Total Thiols and MDA Levels in Patients with Acute Myocardial Infarction Before and After Reperfusion Therapy

Background: Reactive oxygen species have been implicated in the pathogenesis of ischemic and reperfusion injury. In the current work we have measured malondialdehyde (MDA), total thiols, total CK, CK-MB and AST in ECG proven acute myocardial infarction (AMI) patients immediately after admission and 24 hours after administration of thrombolytic agent streptokinase, and in healthy controls. Methods: Blood samples from 44 AMI patients and 25 age and sex matched healthy controls were obtained and analyzed for MDA, total thiols using spectrophotometric methods and cardiac enzymes CK, CK-MB and AST using automated analyzer. Results: We have found significant increase in MDA, CPK, CK-MB, AST (p< 0.001) and significant decrease in total thiols (p<0.001) in AMI patients after thrombolytic therapy compared to values at admission, and healthy controls. MDA correlated negatively with total thiols (r = - 0.333, p<0.05) and positively with CK-MB (r = 0.491, p<0.01) in AMI patients after thrombolytic therapy. Conclusions: Reperfusion following thrombolytic therapy increases reactive oxygen species with concomitant decrease in antioxidant total thiols

Hubungan antara Kadar Creatine Kinase-MB dengan Mortalitas Pasien Infark Miokard Akut Selama Perawatan di RS. Dr. Wahidin Sudirohusodo, Makasar

Increase of CK-MB level is associated with myocardial infarction size and severity. The aim of this study is to evaluate the correlation between the admission CK-MB level of acute myocardial patients and the in-hospital mortality. Secondary data of 60 acute myocardial infarction patientshospitalized in Intensive Cardiac Care Unit of Dr.Wahidin Sudirohusodo Hospital Makassar from June 2010 to July 2011 were taken. Admission CK-MB levels between the period of 3 hours to 1 week after onset were then analyzed. The mean of admission CK-MB level in the in-hospital survived and non survived acute myocardial infarction patients were 89.52+121.59 U/l and 202.88+192.75 U/l respectively (Mann Whitney Test, p=0.005). There were significant mortality rate difference amongall CK-MB quartiles with mortality rate 13.3%, 6.7%, 40% and 46.7 % in 1st, 2nd, 3rd, and 4th quartile respectively (Chi Square Test, p=0.031) but the odds ratio of mortality between quartiles were not different.. There was significant difference of admission CK-MB levels in the in-hospitalsurvived and non survived acute myocardial infarction.Keywords : CK-MB, myocardial infarction, mortalityAbstrakPeningkatan kadar CK-MB pada infark miokard akut menunjukkan luas dan parahnya penyakit. Penelitian ini bertujuan untuk menilai hubungan antara kadar CK-MB pada pasien infark miokard akut saat masuk rumah sakit dan mortalitas pasien selama perawatan di rumah sakit.. Data sekunder diambil dari rekam medis 60 pasien infark miokard akut yang dirawat di Unit Perawatan Jantung Intensif Rumah Sakit Dr. Wahidin Sudirohusodo, Makassar periode Juli 2010 hingga Juni 2011. Kadar CK-MB diperoleh saat masuk rumah sakit antara 3 jam hingga 1 minggu setelah onset. Rerata kadar CK-MB pada penderita infark miokard akut yang survive dan meninggal selama perawatan adalah 89,52+121,59 U/l dan 202,88+192,75U/l (Uji Mann Whitney, p=0,005). Ditemukan perbedaantingkat mortalitas yang bermakna antar kuartil CK-MB masing-masing 13,3%, 6,7%, 40% dan 46,7% pada kuartil 1, 2, 3 dan 4 berturut-turut ( Uji Chi Square, p=0,031) tetapi risiko mortalitas antar kuartil tidak berbeda bermakna. Ditemukan perbedaan bermakna kadar CK-MB pada pasien yang survive maupun yang meninggal selama perawatan.Kata kunci : CK-MB, infark miokard, mortalita

Source, triggers and clinical implications of hyperlactemia in patients undergoing mitral valve surgery using Custodiol cardioplegia

