clin enz 1
TRANSCRIPT
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Clinical enzymologyByDr. Saadia Anjum
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Several ways!
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Enzymes as toolsEnzymes have been used in many fields.
1. As drugs and therapeutic agents
2. as targets for therapy
3. As a diagnostic tool
4. As a prognostic tool
5. In forensic science
6. genetic investigations
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Enzymes as toolsEnzymes have been used in many fields.
7. Enzybiotics
8. Food industry
9. Textile industry
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Enzymes may be:
1.Plasma enzymes2.Cellular enzymes
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enzymes
Plasmaenzymes
found inplasma
cellularenzymes
intra-cellular
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Plasma enzymes
The enzymes which aredetectable in serum
No functionin plasma
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Plasma enzymes
Plasma specificenzymes
Non plasmaspecificenzymes
No function inplasma
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Plasma enzymes
Plasma specificenzymes
Meant for &function in
plasma
Non plasmaspecificenzymes
No function inplasma
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enzymes
Plasmaenzymes
found inplasma
cellularenzymes
intra-cellular
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1. Serum enzymes The enzymes which are detectable in
serum are derived from tissue cells and
are of two types
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1. Serum enzymes The enzymes which are detectable in
serum are derived from tissue cells and
are of two types
1. Physiologically important
2. Physiologically un-important
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1. Serum enzymes The enzymes which are detectable in
serum are derived from tissue cells and
are of two types
1. Those whose primary physiological
function and site of action is in the
plasma2. Those whose presence in serum does
not appear physiologically important
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1. Serum enzymes The enzymes which are detectable in
serum are derived from tissue cells and
are of two types
1. Those whose primary physiological
function and site of action is in the
plasma2. Those whose presence in serum does
not appear physiologically important
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1. Serum enzymes The enzymes which are detectable in
serum are derived from tissue cells and
are of two types
1. Those whose primary physiological
function and site of action is in the
plasma2. Those whose presence in serum does
not appear physiologically important
Primary Serum enzymes
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1. Serum enzymes The enzymes which are detectable in
serum are derived from tissue cells and
are of two types
1. Those whose primary physiological
function and site of action is in the
plasma2. Those whose presence in serum does
not appear physiologically important
Primary Serum enzymes
Secondary Serum enzymes
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1. Serum enzymes The enzymes which are detectable in
serum are derived from tissue cells and
are of two types
1. Those whose primary physiological
function and site of action is in the
plasma2. Those whose presence in serum does
not appear physiologically important
Primary Serum enzymes
Secondary Serum enzymes
Funcional enzymes
Non-Funcional enzymes
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enzymes
Plasmaenzymes
found inplasma
cellularenzymes
intra-cellular
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2. cellular enzymes The enzymes which are found intra-
cellularly and perform within cells
1. They may be produced by the same cell2. Or may have been prodced elsewhere
and transported to their workplace
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2. cellular enzymes The enzymes which are found intra-
cellularly and perform within cells
1. Those produced by the same cell2. Or may have been prodced elsewhere
and transported to their workplace
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2. cellular enzymes The enzymes which are found intra-
cellularly and perform within cells
1. Those produced by the same cell
2. Those that have been produced
elsewhere and have been transported
to their workplace
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Small amount ofintracellular
enzymes are detectable in theblood due to:
1. Transportation from site ofsynthesis to site of action
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Small amount ofintracellular
enzymes are detectable in theblood due to:
1. Transportation from site ofsynthesis to site of action
2. as a result ofnormal cellturnover.
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Small amount ofintracellular
enzymes are detectable in theblood due to:
3. It is now accepted that all cellsleak some of their contents
including proteins, without anysign of cell damage
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THEREFORE:
Small amount ofintracellularenzymes are normallypresent in the blood
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Enzymes in plasma
functional Non-functional
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Enzymes in plasma
functional Non-functional
E in transit
Normal cell turnover
leakage
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Enzymes in plasma
functional Non-functional
E in transit
Normal cell turnover
leakageE released by
injured cells
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E released by
injured cells
This group forms the bases of
clinical enzymology
(H 56 57)
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(Harper: pg 56, 57)
1.functional plasma enzymes
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(H 56 57)
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(Harper: pg 56, 57)
(H 56 57)
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(Harper: pg 56, 57)
(H 56 57)
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(Harper: pg 56, 57)
Enzymes in plasma
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Enzymes in plasma
(Harper)
1.functional plasma enzymes
Enzymes in plasma
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Enzymes in plasma
(Harper)
1.functional plasma enzymes
present at all times in thecirculation
Enzymes in plasma
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Enzymes in plasma(Harper)
1.functional plasma enzymes
present at all times in thecirculation
perform a physiologic functionin the blood.
