

The common unit of enzyme activity is the International Unit ( IU )

1 IU = That amount of enzyme that will convert 1
micromole (1 mole ) of substrate to product per minute
under defined conditions

These conditions are such things as

pH
Temperature
Substrate
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Mathematical expression of enzyme activity



A = The rate of change in Absorbance ( A ) of the
substance being measured
MIN = Time the reaction is measured
TV = Total sample volume ( patient plasma + reagents )
SV = Volume of patient plasma
10
6
= Conversion of moles into micromoles
L = Length of the light path
c = Molar absorptivity
( )
6
10
L X
1
(IU/L) ACTIVITY ENZYME
|
.
|

\
|
|
.
|

\
|
|
.
|

\
|
A
=
SV
TV
MIN
A
c
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Example of Molar Absorptivity calculation

NADH ( a common co-enzyme ) absorbs light at 340 NM
NAD ( the reduced form ) does not absorb light at 340 nm

Increased ( or decreased ) NADH concentration in a solution will
cause the Absorbance ( A ) to change.

A 0.05 X 10
-3
Molar NADH solution placed in a 1 cm light
path has an absorbance of 0.311




L MOLES/ 10 X 6.22
1CM X R MOLES/LITE 10 X 0.05
0.311

3
3 -
= = c
The molar absorptivity of NADH is 6.22 x 10
3
Moles / Liter

Each chemical substance has its own unique molar absorptivity
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Enzymes as reagents

Enzymes are used as reagents in a wide variety of methodologies
to measure other non-enzyme substances
Enzymes help to produce substances that can be easily measured
Enzyme specificity helps to eliminate interfering substances

If the enzyme is used as a reagent, we do not want the enzyme
concentration to be a affect the chemical reaction
To avoid this the enzyme is added in excess so that it cannot
become a rate limiting factor .

Remember, we are just using the enzyme to measure something
else
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Creatine Kinase ( CK , CPK )

CPK catalyzes

Creatine + ATP Creatine phosphate + ADP

High concentrations of CPK in muscle, cardiac and brain tissues
Increased plasma CPK activity is associated with damage to these
tissues

| CPK is especially useful to diagnose

AMIs
Skeletal muscle diseases ( Muscular Dystrophy )
CPK
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CPK ( cont )

CPK has 3 isoenzymes
Each isoenzyme is composed of two different parts ( dimers )

CK - BB BRAIN
CK - MB CARDIAC
CK - MM SKELETAL MUSCLE

Skeletal muscle CPK is 99% CK-MM
Cardiac muscle CPK is 80% CK-MM and 20% CK-MB

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CPK ( cont )

Most normal plasma CPK is CK-MM

Because of CK MBs association with cardiac tissue,
increased CPK MB ( > 6% of the total CPK activity ) is a
strong indication of AMI

Post AMI CPK - MB

CK-MB increases 4 8 hours post AMI
Peaks at 12 - 24 hours post AMI
Returns to normal 24 - 48 hours later
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CPK ( cont )

CPK assays are often coupled assays CPK
In the example below, the rate at which NADPH is produced is a
function of CPK activity in the first reaction.
Hexokinase and G6PD are auxiliary enzymes

Creatine Phosphate + ADP Creatine + ATP


ATP + Glucose Glucose 6 - Phosphate


G 6 - P + NADP 6 - Phosphogluconate + NADPH
CPK
Hexokinase
G6PD
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CPK ( cont )

RBCs lack CPK, but hemolyzed RBCs release adenylate kinase into
the plasma, causing falsely increased CPK activity

Hemolyzed specimens must be recollected

Reference ranges

Males Total CPK 15 - 160 IU / L
Females Total CPK 15 - 130 IU / L

Lets remember 15 150 IU / L

CK - MB: < 6 % of Total CPK

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Lactate dehydrogenase ( LDH , LD )

LDH is found in many different tissues

Skeletal muscle
Cardiac muscle
Renal tissue
RBCs

Plasma LDH activity is elevated in a variety of conditions

Liver disease
Cancers
AMI
Hemolytic diseases
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LDH ( cont )

Lactate + NAD Pyruvate + NADH + H


At pH 9.0 the reactions moves to the right
At pH 6.8 the reaction moves to the left
NADH absorbs light at 340 nm NAD does not

The reaction can be performed either direction

LD
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LDH ( cont )

LDH post AMI

Increases 12 24 hours post AMI
Peaks at 48 72 hours
May remain elevated for 10 days

RBC hemolysis falsely increases plasma LDH

Reference range : 100 - 225 IU / L ( L P )
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LDH Isoenzymes

