Hostname: page-component-78c5997874-v9fdk Total loading time: 0 Render date: 2024-11-18T16:47:25.542Z Has data issue: false hasContentIssue false
  • English
  • Français

Diagnostic parameters of CK–MB and myoglobin related to chest pain duration

Published online by Cambridge University Press:  21 May 2015

Grant Innes ,
James Christenson ,
W. Douglas Weaver ,
Tiepu Liu ,
James Hoekstra ,
Nathan Every ,
Raymond E. Jackson ,
Paul Frederick  and
W. Brian Gibler
Grant Innes*
Affiliation:
St. Paul’s Hospital and the University of British Columbia, Vancouver, BC Royal Columbian Hospital, New Westminster, BC
James Christenson
Affiliation:
St. Paul’s Hospital and the University of British Columbia, Vancouver, BC
W. Douglas Weaver
Affiliation:
Henry Ford Heart and Vascular Institute, Detroit, Mich.
Tiepu Liu
Affiliation:
University of Cincinnati Medical Centre, Cincinnati, Ohio
James Hoekstra
Affiliation:
Ohio State University, Columbus, Ohio
Nathan Every
Affiliation:
University of Washington, Seattle, Wash.
Raymond E. Jackson
Affiliation:
Willian Beaumont Hospital, Royal Oak, Mich.
Paul Frederick
Affiliation:
University of Cincinnati Medical Centre, Cincinnati, Ohio
W. Brian Gibler
Affiliation:
University of Cincinnati Medical Centre, Cincinnati, Ohio
*
Department of Emergency Medicine, St. Paul’s Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6; 604 806-8980, fax 801 659-0455, ginnes@interchange.ubc.ca

Abstract:

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

Cardiac marker sensitivity depends on chest pain duration at the time of sampling. Our objective was to estimate the sensitivity, specificity, and likelihood ratios of early CK–MB and myoglobin assays in patients presenting to the emergency department (ED) with nondiagnostic ECGs, stratified by the duration of ongoing chest pain at the time of ED assessment.

Methods:

This was a prospective observational study carried out in 10 US and 2 Canadian EDs. Patients >25 years of age with ongoing chest pain and nondiagnostic ECGs were stratified by pain duration (0–4 h, 4–8 h, 8–12 h, >12 h). CK–MB and myoglobin assays were drawn at T = 0 (ED assessment) and T = 1 hr. Patients were followed for 7–14 days to identify all cases of acute myocardial infarction (AMI). ED test results were correlated with patient outcomes.

Results:

Of 5005 eligible patients, 565 had AMI. Pain duration was 0–4 h in 3014 patients, 4–8 h in 961, 8–12 h in 487, and >12 h in 543. Marker sensitivity increased with pain duration, ranging from 28%–77% for CK–MB and 39%–73% for myoglobin. The maximal sensitivity achieved by a T = 0 assay was 73%, and this was in patients with 8–12 or >12 h of ongoing pain. No combination of tests achieved 90% sensitivity in any pain duration strata.

Conclusions:

Regardless of chest pain duration, single assays and early serial markers (0+1 hr) do not rule out AMI; therefore, serial assays over longer observation periods are required. Likelihood ratios derived in this study will help physicians who use Bayesian analysis to determine post-test AMI likelihood in patients with chest pain.

Keywords

creatine kinasemyoglobincardiac markermyocardial infarctiontroponinCK-MBdiagnosis
Type
EM Advances • Innovations En MU
Information
Canadian Journal of Emergency Medicine , Volume 4 , Issue 5 , September 2002 , pp. 322 - 330
Copyright
Copyright © Canadian Association of Emergency Physicians 2002