En mes in plasma
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Enzymes in plasma
(Harper)
1. functional plasma enzymes
Examples:
1. lipoprotein lipase,
2. pseudo-cholinesterase,
3. Pro-enzymes of blood coagulation
4. ceruloplasmin
En mes in plasma
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Enzymes in plasma
(Harper)2. Non-functional plasma enzymes
Enzymes in plasma
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Enzymes in plasma
(Harper)2. Non-functional plasma enzymes
perform no known physiological
functions in blood
Enzymes in plasma
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Enzymes in plasma
(Harper)2. Non-functional plasma enzymes
perform no known physiological
functions in blood Arise from the routine normal
destruction of RBC, WBC, and other
cells.
Enzymes in plasma
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Enzymes in plasma
(Harper)2. Non-functional plasma enzymes
In healthy individuals, the blood
levels of these enzymes areconstant, as the rate of releasefrom aging cells into blood isequal to the rate of removal ofenzymes from blood.
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Plasma contains:
About 70 gms of proteins
Only 1 gm is enzymes
Out of this 99% is functional
enzyme!
h h d
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There are two methods to measure or
detect plasma enzymes
Th h d
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There are two methods to measure or
detect plasma enzymes
Measure the
enzyme activity
Th h d
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There are two methods to measure or
detect plasma enzymes
Measure the
enzyme activity
Measure the
enzyme
concentration
Th h d
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There are two methods to measure or
detect plasma enzymes
Measure the
enzyme activity
Less expensive
Less accurate
Measure the
enzyme
concentration
Th t th d t
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There are two methods to measure or
detect plasma enzymes
Measure the
enzyme activity
Less expensive
Less accurate
Measure the
enzyme
concentration
Expensive
accurate
Th t th d t
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There are two methods to measure or
detect plasma enzymes
Measure the
enzyme activity
Less expensive
Less accurate
Measure the
enzyme
concentration
Expensive
accurate
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The measurement of theserum levels of numerous
enzymes has been shownto be ofdiagnostic
significance.
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This is because the presence ofthese enzymes in the serum
indicates that tissue or cellulardamage has occurred resulting
in the release ofintracellularcomponents into the blood.
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Hence, when a physician
indicates that he/she isgoing to assay for liver
enzymes, the purpose is to
ascertain the potential forliver cell damage.
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It was Discovered 50 yrs ago that:
Concentration of non-functional enzymescan be used as markers for clinical diagnosis
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It was Discovered 50 yrs ago that:
Concentration of non-functional enzymescan be used as markers for clinical diagnosis
Changes in concentration of these can help
to
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It was Discovered 50 yrs ago that:
Concentration of non-functional enzymescan be used as markers for clinical diagnosis
Changes in concentration of these can help
to
1. Detect cell and tissue damage
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It was Discovered 50 yrs ago that:
Concentration of non-functional enzymescan be used as markers for clinical diagnosis
Changes in concentration of these can help
to
1. Detect cell and tissue damage
2. Localize cell and tissue damage
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It was Discovered 50 yrs ago that:
Concentration of non-functional enzymescan be used as markers for clinical diagnosis
Changes in concentration of these can help
to
1. Detect cell and tissue damage
2. Localize cell and tissue damage3. Monitor treatment efficacy
Definitions
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Definitions
A biomarker is a substance used as an
indicator of a biological state.
Cardiac markers are substances
released from heart muscle when it is
damaged as a result of myocardialinfarction.
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DISORDERS DIAGNOSED BY
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70
DISORDERS DIAGNOSED BYENZYMES
1) CardiacDisorders.
2) HepaticDisorders.
3)Skeletal MuscleDisorders.
