CASE 2

A 54 year old woman, who is 68 inches tall and weighs 198 Ibs., has a history of high blood pressure and
elevated serum cholesterol levels. After a heated argument with a neighbor, she experienced a tight
pressure like band of pain across her chest, associated with shortness of breath, sweating, and a sense
of light headedness.

After five hours of intermittent chest pain, she went to the hospital emergency department, where her
electrocardiogram showed changes consistent with acute infarction of the anterior wall of her heart. She
was admitted to the cardiac care unit. Blood was sent to the laboratory for various tests, including total
creatine kinase (CK) level and the MB fraction of CK in the blood, cTN-T (cardiac troponin T subunit was also
requested).

1. Explain the biochemical basis for the laboratory tests that were requested for this patient.

Part of the diagnosis of myocardial infarction is the detection of cardiac markers in the blood of the patient.
Damage to cardiac cells due to ischemia will result to the release of cytosolic and structural components
(proteins) which can be quantified to indicate injury or necrosis. Short-time ischemia alters functional, and
later, structural features of the cell membrane allowing the release of cytoplasmic proteins; long-term
ischemia includes tissue necrosis hence structural proteins are released.

Creatine Kinase (CK) is an enzyme acting as a regulator for the production and utilization of high energy
phosphate within contractile tissue. CK specifically transfers high energy phosphate between creatinine
and adenosine diphosphate and is found in all types of muscles, in the brain, and other tissues.

CK exists as mitochondrial and cytoplasmic CK, both being dimers, with mitochondrial CK consisting of
sarcomeric and non-sarcomeric subunits and cytoplasmic CK consisting of the M and/or B subunits (each
subunit of cytoplasmic CK weight approximately 40 kDaltons. Mitochondrial CK is unstable in serum and is
difficult to measure, hence, it has relatively less clinical significance in terms of indicating myocardial
infarction. Cytoplasmic CK can exist in three distinct molecular forms (isoenzyme): CK-MM (muscle type),
CK-MB (hybrid type), and CK-BB (brain-type). CK-MM is the main isoenzyme found in striated muscle and
injury to either skeletal or cardiac muscle will elevate CK-MM. CK-MB is mainly found in cardiac muscle,
with small amounts in skeletal muscle, thus, it is more viable as a cardiac marker.
Serum total CK and CK-MB rise together following myocardial injury. Serum total CK, which also rises with
skeletal damage, must not be used on its own to diagnose myocardial infarction but should be used with
other more specific cardiac markers. Calculation of the CK-MB/CK relative index can assist in differentiating
CK-MB increases from skeletal injury. The relative index can be obtained by taking the CK-MB (mass), which
is measured immunochemically, over the total CK multiplying the quotient by 100. A relative index
exceeding 5 indicates cardiac injury, while less than 3 indicates muscle injury. 3 5 is a grey zone indicating
the need for serial determinations.

Two isoforms of CK-MB can be quantified and utilized in diagnosis of myocardial infarction. CK-MB isoforms
exist in cardiac muscle as CK-MB2, and CK-MB1 in plasma. The removal of the lysine residue from the
carboxy terminus of the single M-subunit, catalyzed by the action of carboxypeptidase- N, gives rise to the
CKMB1 isoform. Charge differences due to the removal of lysine (which is positive) allow the separation of
both isoforms via electrophoresis. In normal plasma, both isoforms exist in a CK-MB2/CK-MB1 ratio of 1 or
less than 1. Myocardial injury prompts release of CK-MB2 into plasma increasing the ratio to 2.

Cardiac troponins (troponin I and T) are the preferred biomarkers for cardiac necrosis. The three individual
proteins, the tropomyosin-binding subunit (TnT, 37 kDa), inhibitory subunit (TnI, 24 kDa), and calcium--
binding subunit (TnC, 18 kDa), form the troponin complex involved in muscle contraction by binding to
calcium and moving tropomyosin to allow the actin-myosin to interact. Troponin I and T have cardiospecific
forms while troponin C has a similar form to that of type 2 muscle fibers. 6-8% of cTnT and 2.8-8.3% of cTnI
are present unbound in the cytosol, while most are present in the contractile unit. In normal healthy
individuals, cTnT and cTnI are not present in serum. The release of cTnT during myocardial infarction is
biphasic. This is due to the first release of the unbound cTnT in the cytoplasm, and the subsequent release
of the TnT bound to the troponin complex (several days later) due to cell necrosis.

2. Describe the clinical course of Troponin T, CK-MB, as well as other related enzymes, in a patient with
myocardial infarction.

MARKER ELEVATION START PEAK RETURN TO NORMAL

(hours) LEVELS
Myoglobin 2-4 6-12 hours 24-36 hours
Creatine Kinase 4-6 12-36 hours 3-4 days
CK-MB 4-6 12-24 hours 2-3 days
Troponin T 4-6 12-24 hours 7-10 days
Troponin I 4-6 12-24 hours 6-8 days
Aspartate 8-12 1-2 days 3-6 days
Aminotransferase
Lactate Dehydrogenase 8-12 2-3 days 7-10 days
Hydroxybutyrate 8-12 2-3 days 7-14 days
dehydrogenase
Heart fatty acid binding 2-3 8-10 hours 18-30 hours
protein
Myosin light chains 3-6 4 days 10-14 days
*Please note that ranges may differ between references

CK-MB rises within 4-6 hours after onset of chest pain, peaks at 12-24 hours and returns to normal within
2-3 days.
In some cases, troponin T exhibits a biphasic pattern on the course of its release. Troponin increase within
4-6 hours after onset of myocardial infarction and peaks after 12-24 hours. The second peak follows 3-4
days later. Troponin I does not usually show a second peak due to smaller free cTnI in the cytoplasm.

References

Pasupathi, P., et. al. (2009). Biochemical Cardiac markers in Clinical Cardiology. J Medicine. doi: 10: 100:108

Fuster, V., Walsh, R., Harrington, R., et. al. (2011). Hursts The Heart. (13th ed.). McGraw Hill

McPherson, R., Pincus, M., (2011). Henrys Clinical Diagnosis by Laboratory Methods. (22nd ed.).
Philadelphia: Elselvier Saunders

Fialova, L., Platenik, J. Biochemical Examination of Acute Myocardial Infarction. Retrieved from:
http://che1.lf1.cuni.cz/html/Cardiomarkers.pdf

Shreiber, D., (Jan 2017). Cardiac Markers. Retrieved from: http://emedicine.medscape.com

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