CARDIAC FUNCTION TEST

INDICATION FOR CARDIAC TESTING

 Any chest pain

 Palpitation
 Breathlessness
 Unstable angina
 Suspicious ECG changes
 Previous history of M.I.
 Following surgical coronary revascularization
 Patient with hypotension and dyspnea
RISK FACTORS
 Modifiable – cigarette smoking, High total
cholesterol, High LDL cholesterol, low HDL
cholesterol, LVH.
Diabetes mellitus, hypertension, physical
inactivity, obesity, high triglycerides, stress.

 Non modifiable factors -

age, male, family history.
MARKERS FOR CARDIAC DISEASES
 Creatine kinase

 Cardiac troponin

 Brain natriuretic peptide ( indicator for ventricular

function)

 C-Reactive protein

 LDH & AST

CREATINE KINASE
 Catalyzes formation of phosphocreatine from creatine and
ATP.

Types –cytosolic and mitochondrial.

 Cytosolic enz. Dimer of two units. M and B.

 Has 3 isoenzymes
 CK-3 (MM)- +nt in heart, skeleton muscle(96% of total)
 CK-2 (MB) – specific for heart ms.( 20% of total).
 CK-1(BB)- mainly in brain tissue, prostate, skeleton ms.
 CK-MM IS MAJOR ISOENZYME IN SERUM OF
HEALTHY PERSONS

Separation of isoforms are done by electrophoresis, ion-

exchange chromatography, RIA, immunoinhibition.
Interpretation-CK activity depends on age, race and sex.
High activity seen in neonates,infants, adolesent
Low activity seen in early pregnancy, women

Males (U/L) Females (U/L)

Cord blood 570 570
12-14 yrs 370 250
20-60 yrs 270 150

Pregnancy(third trimester) 265

CONTD.
 By electrophoresis separates band of CK-3 and
CK-2.
 3 CK3 and 2 CK2 forms exist.
 Tissue form of CK3 is known as CK-33.
 Tissue form of CK2 is known as CK-22.
 Conc of CK is more in pt. of heart diseases.
 Mitochondrial CK (CK-Mt) has two isoenzymes.
CONTD.
 In skeleton muscles 1% is CK-2.

 Persistent elevation of S. CK-2 occurs in muscle

dystrophies.

 Total CK is used to measure polymyositis muscular

dystrophies and MB iso- enzyme is estimated in
myocardial infarction.

 Not present in RBCs

REMARKS
 Sensitive indicator of early stages of M.I. ( rise
within 3-6 hrs, peak at 18-24 hrs).

 More useful in subendocardial infarction.

 Not increased in heart failure and coronary

diseases and hemolysis.
 NON PATHOLOGICAL CAUSES OF RAISED CK

 After heavy exercise( max level after 24 hrs. of

exercise)

 From i.m. injection of certain drugs rise may be

transient or remain upto 8 days.

 After surgery( max .between 1-2 days after

surgery)
OTHER CAUSES OF RAISED CK LEVELS
 Hypothyroidism
 Motor neuron diseases
 Hypothermia
 Hypoxia
 Convulsions
 Prolong immobilization
 Stroke
 Malignant hyperpyrexia (due to halothane,
suxamethonium)
LDH
 Catalyzes the reversible conversion of pyruvic
acid and lactic acid.
 Normal serum level is – 60-250 IU/L.
 In AMI serum levels rises within first 12-24
hours, peak at 48 hours ,return to normal in 8-
14 days.
 LDH is nonspecific for myocardial tissue
 RBCs are rich in LDH
CONTD.
 LDH -2 (H3M1)-- concentration in blood is
more than LDH-1(H4).
 Pattern is reversed in M.I. this is known as
flipped pattern.
raised in – acute leukemia
Pulmonary infarction
Renal necrosis.
Inflammatory hepatic disorders
 ISOENZYMES OF LDH
TYPE POLYPEPTIDE ELECTROPHOR TISSUE RICH IN
CHAINS ETIC MOBILITY FORM

LDH-1 (H4) FAST MOVING FOUND IN

HHHH MYOCARDIUM

LDH-2 (H3M) Kidney

HHHM

LDH-3 (H2M2) Spleen,

HHMM lung, ,pancreas,
thyroid
LDH-4 (HM3) Found in liver
HMMM

LDH-5 (M4) SLOWEST FOUND IN LIVER

MMMM MOVING
CHARACTERISTIC OF LDH ISOENZYMES
Isoenzyme Subunits Electroph activity at tissue of % in
s oretic 60ᵒ for 30 origin human
mobility min serum
at pH 8.6
LDH-1 H4 FASTEST N.D. Heart ms. 30%

LDH-2 H3M1 FASTER N.D. RBC 35%

LDH-3 H2M2 FAST P.D. Brain 20%

LDH-4 H1M3 SLOW D Liver 10%

LDH-5 M4 SLOWEST D. Skeleton 5%

ms.
CONTD.
 NORMAL SERUM LDH-2 (H3M) most
prominent isoenzymes

 After MI, LDH-1 and LDH-2 predominates.

 Acute viral hepatitis LDH-5 and LDH-4 (HM3)

predominates.
CARDIAC TROPONIN
 Complex of 3 protein subunits

 Troponin C ( calcium binding component)

 Troponin I (inhibitory component)
 Troponin T ( tropomyosin binding component)

 Located mainly in myofibrils (94-97%)

 Cytoplasmic fraction is only (3-6%)
TROPONIN I AND T
 Troponin present in skeleton muscles and cardiac
muscles but not in smooth muscles.
 Troponin I released in blood within 4 hrs. after
onset of symptoms of M.I., peak at 14-24 hrs. and
remains elevated for 3-5 days after infarction .
 Troponin T released in blood within 6 hrs. after
onset of symptoms of M.I., peak at 72 hrs. and
remains elevated for 7-14 days after infarction .
CONTD.
 Two isoforms of cardiac TnT (TnT1, TnT2)
present in adult human cardiac tissue.