Because increased total LDH is relatively non-specific, LDH
isoenzymes can be useful

5 isoenzymes composed of a cardiac ( H ) and muscle ( M )
component

LD - 1 ( HHHH ) Cardiac , RBCs
LD - 2 ( HHHM )
LD - 3 ( HHMM ) Lung, spleen, pancreas
LD - 4 ( HMMM ) Hepatic and skeletal
LD - 5 ( MMMM )

A flipped LD - 1 / LD - 2 ( LD-1 > LD-2 ) consistent with
AMI
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Aspartate Aminotransferase ( AST, SGOT, GOT )

High concentrations of AST are found in

Skeletal muscle
Cardiac muscle
Liver tissue
Lung tissue

Post AMI

Rises 6 8 hours
Peaks at 24 hours
Returns to normal by day 5

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AST ( cont )

AST assays usually utilize a coupled enzyme technique


Aspartate + o - Keto - Glutarate Oxaloacetate + Glutamate

Oxaloacetate + NADH + H Malate + NAD

MD is an auxiliary enzyme

NADH absorbs light at 340 nm NAD does not

Reference Range : 5 - 30 IU / L
AST
MD
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Alanine aminotransferase ( ALT, SGPT )

Highest concentrations in the liver
Increased plasma ALT closely associated with liver disease

Alanine + - Ketoglutarate Pyruvate + Glutamate

Pyruvate + NADH + H Lactate + NAD



NADH absorbs light at 340 nm NAD does not

Reference range : 5 - 35 IU / L
ALT
LD
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Chemical reactions of the amino-transferases AST and ALT
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Alkaline phosphatase ( ALK, ALK PHOS )

Optimal pH at 9.0 10.0 ( alkaline )
Removes phosphates ( PO
4
) from organic compounds
Requires Mg as an activator

High concentrations in

Bone
Liver

Best utilized to diagnose bone and liver disease

Reference range : 30 90 IU / L

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Amylase ( AMY, AMYL )

Catalyzes breakdown of starch and glycogen to glucose

High concentrations in

Pancreas
Saliva Chew on some bread !!!

Amylase is filtered into the urine ( unusual for a protein )
Urine amylases are occasionally ordered

Increased plasma or urine amylase is very suggestive of
pancreatitis or pancreatic malignancy
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Amylase ( cont )

Because amylase is concentrated and excreted in the urine, urine
amylase values may be more diagnostic that plasma

Many different amylase methodologies varying in the types of
substrates used

Reference range : 60 180 SU / dl
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Acid phosphatase ( ACP, Acid Phos )

Same function as ALK PHOS, but at a different pH
Optimal pH is 5.0 ( acid )

High concentrations in the prostate gland made it a useful test for
the diagnosis of prostate cancer

Its use is declining because of other, better tests for prostate cancer
( Prostate Specific Antigen - PSA )
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Gamma Glutamyltransferase ( GGT )

High concentrations in liver tissue

Increased plasma GGT is associated with

Hepatobiliary disease
Alcoholic cirrhosis

Insurance companies utilize GGT to detect alcoholism

Reference range : 6 45 IU / L
GGT
Glutathione + amino acid Glutamyl peptide + L-Cysteine
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Lipase ( LIP )

Hydrolyze ( breaks down ) fat

High concentrations in the pancreas .
Increased plasma lipase associated with pancreatitis

Lipase is more specific than amylase for the detection of
pancreatitis

Reference range : 0.0 - 1.0 U / ml
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Pseudocholinesterase ( SChE )

Considered a screening test for exposure to organophosphate exposure
( pesticides)

SChE is found in plasma, liver, pancreas and brain

Reference Range : 4,000 - 12000 IU / L
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Diagnosis of AMI ( Acute Myocardial Infarction )

Remember cardiac disease is the #1 cause of death in the United States

#1 Symptoms, physical examination , and patient history
But there are many causes of chest pain other than AMI

#2 EKG only 50% reliable - may be normal even during AMI

#3 Laboratory tests ( Troponin I , CKMB , Myoglobin , BNP )


Cardiac cellular necrosis following ischemic event causes soluble proteins
to leak into the plasma

Rephrased : When coronary arteries are blocked ( ischemic event ) cardiac
tissue is deprived of oxygen and dies, and dead cardiac tissue cells spill
their guts into the plasma
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Myoglobin