Postoperative blood hyperlactaemia is an indicator of organ anaerobic metabolism and is associated with morbidity after cardiac surgery. This prospective study aims to explore the source, triggers and clinical implications for hyperlactaemia in patients undergoing mitral valve surgery using Custodiol cardioplegia. Methods: Twenty consecutive elective patients undergoing open-heart surgery for mitral valve repair/replacement using Custodiol (based on Bretschneider’s HTK-solution) cardioplegia were recruited. A serial measurement of arterial blood lactate was performed. Pre-, intra-and post-operative clinical data were obtained and cardiac injury was determined by serial plasma measurement of postoperative release of CK-MB. Results: There were no in-hospital deaths. Most of the patients (n = 16) needed intraoperative direct current cardioversion to treat ventricular arrhythmias or post-operative vasopressors (n = 13) to treat vasoplegia. There was significant cardiac injury as determined by the marked increase of serum CK-MB (p &lt; 0.05). A significant (p &lt; 0.05) increase in blood lactate was found to follow a biphasic profile. The first peak (from 0.54 ± 0.03 to 1.3 ± 0.07 mM) was observed immediately following the release of the aortic cross-clamp and remained high for 1 hour. This was followed by a second peak at 12 hours post-operatively (1.9 ± 0.2 mM). The second rise in lactate was seen only in patients that required post-operative vasopressors (1.3 ± 0.2 vs 2.2 ±0.3 mM, p &lt; 0.05), in whom a significant late decrease in CVP was also observed (12.2 ± 1.0 to 7.7 ± 1.0 for 1 and 12 hours postoperative, respectively). Hyperlactaemia did not correlate with any other variables including CK-MB levels, cross-clamp or cardiopulmonary bypass time. Conclusions: In patients undergoing mitral valve surgery with Custodiol cardioplegia there is marked cardiac injury and a biphasic release of blood lactate. The initial peak in lactate occurs immediately following unclamping the aorta and is likely to be of organ (e.g. heart and lungs) origin. A second peak is only seen in patients requiring postoperative vasopressors to treat vasoplegia. Hyperlactaemia following mitral valve surgery with Custodiol cardioplegia does not seem to be related to myocardial injury as expressed by CK-MB release

Cardiac biomarkers in premature calves with respiratory distress syndrome

The aim of this study was to determine the clinical relevance of cardiac biomarkers [troponin I and T, creatine kinase-MB fraction (CK-MB) and lactate dehydrogenase (LDH)] in premature calves with respiratory distress syndrome. Seventy premature calves were admitted to the clinic within 24 h after birth. Respiratory distress syndrome was diagnosed in premature calves by clinical examination and venous blood gas analysis. Ten healthy calves, aged 5 days, were used as control. Cardiac troponin I and T were analysed using ELISA and ELFA, respectively. Serum CK-MB and LDH were also analysed in an automatic analyser. The calves had low venous pH, pO2, O2 saturation and high pCO2 values consistent with dyspnoea, hypoxaemia, and inadequate oxygen delivery. Mean serum troponin I, troponin T, CK-MB and LDH levels were increased in the premature calves compared to the control group. In conclusion, the results in this study demonstrated that serum CK-MB, troponin I and troponin T concentrations could be used for evaluating myocardial injury in premature calves with respiratory distress syndrome

Incidence, Predictors, and Significance of Abnormal Cardiac Enzyme Rise in Patients Treated With Bypass Surgery in the Arterial Revascularization Therapies Study (ARTS)

BACKGROUND: Although it has been suggested that elevation of CK-MB after percutaneous coronary intervention is associated with adverse clinical outcomes, limited data are available in the setting of coronary bypass grafting. The aim of the present study was to determine the incidence, predictors, and prognostic significance of CK-MB elevation following multivessel coronary bypass grafting (CABG). METHODS AND RESULTS: The population comprises 496 patients with multivessel coronary disease assigned to CABG in the Arterial Revascularization Therapies Study (ARTS). CK-MB was prospectively measured at 6, 12, and 18 hours after the procedure. Thirty-day and 1-year clinical follow-up were performed. Abnormal CK-MB elevation occurred in 61.9% of the patients. Patients with increased cardiac-enzyme levels after CABG were at increased risk of both death and repeat myocardial infarction within the first 30 days (P=0.001). CK-MB elevation was also independently related to late adverse outcome (P=0.009, OR=0.64). CONCLUSIONS: Increased concentrations of CK-MB, which are often dismissed as inconsequential in the setting of multivessel CABG, appear to occur very frequently and are associated with a significant increase in both repeat myocardial infarction and death beyond the immediate perioperative period

Differentiating muscle damage from myocardial injury by meaans of the serum creatinine kinase (CK) isoenzyme MB mass measurement/total CK activity ratio

We immunoenzymometrically measured creatine kinase (CK) isoenzyme MB in extracts of myocardium and in homogenates of five different skeletal muscles. CK-MB concentrations in the former averaged 80.9 micrograms/g wet tissue; in the skeletal muscles it varied widely, being (e.g.) 25-fold greater in diaphragm than in psoas. CK-MB in skeletal muscles ranged from 0.9 to 44 ng/U of total CK; the mean for myocardium was 202 ng/U. In sera from 10 trauma and 36 burn patients without myocardial involvement, maximum ratios for CK-MB mass/total CK activity averaged 7 (SEM 1) ng/U and 18 (SEM 6) ng/U, respectively. Except for an infant (220 ng/U), the highest ratio we found for serum after muscular damage was 38 ng/U. In contrast, the mean maximum ratio determined in 23 cases of acute myocardial infarction exceeded 200 ng/U. Among seven determinations performed 8 to 32 h after onset of symptoms, each infarct patient demonstrated at least one ratio greater than or equal to 110 ng/U. Ratios observed after infarct were unrelated to treatment received during the acute phase. We propose a CK-MB/total CK ratio of 80 ng/U as the cutoff value for differentiating myocardial necrosis from muscular injury