 Two more isoforms are present in fetal cardiac

tissue due to alternative splicing of mRNA.

 TnT2 is 100% sensitive and 95% specific for

detection of M.I.
CONTD.

 cTnI is having 30 amino acid residues longer

than skeleton ms.

 cTnT has unique 11 amino acid sequence

(specific for cardiac ms.)

 Only cardiac specific is cTnI.

 MEASUREMENT
 Cardiac troponin I (cTnI) - by monoclonal
antibody based immunoassay
 Assay time range is 7-30 min.
 From different assay range varies.
 Troponin T - uses third generation reagent and
antibodies which shows no cross reactivity with
troponin of skeleton muscles
MYOGLOBIN
 Composed of 153 amino acids and one iron atom in
ferrous form., mol. wtg is 7,000.

 Oxygen binding low molecular wtg. protein of cardiac

and skeleton ms.

 Appears early in circulation after ms. injury.

 Increased level is seen in trauma to cardiac, skeleton ms.

or AMI.
 MYOGLOBIN

 Increased with in 1 hour after AMI, with peak

activity in 4-12 hours.

 Activity decreases after 12 hours.

 Rapidly cleared from kidney due to small size.

 Increased level leads to kidney damage.

BNP
 synthesized and secreted from ventricles, in
response with excessive stretching, present in
brain also
 Pro –BNP consist of 108 amino acid
 Cleaved at cardiac myocytes into active C-
terminal BNP(32 AA) and inactive pro BNP1-76.
Raised in ventricular dysfunction
 Use to differentiate dyspnea caused by heart ds or
lung
C-REACTIVE PROTEIN

Bind with C-polysaccharide of cell wall of

streptococcus pneumoniae.
Synthesized in parenchymal cells of liver.
Raised in M.I. after 6-12 hrs. of symptoms.
Indicator of-
screening of organic diseases.
Assessment of inflammatory diseases.
Management of neonatal septicemias.
ASPARTATE AMINO TRANSFERASE
 Or SGOT
 Needs pyridoxal phosphate as a coenzyme
 Good marker of cardiac ds.
 Normal level- 8-20 IU/L.
 Level > 350 IU/L is fatal
 Level> 150 IU/L is associated with high
mortality.
 Level< 150 IU/L is associated low mortality.
 RISK DEPEND ON SIZE OF INFARCTION
AST- ISOENZYME

m- AST (mitochondrial)- in serum

contributes less than 12% of total AST activity, but
main in liver, heart, kidney, spleen and muscles.

s –AST (cytosolic).

Isoenzymes are separated by electrophoresis,

chromatography, immunochemical methods.
CONTD.
 In AMI serum levels rises within first 12 hours,
peak at 24 hours , return to normal in 3-5 days.

 Also elevated in muscle diseases, hepatic disease.

NO RISE OF SGPT IN MYOCARDIAL

INFARCTION.
GAMMA –GLUTAMYL TRANSPEPTIDASE

 Also known as gamma glutamyl transferase.

 Catalyzes transfer of ϒ- glutamyl group from
one peptide to another peptide.
 Normal serum value-male 10-47 IU/L
Female – 7-30 IU/L.
 High activity seen in kidney, liver, lung,
pancreas and prostate.
 Heart contain very less amount.
 CONTD.
 Indicator of MI in later stages.
 Derived from vascular endothelium from
angioblastic proliferation.
Increased levels - also seen in
 Obstructive jaundice, cholangitis, cholecystitis.
 In alcoholics
 Pancreatic diseases
 Medicines ( anticonvulsant)
INDICATION OF CHECKING LIPID PROFILE
 Suspected cardiovascular diseases, CAD, PVD.

 All patients with diabetes mellitus, at least once

in 6 month.

 Thyroid, and liver diseases.

 All persons above 40 yrs.

 SERUM CHOLESTEROL

 Normal levels- 150-200mg/dl

 Level at- 220mg/dl- moderate risk
 Level at- 240mg/dl- high risk.
 Women have low level of cholesterol
 LDL cholesterol- level should be under
130mg/dl.
 Level between 130-159 are borderline.
 Level above 160mg/dl high risk.
 HDL

 HDL cholesterol – level above 60mg/dl

protect against heart disease.
 below 40mg/dl increases risk of heart
diseases
For every 1mg/dl drop in HDL risk of
heart diseases increased by 3%.
APO PROTEIN
 Apo-A-1 measures HDL cholestrol
 Apo-B measures LDL cholestrol
 Apo B: A-1 should be 0.4
 Serum triglycerides- normal level is 50-
150 mg/dl.
 CHD RISK AND LIPID PARAMETERS

Low risk Borderline High risk

risk

Total cholestrol <200 200-240 >240

(mg/dl)

LDL cholestrol <130 130-160 >160

(mg/dl)

HDL cholestrol >60 35-60 <35

(mg/dl)

Triglycerides <150 200-400 >400

(mg/dl)
CHOLINESTERASE
 Hydrolyze esters of choline to give choline and
acid.
 Types –
 True and pseudo
 Normal value- 2.17 to 5.17 IU/mL.
 Serum enzyme activity is a sensitive index for
cellular necrosis in myocardium.
OTHER TESTS
 Lab tests - liver and renal function, lipids,
glucose
 ECG
 Echo
 Cardiac catheterization
 CT/MRI chest
 Barium studies/upper GI endoscopy/abdominal
US
Thank you