Soluble heme protein
Present in all muscle cells, cardiac and skeletal
Plasma myoglobin is elevated in various forms of muscle damage -
surgery, strenuous exercise, degenerative muscle diseases and physical
trauma
Myoglobin can also be elevated from decreased renal clearance
Relatively low molecular weight , water solubility and high cellular
cytoplasm concentrations cause myoglobin to be the first marker to be
released from damaged cells


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Troponin I

Contractile protein associated with cardiac and skeletal tissue
Two forms Troponin I and Troponin T
Troponin I from cardiac tissue has a unique antigenic structure that
differentiates it from skeletal Troponin I and facilitates its measurement

Of all the cardiac markers , Troponin I is the most specific for cardiac
injury

CK-MB

Iso-enzyme found in cardiac and skeletal tissue
Plasma CKMB concentrations are increased in AMI and various forms of
skeletal muscle trauma
Although not absolutely specific, very high concentrations in cardiac
tissue make it a good marker for AMI
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B- Type Natremic Protein ( BNP )

Increased plasma BNP is associated with Congestive Heart Failure ( CHF )

CHF is one of the most common reasons for hospitalization in patients greater
than 70 years old

BNP assays are often ordered with AMI markers to differentiate between AMIs
and CHF

BNP in normal in AMI

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Cardiac enzymes

In the good old days , AMIs were diagnosed with the cardiac
enzymes
The cardiac enzymes consisted of Total CPK, LDH and AST
Although still useful, the more specific markers such as
Troponin I, Myoglobin and CK-MB have largely replaced the
cardiac enzymes
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TRIAGE CARDIAC PANEL FOR RAPID QUANTIFICATION OF
CK-MB, MYOGLOBIN , TROPONIN I and BNP
TRIAGE is a common commercial test package that quantitates the
three most significant laboratory markers for AMI - CK-MB ,
Troponin I and Myoglobin

Procedure summary
Lithium heparin whole blood is added to the cartridge system
Plasma separates from RBCS after passing through a filter
Plasma ( CK-MB , Troponin I and Myoglobin ) reacts with fluorescent
tagged anti-CKMB, anti-Troponin and anti-Myoglobin monoclonal
antibodies in the reaction chamber
Concentration of the analyte is directly proportional to fluorescence that
is measured on the Triage Meter
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Triage system cut - off ranges for cardiac markers . Values above the
cut-off ranges indicate possible AMI

Troponin I < 0.6 ng / ml

Myoglobin < 107 ng / ml

CK-MB < 4.3 ng / ml


Reference ranges for the cardiac enzymes

Total CPK 15 - 150 U / L

LDH 100 - 225 U / L

AST 5 - 30 U / L
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Summary of Triage cardiac markers after AMI
Increases Peaks Normal
Myoglobin 2 hrs 6 8 hrs 20 36 hrs
Troponin I
4 8 hrs
12 16 hrs 6 10 days
CK MB 4 8 hrs 12 24 hrs 72 hrs
Although any single analyte may not be adequate to diagnose an AMI, the
collective information from all three analytes can be very useful
The interpretation of cardiac markers can be difficult because blood specimens
are not always collected soon after patients suffer chest pains - delays of hours
to days are common before patients seek medical attention
The most common symptom of a heart attack is .
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Enzyme Top 10
Enzymes are protein catalysts that lower activation energy of chemical reactions

Enzymes are not consumed in the reactions they catalyze

Enzymes are measured in terms of activity ( know the definition of an IU )

Enzymes are measured at zero order kinetics

CPK Cardiac and skeletal muscle
ALK Bone and hepatic tissue
GGT and ALP Hepatic tissue
AMY and LIP Pancreas
LDH Hepatic, Cardiac , RBCs ( lots of others )
AST Cardiac, Hepatic and skeletal
CK-MB Cardiac ( good to diagnose AMI )
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REFERENCE RANGES

ALT 5 - 35 IU/L
AST 5 - 30 IU/L
CPK 15 - 150 IU/L
GGT 5 - 45 IU/L
LDH 100 - 225 IU/L
ALK 30 - 90 IU/L
AMYL 60 - 180 SU/Dl
LIPASE 0.0 - 1.0 IU/ML
CK-MB LESS THAN 6% OF CPK
ACID PHOS 3.0 - 12.0 IU/L


MYOGLOBIN 30 90 mg/dl
TROPONIN I < 0.6 ng/ml
BNP < 100 pg/ml
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Enzyme Links
http://www.bact.wisc.edu/microtextbook/Metabolism/Enzymes.html

http://med6.bham.ac.uk/teaching/clinyear3/enzymslide/

http://ull.chemistry.uakron.edu/genobc/Chapter_20/

http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/E/Enzymes.html