Laboratory diagnosis of heart diseases: Cardiometabolic risk AMI Heart failure

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Erik Shepherd
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1 Laboratory diagnosis of heart diseases: 2017 Cardiometabolic risk AMI Heart failure

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3 Suggested Risk Factors for CVD LDL Oxidation LDL-C Anti-OxLDL OxLDL LDL Oxid. Lag Time Negative LDL HDL-C Paraoxonase PAF acetylhydrolase F2-Isoprostanes TBARS ORAC Breath Ethane Inflammatory Response C-Reactive Protein IL-6 Lp-PLA 2 Endothelial Injury Triglycerides/VLDL Non-HDL-C apoa-1/apob HDL-2/HDL-3 LDL size Postprandial TG IDL Chylo. Remnants Blood Pressure Homocysteine Endothelial Dysfunction von Willibrand s Factor P-Selectin sicam-1 svcam-2 Assymetric Dimethyl Arginine Nitrate/Nitrite Plaque Instability Plasma Metaloproteinase-9 Thrombus Formation Factor VII Fibrinogen PAI-1 Factor VII Tissue Plasminogen Activator D-Dimer Plasmin-Antiplasmin Complex Prothrombin Fragment 1+2 Platelet Activation

4 Metabolic Syndrome Abdominal obesity Hyperinsulinemia High fasting plasma glucose Impaired glucose tolerance Hypertriglyceridemia Low HDL-cholesterol Hypertension

5 A szívinfarktus definíciója Az akut szívinfarktus miokardiális sejtelhalás, amelyet elhúzódó miokardiális ischemia okoz Patológia

6 Classification of AMI 6

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9 CARDIAC TROPONINS

10 Necrosis markers Myoglobin: Rapid release within 2 hours, Not cardiac specific, Rule out for infarction rather than rule in!

11 Necrosis markers CK: 3 major isoenzymes- CK- MM, MB & BB total CK activity sk musc (2500 U/g); hrt (473 U/g); brain (55 U/g). small intest, tongue,diaphragm,uterus & prostate tissue-to-plasma ratio sk muscle & myocard total CK -not recommended for routine MI

12 Necrosis markers Elevated CK with elevated CK-MB is a good tool to confirm MI However: Body mass of skeletal muscle ~100-fold than myocardial muscle CK-MB index 2.5% usually myocardial source Problem (both myocardial & skeletal muscle injury) Skeletal muscle CK-MB may confound CK-MB index by masking relatively subtle myocardial CK- MB & effectively swamping the denominator

13 Necrosis markers

14 Necrosis markers A combination of an early marker (CKMB) and a specific one (troponin) is recommended for use. The result must be ready within 30 min! The method must be reliable (good positive predictive power).

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16 DISADVANTAGES 16

17 European Society of Cardiology: High sensitive Troponin Guideline

20 Not quite infarction: ischemia New tools are coming! Ischemia modified albumin Albumin s capacity to bind to cobalt is reduced during myocardial ischemia (N-terminal) Rises within minutes of ischemia, stays up for 6-12 hrs and normalizes within 24 hrs. Elevated after enduring sports, but; after 24 hrs. (?GI ischemia) Inhibited by endogenous lactate-limited use in DKA, Sepsis, CKD Less specific cancers, CKD, sepsis, liver disease

Congestive heart failure BNP and ANP are left ventricular neuroendocrine hormones which participate in volume regulation by increasing urine Na secretion and

21 Congestive heart failure BNP and ANP are left ventricular neuroendocrine hormones which participate in volume regulation by increasing urine Na secretion and volume, cause vascular smooth muscle relaxation, and inhibit the renin angiotensin system. Elevated BNP was found highly specific and sensitive for chronic heart failure!

22 Congestive heart failure BNP levels differentiate between acutely dyspnoic patients who have a primary lung disorder versus patients who have decompensated CHF. BNP is also an attractive indicator of prognosis in patients who have CHF where elevated levels portend a poor prognosis & predictor of sudden cardiac death.

23 BNP in ventricular dysfunctions

24 BNP in chronic heart failure

25 38 y old woman Severe substernal chest pain at rest (intractable for 2 hours), radiating to face, arms, shoulder. Smoker, mother died from AMI ECG: ST segment elevation Sublingual NG: transient relief On admission Myoglobin: 380 ug/l (0-70) Troponin I 24 ng/ml (2 ng/ml) After thrombolytic therapy Myoglobin 570 ug/l Troponin I 43 ng/ml

26 Related exam questions 1. Laboratory findings in diagnostics of myocardial infarction. 2. Laboratory monitoring of treatment of acute myocardial infarction (AMI), e.g. reperfusion, fibrinolytic therapy. 3. Laboratory approaches in chronic heart failure (BNP, probnp, electrolytes). 4. Assessment of cardiovascular risk factors by laboratory testing.

Acute coronary syndrome. Dr LM Murray Chemical Pathology Block SA

Acute coronary syndrome. Dr LM Murray Chemical Pathology Block SA Acute coronary syndrome Dr LM Murray Chemical Pathology Block SA13-2014 Acute myocardial infarction (MI) MI is still the leading cause of death in many countries It is characterized by severe chest pain,