4) Bone Disorders.
5) Pancreatic
Disorders.
6) Salivary glanddiseae (Mumps)
7) Malignancies
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Intracellular Distribution of DiagnosticEnzymes
Liver Heart Pancreas SalivaryGlands
Bone Muscle BiliaryTract
Prostate
LD5ALTAST
LD1ASTCK
MgTpn
LPSAMS
AMS ALP CK ALPGGT
ACP
1 Cardiac Disorders:
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1. Cardiac Disorders:
e.g. Acute Myocardial Infarction (AMI).
1) The myocardium becomes ischemic andundergoes necrosis.
2) Cellular contents are released into thecirculation. Blood levels of the followingenzymes increase:
AST LDH1 CK
Tpn Mg
2 H i Di d
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73
2. Hepatic Disorders
a) Hepatocellular Disorders:(1) Viral hepatitis: Hepatitis B & Hepatitis C.
(2) Toxic hepatitis: caused by chemicals &
ToxinsIncreased levels of the following enzymes :
ALT AST LDH5
2 H ti Di d
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b) Biliary tract disorders:
The plasma levels of the following
enzymes increase:
ALP GGT
2. Hepatic Disorders
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3. Skeletal Muscle Disorders
Muscle dystrophy. Muscle trauma. Muscle hypoxia. Frequent I.M Injections. The plasma levels of thefollowing enzymes increase:
CK AST
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76
4. Bone Disorders:
1)Pagets Bone Disease: caused byincreased osteoclastic activity.
2) Rickets
3) Osteomalacia:The plasma levels of the following
enzyme increase:
ALP
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5. Acute Pancreatitis
The plasma levels of the followingenzymes increase:
Lipase AMS
6 Salivary Gland
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78
6. Salivary GlandInflammation:
In Mumps:
The levels of -Amylase (AMS)is significantly increased
l
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79
7. Malignancies
a) Plasma (Acid phosphatase) ACPlevels increase in:
Prostatic carcinoma. Bone metastatic carcinoma
M l
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80
b) Plasma levels of Alkalinephosphatase (ALP) increase in:
Pancreatic carcinoma.
Bile duct carcinoma.
Liver metastasis.
7. Malignancies
7 M li i
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c) Plasma levels of Total Lactatedehydrogenase (LDH) increase
in: Leukemia Lymphomas. Liver metastasis.
7. Malignancies
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Clinical
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Clinical
Applications ofEnzymes
Clinical examples
and case studies.
Case
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Case
presented A 36-year old man was admitted to a
hospital following episodes of nausea,vomiting, and general malaise.
His urine was darker than usual.
Upon examination it was discovered that
his liver was enlarged and tender topalpation.
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Hepatitis?
A 36-year old man was admitted to ahospital following episodes of nausea,vomiting, and general malaise.
His urine was darker than usual.
Upon examination it was discovered that
his liver was enlarged and tender topalpation.
Li f ti t t b l
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Liver function tests were abnormal;plasma ALT was 1500 IU/L (Alanine
aminotransferase 6.0 21 IU/L); AST was400 IU/L (Aspartate aminotransferase 7.0 20 IU/L).
Li f ti t t b l
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Liver function tests were abnormal;plasma ALT was 1500 IU/L (Alanine
aminotransferase 6.0 21 U/L); AST was400 IU/L (Aspartate aminotransferase 7.0 20 U/L).
During the next 24 hours the mandeveloped jaundice, and his plasmatotal bilirubin was 9.0 mg/dL (0.2 1mg/dL).
Liver function tests were abnormal
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Liver function tests were abnormal;plasma ALT was 1500 IU/L (Alanine
aminotransferase 6.0 21 U/L); AST was400 IU/L (Aspartate aminotransferase 7.0 20 U/L).
During the next 24 hours the mandeveloped jaundice, and his plasmatotal bilirubin was 9.0 mg/dL (0.2 1mg/dL).
A diagnosis of hepatitis was made.