References

1.Pope, JH, Aufderheide, TP, Ruthazer, R, Woolard, R, Feldman, J, Beshansky, JR, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163–70.CrossRefGoogle ScholarPubMed
2.Lee, TH, Goldman, L.Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187–95.Google Scholar
3.Lee, TH, Juarez, G, Cook, F, Weisberg, M, Rouan, G, Brand, DA.Ruling out acute myocardial infarction: a prospective multicentre validation of a 12-hour strategy for patients at low risk. N Engl J Med 1991;324:1239–46.Google Scholar
4.McCarthy, BD, Beshansky, JR, D’Agostino, R, Selker, H.Missed diagnosis of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med 1993;22:579–82.CrossRefGoogle ScholarPubMed
5.Farkouh, ME, Smars, P, Reeder, G, Zinsmeister, A, Evans, RW, Meloy, TD, et al. A clinical trial of a chest pain observation unit for patients with unstable angina. N Engl J Med 1998;339:1882–8.Google Scholar
6.Gibler, WB, Young, GP, Hedges, JR, Lewis, LM, Smith, MS, Carleton, SC, et al. acute myocardial infarction in chest pain patients with nondiagnostic ECGs: serial CK–MB sampling in the emergency department. Ann Emerg Med 1992;21:504–12.Google Scholar
7.Sayre, MR, Kaufmann, K, Chen, IW, Sperling, M, Sidman, R, Diercks, D.Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain. Ann Emerg Med 1998;31:539–49.CrossRefGoogle ScholarPubMed
8.Gibler, WB, Lewis, LM, Erb, R, Makens, P, Kaplan, BC, Vaughan, R, et al. Early detection of acute myocardial infarction in patients presenting with chest pain and nondiagnostic ECGs: serial CK–MB sampling in the emergency department. Ann Emerg Med 1990;19:1359–66.Google Scholar
9.Gibler, WB, Runyon, JP, Levy, R, Sayre, M, Kacich, RHattemer, CR, et al. A rapid diagnostic and treatment centre for patients with chest pain in the emergency department. Ann Emerg Med 1995;25:1–8.Google Scholar
10.Mutrie, D.A new chest pain strategy in Thunder Bay. CJEM 1999;1(1):57–61.Google Scholar
11.Zimmerman, J, Fromm, R, Meyer, D, Boudreaux, A, Wun, CC, Smalling, R, et al. Diagnostic marker cooperative study for the diagnosis of acute myocardial infarction. Circulation 1999;99:1671–7.Google Scholar
12.Tsang, T, Neal, C, Walker, A., Taylor, D, Sosnowski, T, Poplawski, S, et al. Patterns of practice in emergency department management of chest pain of suspected cardiac origin: clinical utility of single stat CK. J Emerg Med 1995;13:471–5.Google Scholar
13.Irvin, RG, Cobb, FR, Roe, CR.acute myocardial infarction and MB creatine phosphokinase. Arch Intern Med 1980;140:329–34.Google Scholar
14.Wu, AH, Apple, FS, Gibler, WB, Jesse, RL, Warshaw, MM, Valdes, R Jr. National Academy of Clinical Biochemistry Standards of Laboratory Practice: recommendations for the use of cardiac markers in coronary artery diseases. Clin Chem 1999;45(7): 1104–21.Google Scholar
15.Marin, MM, Teichman, SL.Use of rapid serial sampling of CK–MB for very early detection of acute myocardial infarction in patients with acute chest pain. Am Heart J 1992;123:354–61.Google Scholar
16.Mair, J, Artner-Dworzak, E, Dienstl, A, Lechleitner, P, Morass, B, Smidt, J, et al. Early detection of acute myocardial infarction by measurement of mass concentration of CK–MB. Am J Cardiol 1991;68:1545–50.Google Scholar
17.Puleo, PR, Guadagno, PA, Roberts, R, Scheel, MV, Marian, AJ, Churchill, D, et al. Early diagnosis of acute myocardial infarction based on assay for subforms of CK–MB. Circulation 1990;82:1073–5.Google Scholar
18.Young, G, Green, TR.The role of single ECG, CK and CK–MB in diagnosing patients with acute chest pain. Am J Emerg Med 1993;11:444–9.Google Scholar
