Comparison of Creatine Kinase Activity and Myoglobin Blood Level in Acute Myocardial &Infarction Patients
Sabaheta Hasić*, Radivoj Jadrić, Emina Kiseljaković, Jovan Radovanović, Mira Winterhalter-Jadrić
Department of Biochemistry, Faculty of Medicine, University of Sarajevo, Čekaluša , Sarajevo, Bosnia and Herzegovina
* Corresponding author
Abstract
The aim of this prospective study was to evaluate and compare the relative increase of serum myoglobin level and total creatine kinase (CK) activity in acute myocardial infarction (AMI) patients (n=). We measured serial changes in total CK activity and myoglobin serum level in three-time periods (- hours, hours and - days) from chest pains onset. Myoglo- bin peaked during the first - hours but total CK reached its peak activity after hours from AMI symptoms onset. Results of this study showed that as non-specific cardiac marker myoglobin had better sensitivity and earlier rise in serum than total CK activity in AMI pa- tients. Rapid kinetic of myoglobin level is important for its utility as marker for re-infarction diagnosis. Early myoglobin increase in serum is important for early triage of AMI patients and early “ruling out” of AMI diagnosis if there is no evidence of its elevation in circulation.
KEY WORDS: myoglobin, creatine kinase, acute myocardial infarction
Introduction
Diagnosis of AMI is based on clinical features, (presence of risk factors), electro- cardiogram (ECG) changes and levels of cardiac biomarkers. Necrotic cells of heart muscle release a variety of enzymes and proteins that can be measured in periph- eral blood. Intracellular concentration, fractional release and normal serum levels determine the relative increase of a marker molecule in blood (). Biochemical test- ing for the AMI diagnosis is rapidly changing from traditional enzymatic assay to immunoassay of more sensitive markers (). Serial measurement of biochemical markers is now accepted universally as an important determinant in “ruling in” or “ruling out” of AMI diagnosis. “Rule in” of AMI diagnosis requires a high diagnostic
BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2006; 6 (1): 19-23 SABAHETA HASIĆ ET AL.: COMPARISON OF CREATINE KINASE ACTIVITY AND MYOGLOBIN BLOOD LEVEL IN ACUTE MYOCARDIAL INFARCTION PATIENTS specificity while “rule out” a high diagnostic sensitivity confirmed AMI diagnosis ( males and fe- of cardiac marker (). For many years, CK (E.C.....) males, age range - years). They were random- was used together with ECG to confirm the presence ized in three groups according to the time from the of myocardial infarction. The physiological role of CK chest pains onset: group I (- hours); group II ( enzyme is maintenance of an adequate store of high-en- hours) group III (- days). Control group represent- ergy phosphorylated creatine, which is used to restore ed a healthy subjects (n=; males and females). adenosine triphosphate (ATP) levels depleted during muscle contraction. Elevation in total CK is not specific METHODS for myocardial injury, because the most of CK is located Venepuncture was performed on each patient and in skeletal muscle and elevations are possible from vari- blood samples were drawn within -, hours and - ety of non-cardiac conditions (, , ). Peak levels of CK days after the onset of chest pains. Samples were centri- typically occur from - hours after the onset of chest fuged at r.p.m. for minutes to separate the se- pain and decline to normal by about days. Myoglobin rum and it was used immediately for the measurement was the first serum cardiac marker that was not an en- of total CK activity and myoglobin serum concentra- zyme or an isoenzyme. It is relatively small (, kDa) tion. The Ethical Committee of our institution approved heme protein and transports oxygen within muscle cells. the protocol of this study. Myoglobin was measured Myoglobin constitutes about of muscle protein in with the Abbott immunoassay system (Microparticle both skeletal and cardiac muscle (). Because of its low Enzyme Immunoassay) using AxSYM analyzer. The molecular weight, myoglobin is rapidly released into the upper reference limit was ng/ml. Total CK ac- circulation and is the first marker to rise after an AMI. tivities in serum were measured at °C with N-acet- Very little free myoglobin circulates as result of natural ylcysteine-activated reagents (Chronolab) used Flexor protein turnover. Serum myoglobin levels are elevated analyzer. The upper reference limit was , μkat/l. in conditions unrelated to AMI, such as skeletal muscle, neuromuscular disorders, renal failure, intramuscular STATISTICAL ANALYSIS injection, strenuous exercise and in presence of various The data were evaluated statistically by using Krus- toxins and drugs (, ). During the course of a myocar- kal-Wallis test and post-hoc Tukey test. Variable are dial infarction, myoglobin escapes from the ischaemic described in terms of summary statistics (median, first cardiac muscle and can reach levels - times from and third quartile, minimum and maximum). Sig- normal during the first - hours. It is rapidly removed nificance was assumed at a probability value of p<,. from circulation, filtered through the glomerular mem- brane of the kidney, and excreted in the urine (). Rap- Results id kinetic of myoglobin serum level is important for its utility as marker for reperfusion () and re-infarction Median age of patients included in study was vary- diagnosis (). Myoglobin precedes the total creatine ing from to . Myoglobin peaked during the first kinase serum elevations. The diagnosis of AMI might - hours from onset of ischaemic symptoms (Figure be made earlier if serum myoglobin levels are measured. .). Kruskal-Wallis test showed statistically significant difference in all groups (H=,; p<,). Post- Objective hoc Tukey test showed significant difference between