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Isoenzymes
found in
plasma
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Isoenzymes
Multiple forms of same
enzyme
I
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Isozymes
Multiple forms of same enzyme
Catalyze same reaction
Differ in molecular weight ,structureand charge
Have different Km for same substrate Important in diagnosis of diseases
109
Isozyme or isoenzymes
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Isozyme or isoenzymes
Isozyme or isoenzymes
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Isozyme or isoenzymes
are enzymes that differ in aminoacid sequence but catalyze the
same chemical reaction
Isozyme or isoenzymes
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Isozyme or isoenzymes
are enzymes that differ in aminoacid sequence but catalyze the
same chemical reaction
They are differentiated by
variations in physical properties.
Isozyme or isoenzymes
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They catalyze the samereaction but migrate
differently on
electrophoresis
Isozyme or isoenzymes
What is electrophoresis?
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What is electrophoresis?
What is electrophoresis?
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What is electrophoresis?
Electrophoresis is a
separation technique thatis based on the mobility of
ions in an electric field.
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Example of isoenzymes
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Example of isoenzymes:
1. Alkaline Phosphatase
2. Lactate Dehydrogenase Test
3. Creatinine phospho kinase
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halflife
t1/2
What is half life?
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What is half life?
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the time it takes for the blood plasma
concentration of a substance to half ("plasmahalf-life").
What is half life?
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the time it takes for the blood plasma
concentration of a substance to half ("plasmahalf-life").
The period of time required for the conc. or
amount of drug in the body to be reduced toexactly one-half of a given conc. or amount.
What is half life?
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the time it takes for the blood plasma
concentration of a substance to half ("plasmahalf-life").
The period of time required for the conc. or
amount of drug in the body to be reduced toexactly one-half of a given conc. or amount.
usually denoted by the abbreviation t1/2
What is half life?
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the time it takes for the blood plasma
concentration of a substance to half ("plasmahalf-life").
The period of time required for the conc. or
amount of drug in the body to be reduced toexactly one-half of a given conc. or amount.
usually denoted by the abbreviation t1/2
The half life ofcardiac LD is about three days,
while the half life ofLD released from skeletal
muscle and liver is about ten hours
LDH exists in 5 forms, which differ
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slightly in structure. All of these can
be measured in the blood. LDH-1 heart muscle , RBC
LDH-2 white blood cells
LDH-3 lung
LDH-4 kidney, placenta, pancreas
LDH-5 liver , skeletal muscle
Greater-than-normal LDH levels may
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suggest:
Heart attack
Hemolytic
anemia
Hypotension
Infectious
mononucleosis Liver disease such
as hepatitis
Muscle injuryMuscular dystrophy
Pancreatitis
Lung tissue death
Stroke
Ischemic
cardiomyopathy
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Cardiac Enzyme Studies
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Cardiac Enzyme Studies
Cardiac Enzyme Studies
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Cardiac Enzyme Studies
Cardiac enzyme studies measurethe levels of enzymes and
proteins that are linked with
injury of the heart muscle.
Cardiac Enzyme Studies
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Cardiac Enzyme Studies
Cardiac enzyme studies measurethe levels of enzymes and
proteins that are linked with
injury of the heart muscle.
Myocardial
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infarction
Classical definition of myocardial
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y
infarction ---WHO
Presence of at least two of the
following criteria:
1. Typical history
2. Enzyme increase typical of
myocardial necrosis
3. ECG characteristic of MI
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BIOCHEMICAL MAKERS OF
CARDIAC DISEASE
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BIOCHEMICAL MAKERS OF
CARDIAC DISEASE
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BIOCHEMICAL MAKERS OF
CARDIAC DISEASE
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BIOCHEMICAL MAKERS OF
CARDIAC DISEASE
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BIOCHEMICAL MAKERS OF
CARDIAC DISEASE
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diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes
diagnosis
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Typical history
ECG findings
Cardiac enzymes
diagnosis
diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes
diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes
diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes
diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes
diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes
diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes
diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes
diagnosis
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diagnosis
Typical history
ECG findings
Cardiac enzymes / markers
AST LD1
CK
Mgb troponin
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AST LD1 CK
Mgb troponin
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myoglobinl l l i ht h t i f d i
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a low molecular weight heme protein found in
cardiac and skeletal muscle,
myoglobinl l l i ht h t i f d i
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a low molecular weight heme protein found in
cardiac and skeletal muscle,a low molecular weight hemeprotein found in cardiac and
skeletal muscle,
myoglobinl l l i ht h t i f d i
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a low molecular weight heme protein found in
cardiac and skeletal muscle,It may appear in the blood inabnormal levels as early as 1
to 3 hours after onset of
myocardial ischemia.