19.Hoekstra, JW, Hedges, JR, Gibler, WB, Rubison, M, Christenson, R.Emergency department CK–MB: a predictor of ischemic complications. Acad Emerg Med 1994;1:17–28.Google Scholar
20.Young, GP, Gibler, WB, Hedges, JR, Hoekstra, JW, Slovis, C, Aghababian, R, et al. Serial CK–MB results are a sensitive indicator of acute myocardial infarction in chest pain patients with nondiagnostic electrocardiograms. Acad Emerg Med 1997;4: 869–77.Google Scholar
21.deWinter, RJ, Bholasingh, R, Nieuwenhuijs, AB, Koster, RW, Peters, RJ, Sanders, GT.Ruling out acute myocardial infarction early with 2 serial CK–MB mass determinations. Eur J Emerg Med 1998;5:219–24.Google Scholar
22.Hedges, JR, Rouan, GW, Toltzis, R, Goldstein-Wayne, B, Stein, EA.Use of cardiac enzymes identifies patients with acute myocardial infarction otherwise unrecognized in the emergency department. Ann Emerg Med 1987;16(3):248–52.Google Scholar
23.Bakker, AJ, Gorgels, J, van Vlies, B, Koelemay, MJ, Smits, R, Tijssen, J, et al. Contribution of CK–MB mass concentration at admission to early diagnosis of acute myocardial infarction. Br Heart J 1994;72:112–8.Google Scholar
24.Hedges, JR, Young, G, Henkel, G, Gibler, WB, Green, TR, Swanson, JR.Serial ECGs are less accurate than serial CK–MB results for emergency department diagnosis of acute myocardial infarction. Ann Emerg Med 1992;21:1445–50.Google Scholar
25.Puleo, PR, Meyer, D, Wathen, C, Tawa, CB, Wheeler, S, Hamburg, RJ.Use of a rapid assay for subforms of CK–MB to diagnose or rule out acute myocardial infarction. N Engl J Med 1994;331: 561–6.Google Scholar
26.Lee, HS, Cross, SJ, Garwaite, P, Dickie, A, Ross, I, Walton, S, Jennings, K.Comparison of the value of novel rapid measurement of myoglobin, creatine kinase, and creatine kinase MB with the electrocardiogram for the diagnosis of acute myocardial infarction. Br Heart J 1994;71:311–5.Google Scholar
27.Chang, CC, Ip, M, Hsu, R, Vrobel, T.Evaluation of a proposed panel of cardiac markers for the diagnosis of acute myocardial infarction in patients with atraumatic chest pain. Arch Pathol Lab Med 1998;122:320–4.Google Scholar
28.Levitt, MA, Promes, SB, Bullock, S, Disano, M, Young, GP, Gee, G, Peaslee, D.Combined cardiac marker approach with adjunct 2-D echocardiography to diagnose acute myocardial infarction in the emergency department. Ann Emerg Med 1996;27:1–7.Google Scholar
29.deWinter, RJ, Koster, RW, Sturk, A, Sanders, GT.Value of myoglobin, troponin T, and CK–MB mass in ruling out acute myocardial infarction in the emergency department. Circulation 1995;92:3401–7.Google Scholar
30.Green, GB, Li, DJ, Bessman, ES, Cox, JL, Kelen, GD, Chan, DW.The prognostic significance of troponin I and troponin T. Acad Emerg Med 1998;5(8):758–67.Google Scholar
31.Gibler, WB, Gibler, CD, Weinshenker, E, Abbottsmith, C, Hedges, JR, Barsan, WG, et al. Myoglobin as an early indicator of acute myocardial infarction. Ann Emerg Med 1987;16:851–6.Google Scholar
32.Brogan, GX Jr, Friedman, S, McCuskey, C, Cooling, DS, Berrutti, L, Thode, HC Jr, Bock, JL.Evaluation of a new rapid quantitative immunoassay for serum myoglobin versus CK–MB for ruling out acute myocardial infarction in the emergency department. Ann Emerg Med 1994;24(4):665–71.Google Scholar
33.D’Costa, M, Fleming, E, Patterson, M.Cardiac troponin I for the diagnosis of acute myocardial infarction in the emergency department. Am J Clin Pathol 1997;108:550–5.Google Scholar
34.Kontos, MC, Jesse, R, Anderson, P, Schmidt, KL, Ornato, JP, Tatum, JL.Comparison of myocardial perfusion imaging and cardiac troponin I in patients admitted to the emergency department with chest pain. Circulation 1999;99:2073–8.Google Scholar