Effect of Staged Preconditioning on BiochemicalMarkers in the Patients Undergoing Coronary Artery Bypass Grafting

The present study has investigated the effectiveness of staged-preconditioning, in both remote and target organs. After IP the myocardial release of the biochemicalmarkers including, creatine phosphokinase (CPK), cardiac creatine kinase (CK-MB), cardiac troponin T (cTnT) and lactate dehydrogenase (LDH) were evaluated in patients who underwent CABG, with and without staged-preconditioning. Sixty-one patients entered the study; there were 32 patients in the staged-preconditioning group and 29 patients in the control group. All patients underwent on-pump CABG using cardiopulmonary bypass (CPB) techniques. In the staged-preconditioning group, patients underwent two stages of IP on remote (upper limb) and target organs. Each stage of preconditioning was carried out by 3 cycles of ischemia and then reperfusion. Serum levels of biochemical markers were immediately measured postoperatively at 24, 48 and 72 h. Serum CK-MB, CPK and LDH levels were significantly lower in the staged-preconditioning group than in the control group. The CK-MB release in the staged-preconditioning patients reduced by 51% in comparison with controls over 72 h after CABG. These results suggest that myocardial injury was attenuated by the effect of three rounds of both remote and target organ IP

Which diagnostic tests are most useful in a chest pain unit protocol?

Background The chest pain unit (CPU) provides rapid diagnostic assessment for patients with acute, undifferentiated chest pain, using a combination of electrocardiographic (ECG) recording, biochemical markers and provocative cardiac testing. We aimed to identify which elements of a CPU protocol were most diagnostically and prognostically useful. Methods The Northern General Hospital CPU uses 2–6 hours of serial ECG / ST segment monitoring, CK-MB(mass) on arrival and at least two hours later, troponin T at least six hours after worst pain and exercise treadmill testing. Data were prospectively collected over an eighteen-month period from patients managed on the CPU. Patients discharged after CPU assessment were invited to attend a follow-up appointment 72 hours later for ECG and troponin T measurement. Hospital records of all patients were reviewed to identify adverse cardiac events over the subsequent six months. Diagnostic accuracy of each test was estimated by calculating sensitivity and specificity for: 1) acute coronary syndrome (ACS) with clinical myocardial infarction and 2) ACS with myocyte necrosis. Prognostic value was estimated by calculating the relative risk of an adverse cardiac event following a positive result. Results Of the 706 patients, 30 (4.2%) were diagnosed as ACS with myocardial infarction, 30 (4.2%) as ACS with myocyte necrosis, and 32 (4.5%) suffered an adverse cardiac event. Sensitivities for ACS with myocardial infarction and myocyte necrosis respectively were: serial ECG / ST segment monitoring 33% and 23%; CK-MB(mass) 96% and 63%; troponin T (using 0.03 ng/ml threshold) 96% and 90%. The only test that added useful prognostic information was exercise treadmill testing (relative risk 6 for cardiac death, non-fatal myocardial infarction or arrhythmia over six months). Conclusion Serial ECG / ST monitoring, as used in our protocol, adds little diagnostic or prognostic value in patients with a normal or non-diagnostic initial ECG. CK-MB(mass) can rule out ACS with clinical myocardial infarction but not myocyte necrosis(defined as a troponin elevation without myocardial infarction). Using a low threshold for positivity for troponin T improves sensitivity of this test for myocardial infarction and myocardial necrosis. Exercise treadmill testing predicts subsequent adverse cardiac events

Peak CK-MB has a strong association with chronic scar size and wall motion abnormalities after revascularized non-transmural myocardial infarction - a prospective CMR study

Background: Large myocardial infarction (MI) is associated with adverse left ventricular (LV) remodeling (LVR). We studied the nature of LVR, with specific attention to non-transmural MIs, and the association of peak CK-MB with recovery and chronic phase scar size and LVR. Methods: Altogether 41 patients underwent prospectively repeated cardiovascular magnetic resonance at a median of 22 (interquartile range 9-29) days and 10 (8-16) months after the first revascularized MI. Transmural MI was defined as >= 75% enhancement in at least one myocardial segment. Results: Peak CK-MB was 86 (40-216) mu g/L in median, while recovery and chronic phase scar size were 13 (3-23) % and 8 (2-19) %. Altogether 33 patients (81%) had a non-transmural MI. Peak CK-MB had a strong correlation with recovery and chronic scar size (r >= 0.80 for all, r >= 0.74 for non-transmural MIs; p = 0.75 for all, r >= 0.73 for non-transmural MIs; p <0.001). There was proportional scar size and LV mass resorption of 26% (0-50%) and 6% (-2-14%) in median. Young age (<60 years, median) was associated with greater LV mass resorption (median 9% vs. 1%, p = 0.007). Conclusions: Peak CK-MB has a strong association with chronic scar size and wall motion abnormalities after revascularized non-transmural MI. Considerable infarct resorption happens after the first-month recovery phase. LV mass resorption is related to age, being more common in younger patients.Peer reviewe