myoglobinl l l i ht h t i f d i
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a low molecular weight heme protein found in
cardiac and skeletal muscle,is valuable in the earlyevaluation of chest pain
patients
myoglobinl l l i ht h t i f d i
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a low molecular weight heme protein found in
cardiac and skeletal muscle,Myoglobin is not specific tocardiac muscle
myoglobinl l l i ht h t i f d i
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a low molecular weight heme protein found in
cardiac and skeletal muscle,Myoglobin is not specific tocardiac muscle
it is useful in the detection of
MI in the absence of skeletal
muscle trauma
LDH
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LDH
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AST
LDH
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LDH in myocardial disease
LDH i f ll i di l
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LDH may rise following myocardial
infarction and in myocarditis.
LDH in myocardial disease
F ll i di l i f i
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Following a myocardial infarction:
levels increase after 12 to 24 hours
peak at 48 to 72 hours
return to normal after 8 to 10 days,providing there are no complications
the peak reached is from two to ten times
the upper reference limitthe normal plasma LD1:LD2 isoenzyme
ratio of is reversed
What is creatine kinase?
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What is creatine kinase?
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An enzyme
What is creatine kinase?
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An enzyme
Can remove ~P from creatineP
and paste it on ADP ATP
What is creatine kinase?
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An enzyme
Can remove ~P from creatineP
and paste it on ADP ATP Found in tissues that require lots
ofATP
What is creatine kinase?
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An enzyme
Can remove ~P from creatineP
and paste it on ADP ATP Found in tissues that require lots
ofATP Starts its job when ATP gets
depleted
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CPK levels
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CPK levels
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When the total CPK level is very high,
it usually means there has been injury
or stress to the heart, the brain, or
muscle tissue.
CPK isoenzymes test
Th CPK i t t
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The CPK isoenzymes test measures
the different forms of creatinephosphokinase (CPK) in the blood.
This test is done if a CPK test revealselevated levels.
CPK isoenzyme testing can helppinpoint the exact source of the
damaged tissue.
CPK is made of three slightly different
substances
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substances
CPK-1 (also called CPK-BB) is found mostly inthe brain and lungs
CPK-2 (also called CPK-MB) is found mostly in
the heart CPK-3 (also called CPK-MM) is found mostly in
skeletal muscle
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Troponin I
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in acute MI. Cardiactroponins
have become the goldstandard
Troponin
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Troponin actually refers to threeproteins the body produces that
are classed as I, C and T.
These are present in cardiac
muscles and skeletal muscles, and
most times they are at extremely
low levels.
Troponin I
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Cardiac troponins T and I are
highly sensitive and specific
for cardiac damage. Troponin I
and T are of equal clinical
value
Troponin
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Cardiac troponins elevaterelatively early
have the most favorableprofile with respect to both
sensitivity andspecificity forcardiac necrosis
Troponin
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located at regular intervals along thelength of actin filaments
play a key role in muscle contraction.
Troponin I (TnI) and T (TnT) have
cardiac specific isoforms and are used
for assessing cardiac injury.
Troponin
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located at regular intervals along the
l th f ti fil t
Troponin
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play a key role in muscle contraction.
Troponin I (TnI) and T (TnT) have cardiac
specific isoforms and are used for assessing
cardiac injury
Troponin
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Apart from their proximity to each other in the
troponin complex, troponin T, C and I are
otherwise unrelated proteins
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Troponin
a myocardial
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y
specific myo-filament
component.
Troponin
relatively early
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relatively early
release from dead
cells.
Troponin
The slower release of
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the myofilamentcomponent provides
for detection for aslong as a week
following MI.
Troponinis released as early as
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y
CK-MB and remainselevated for as long as
LDH
Troponin
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has the potential toserve as a sole
marker for MI.
Troponin I & Ta myocardial
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y
specific myo-filament
component.
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Diagnostic enzymes
Cardiac enzymes
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