group I and II versus control group (p<,). There The aim of this prospective study was to evaluate and was no difference between group III and control group compare the relative increase of serum myoglobin level p>,. Post-hoc Tukey test showed statistically signifi- and total CK activity in AMI patients. We analyzed their cant difference p<, between group I and III. Total relative increase and window-time duration in serum. CK reached its maximum value hours from isch- We have made effort to detect the time of the highest aemic symptoms onset (Figure .) Kruskal-Wallis test diagnostic significance in AMI diagnosing by measuring showed statistically significant difference in all groups total CK activity and myoglobin serum concentration. (H= ,; p<,). Post-hoc Tukey test showed significant difference between group II and I versus Patients and Methods control group (p<,). There was no difference be- tween group III and control group. Difference between PATIENTS group I and III was p<, and group II and III p<,. The prospective study included patients with We compared relative increase of serum myoglobin level
BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2006; 6 (1): 19-23 SABAHETA HASIĆ ET AL.: COMPARISON OF CREATINE KINASE ACTIVITY AND MYOGLOBIN BLOOD LEVEL IN ACUTE MYOCARDIAL INFARCTION PATIENTS
and total CK activity in AMI patients (Figure .) in three than myoglobin because its median value was ,-times time periods from AMI symptoms onset. Myoglobin higher than control. In AMI patients of group III (after - median value within - hours was -times higher than days) levels of both markers returned to normal range. median value of healthy control group. In the same time, CK activity in serum was ,-times higher than control. Discussion After hours from symptom onset myoglobin blood level represented as median value is ,-times higher Acute myocardial infarction, as the most complicated than control. In this time CK had a higher sensitivity form of acute coronary syndrome, is one of the leading
BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2006; 6 (1): 19-23 SABAHETA HASIĆ ET AL.: COMPARISON OF CREATINE KINASE ACTIVITY AND MYOGLOBIN BLOOD LEVEL IN ACUTE MYOCARDIAL INFARCTION PATIENTS causes of mortality in the world. Biochemical markers one of the causes of vary blood levels of both markers had essential importance in “ruling in” or “ruling out” of in single AMI groups (). Myoglobin peaked during AMI diagnosis. Insufficient sensitivity of specific cardiac the first - hours from onset of ischaemic symptoms. markers in early hours from ischaemic symptoms onset Our results showed that myoglobin serum concentra- requires using non-specific markers that have higher tions, in some patients of group II, were not in the refer- sensitivity compared to specific markers. Myoglobin was ence range. It points on slower myoglobin elimination introduced as an early marker, but most studies have not from circulation and is caused by a possible large infarc- compared it to total CK. The total CK is a simple, fast tion or renal insufficiency (, ). During the first - and inexpensive test that is available for usage on many hours CK showed elevation of activity but reached its laboratory instruments. From a physiologic point of maximum hours from ischaemic symptoms onset. view, CK and myoglobin are similar. They are both cyto- Extreme values of myoglobin concentration and to- plasmic proteins and both depend on gender, race and tal CK serum activity in groups can be caused by non- age. Myoglobin is low molecular weight protein (, cardiac conditions (,). Results of this study showed kDa). Its half-life is - hours when glomerular filtration greater elevation degree of myoglobin concentration rate is normal (). Molecular weight of CK is about in serum after - hours from onset of AMI symptoms kDa and its half-life is approximately hours (). In in comparison with CK serum activity. After hours our investigation we obtained wide variation of levels blood myoglobin level shows rapid myoglobin elimi- of observed two markers in single patient groups. Vary nation from circulation except in some patients with ranges of marker in heart tissue content cause difference large infarction or renal insufficiency. According to in blood levels of marker among patients. Swaanenburg our presented results, we consider myoglobin as more and co-workers found significant differences in the con- sensitive marker then CK. Lim and co-workers had the tent, expressed per gram wet weight tissue, in the right same result in their investigation (). Better sensitiv- and left ventricles for troponin I, troponin T, myoglobin ity and earlier rise of blood myoglobin is caused by its and α-hydroxybutiric acid dehydrogenase (). Differ- higher heart tissue content, lower molecular weight ent myocardial infarction size between patients can be and shorter blood half-life in comparison with CK.
Conclusion
This prospective study showed that myoglobin, as non-specific cardiac marker, had earlier rise and bet- ter sensitivity in AMI patients compared to total CK activity. Early myoglobin increase in serum is impor- tant for early triage of AMI patients and early “ruling out” of AMI diagnosis if there is no evidence of its elevation in circulation. Myoglobin is favorable marker of reperfusion for its rapid kinetic. Rapid myoglobin release- kinetic is important for its utility as marker for re-infarction diagnosis. Myoglobin measurement should be used to- gether with cardiac specific marker measurement for finally AMI diagnosing, because of its poor cardiac specificity.
BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2006; 6 (1): 19-23 SABAHETA HASIĆ ET AL.: COMPARISON OF CREATINE KINASE ACTIVITY AND MYOGLOBIN BLOOD LEVEL IN ACUTE MYOCARDIAL INFARCTION PATIENTS
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