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Pemeriksaan Laboratorium pada kel jantung

Syukrini Bahri

ACUTE CORONARY SYNDROME (ACS)Ischemic heart diseases (acute coronary syndrome) terdiri dari 1-Angina 2-Unstable angina 3-Infark Miocardial jika berat kematian otot jantung

Penyebab Utama : atherosclerosis.

Faktor risiko : Umur, Gender, riw keluarga, hiperlipidemia, rokok, Hipertensi, DM, Obesitas, homosistein yang tinggi

CRITERIA FOR DIAGNOSIS OF ACSKriteria D/: Gambaran klinis: Nyeri dadaPerubahan ECG sesuai dengan acute MIPeningkatan serum cardiac MARKERSDiagnosis : paling tidak 2 dari kriteria diatas

CARDIAC MARKERS HARUS:

Located in the myocardium.Dilepas saat ada trauma pada jantung, misal pada: Myocardial infarction Non-Q-wave infarction Unstable angina pectoris kondisi lain yang pada otot jantung (trauma, cardiac surgery, myocarditis etc.)Dapat diperiksa dalam darahScand J Clin Lab Inves 1999;59 (Suppl 230):113-123 Found in high concentrations in myocardium Released rapidly after the onset of pain Not be found in other tissues even in trace amounts or under pathological conditions Have a convenient diagnostic time window Reflect as much as possible the evaluation of myocardial damage

An Ideal Marker for Myocardial InjuryWould Be

Sel Otot JantungSize and subcellular distribution of myocardial proteins determines time course of biomarker appearance in the general circulation

CLASSIFICATION OF LABORATORY TESTS IN CARDIAC DISEASEMarkers of cardiac tissue damage

Markers of myocardial function

Cardiovascular risk factor markers

Genetic analysis for candidate genes or risk factorsPATHOPHYSIOLOGY OF ACSProinflammatory CytokinesIL-6Plaque DestabilizationMPOPlaque RupturesCD40LAcute Phase Reactants hs-CRP IschemiaIMANecrosis cTnTcTnIMyocardial DysfunctionBNPNT-proBNP

BIOCHEMICAL MARKERS IN MYOCARDIAL ISCHAEMIA / NECROSISRECENTCK-MB (mass)c.Troponins (I or T)MyoglobinTraditionalAST activityLDH activityLDH isoenzymesCK-TotalCK-MB activityCK-Isoenzymes

FUTURE:Ischaemia Modified AlbuminGlycogen Phosphorylase BBFatty Acid binding ProteinHighly sensitive CRP.ASPARATATE AMINOTRANFERASE (AST)

enzyme : catalysis the transfer of amino group from amino acid to keto acid which is important for providing keto acid for tricarboxylic acid cycle (energy production) and providing amino acid for urea cycle.Dijumpai di jantung, liver, otot rangka, ginjal dan eritrosit.AST meningkat setelah MIDapat juga meningkat pada : Kelainan hati : hepatitis, cirosis, keganasan Kelainan otot : muskular distrofi, dermatomiositisLACTATE DEHYDROGENASE (LDH)

LDH is a hydrogen transfer enzyme that catalysis the oxidation of L-Lactate to Pyruvate.Terdiri dari 2 sub unit : Otot dan JantungTerdiri dari 5 isoenzim: LD-1 (4 H subunits) LD-2 (3 H and 1 M sumunits) LD-3 (2 H and 2 M sumunits) LD-4 (1 H and 3 M sumunits) LD-5 (4 M subunits)LDHLDH total dan LDH isoenzymes meningkat pada kerusakan otot jantung peningkatan LD-1 terjadi 10 12 jam setelah acute myocardial infarction, puncak hari ke 2 dan kembali normal dalam 7-10 hariBiasanya kadar LD-2 dalam darah lebih tinggi dari LD-1. pada IMA LD-1 lebih dari LD-2 (ratio > 1) disebut "Flipped Ratio".sensitivity and specificity :75% - 90% utk D/ IMA.

CREATINE KINASECK is a dimeric enzyme that regulates high energy phosphate production and utilization in contractile tissues. Terdiri dari 2 subunits:Subunit M subunit B3 isoenzymes:CK1 (CK-BB): dijumpai di Otak CK2 (CK-MB): 20 30 % dari total CK pada kelainan otot jantung CK3 (CK-MM): 98% otot rangka dan 1% otot jantung.

CREATINE KINASENORMAL VALUES:

Vary according to agesexracephysical conditionmuscle mass

PATHOLOGICAL INCREASES:

Myocardial infarction or injurySkeletal muscle injury or diseaseHypothyroidismIM injectionsGeneralised convulsionsCerebral injuryMalignant hyperpyrexiaProlonged hypothermiaCREATINE KINASE: CK-MB pada populasi normal CK-MB < 6% Total CK Sensitive marker with rapid rise & fall: Serum CK-MB meningkat dalam 2~8 jam setelah AMI. CK-MB kembali normal 2~3 hari setelah serangan lebih specific dari CK total tp mempunyai keterbatasan: tinggi palsu pada keadaan: -perioperative patients without cardiac injury -Skeletal muscle injury -Marathon runners -Chronic renal failure -HypothyroidismMB Index = (CKMB /total CK) x 100Combined use with MB Index helps to rule-out patients with skeletal muscle injuryCK-MB RELATIVE INDEX AND CK-MB mass:

CK-MB MASS: Measure the concentration of CK-MB protein is now available using sandwich technique with a detection limit < 1g/dl. More sensitive than measurement of activity. MB Index = (CKMB /total CK) x 10 Combined use with MB Index helps to rule-out patients with skeletal muscle injury MYOGLOBIN (Mb)Low MW proteinSkeletal & cardiac muscle Mb identicalKadar dalam Serum meningkat dalam 2 jam setelah kerusakan otot Puncaknya pada jam 6 9Normal dalam 24 36 jamExcellent NEGATIVE predictor of myocardial injury2 samples 2 4 hours apart with no rise in levels virtually excludes AMIRapid, quantitative serum immunoassaysCARDIAC TROPONINSTerdiri dari 3 subunits : troponin C, I, and T.The complex regulates the contraction of striated muscle.TnC berikatan dengan ion calcium.TnI berikatan dengan actin dan menghambat interaksi actin-myosin TnT berikatan dengan tropomyosin, menempel pada filamen.THE TROPONIN REGULATORY COMPLEX

1. Cardiac Troponin I (cTnl) is a cardiac muscle protein with a molecular weight of 24 kilo-Daltons.2. The human cTnl has a additional amino acid residues on its N-terminal that are not exist on the skeletal form.3. The half life of cTnI is estimated to be 2~4 hours.4. Serum increase is found between 2-8 hours and returns to normal 7~10 days after AMI.5. Cardiac TnI levels provide useful prognostic information.6. Reference range: cTnI