35.Antman, EM, Grudzien, C, Sacks, D.Evaluation of a rapid bedside assay for detection of serum cardiac troponin T. JAMA 1995; 273:1279–82.Google Scholar
36.Hamm, CW, Goldmann, BU, Heeschen, C, Kreymann, G, Berger, J, Meinertz, T.Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med 1997;337:1648–53.CrossRefGoogle ScholarPubMed
37.Hamm, C, Ravkilde, J, Gerhardt, W, Jorgenson, P, Peheim, E, Ljungdahl, L, et al. The prognostic value of serum troponin T in unstable angina. N Engl J Med 1992;327:146–50.Google Scholar
39.Ravkilde, J.Risk stratification in ACS using cardiac troponin I. Clin Chem 2000;46:443–4.CrossRefGoogle Scholar
40.Morrow, DA, Rifai, N, Tanasijevic, MJ, Wybenga, DR, de Lemos, JA, Antman, EM.Clinical efficacy of three assays for cardiac troponin I for risk stratification in acute coronary syndromes: a Thrombolysis In Myocardial Infarction (TIMI) 11B Substudy. Clin Chem 2000;46(4):453–60.Google Scholar
41.Foy, SG, Kennedy, IC, Ikram, H, Low, CJ, Shirlaw, TM, Crozier, IG.The early diagnosis of acute myocardial infarction. Aust N Z J Med 1991;21:335–7.Google Scholar
43.Grenadier, E, Keidar, S, Kahana, L, Alpan, G, Marmur, A, Palant, A.The roles of serum myoglobin, CK–MB in the acute phase of myocardial infarction. Am Heart J 1983;105:408–16.Google Scholar
44.Apple, FS, Christenson, RH, Valdes, R, Andriak, AJ, Berg, A, Duh, SH, et al. Simultaneous rapid measurement of whole blood myoglobin, CK–MB, and cardiac troponin I by the triage cardiac panel for detection of myocardial infarction. Clin Chem 1999;45:199–205.Google Scholar
45.Katus, HA, Remppis, A, Neumann, FJ, Scheffold, T, Diederich, K, Vinar, G.Diagnostic efficiency of troponin T measurements in acute myocardial infarction. Circulation 1991;83:902–12.CrossRefGoogle ScholarPubMed
46.Gibler, WB, Hoekstra, JW, Weaver, WD, Krucoff, MW, Hallstrom, AP, Jackson, R, et al. A randomized trial of the effects of early cardiac serum marker availability on reperfusion therapy in patients with acute myocardial infarction: the serial markers, acute myocardial infarction and rapid treatment trial (SMARTT). J Am Coll Cardiol 2000;36(5):1500–6.Google Scholar
47.Lang, TA, Secic, M, eds. How to report statistics in medicine. Philadelphia: American College of Physicians Publishing; 1997. p. 147–69.Google Scholar
48.Panju, A, Hemmelgarn, B, Guyatt, G, Simel, DL.Is this patient having a myocardial infarction? JAMA 1998;280:1256–63.CrossRefGoogle ScholarPubMed
49.McErlean, ES, Deluca, SA, van Lente, F, Peacock, F IV, Rao, JS, Balog, CA, et al. Comparison of troponin T vs. CK–MB in suspected acute coronary syndromes. Am J Card 2000;85:421–6.Google Scholar
50.Polanczyk, CA, Johnson, PA, Cook, EF, Lee, TH.A proposed strategy for utilization of CK–MB and troponin I in the evaluation of acute chest pain. Am J Cardiol 1999;83:1175–80.Google Scholar
51.Adams, JE, Schectman, KB, Landt, Y, Ladenson, J, Jaffe, A.Comparable detection of acute myocardial infarction by CK–MB isoenzyme and cardiac troponin I. Clin Chem 1994;40:1291–5.CrossRefGoogle Scholar
52.Mair, J, Morandell, D, Genser, N, Lechleitner, P, Dienstl, F, Puschendorf, B.Equivalent early sensitivities of myoglobin, CK–MB mass, CK isoform ratios and cardiac troponins I and T for acute myocardial infarction. Clin Chem 1995;41:1266–72.Google Scholar
53.Wu, AH, Lane, PL.Meta-analysis in clinical chemistry: validation of troponin T as a marker for ischemic heart disease. Clin Chem 1995;41:1228–33.Google Scholar
54.Zaninotto, M, Altinier, S, Lachin, M, Carraro, P, Plebani, M.Fluoroenzymometric method to measure cardiac troponin I in sera of patients with myocardial infarction. Clin Chem 1996;42:1460–6.Google Scholar