Document Detail

Role of biomarkers in risk stratification of acute coronary syndrome.
Jump to Full Text
MedLine Citation:
PMID:  21150016     Owner:  NLM     Status:  MEDLINE    
Diagnosis of acute coronary syndrome (ACS) encompasses a wide spectrum of myocardial ischaemia varying from assuredly benign to potentially fatal. Cardiac biomarkers have had a major impact on the management of this disease and are now the cornerstone in its diagnosis and prognosis. In this review we discuss both the established and the newer emerging biomarkers in ACS and their role in highlighting not only myocardial necrosis but also different facets of the pathophysiology of ACS. The future of cardiac biomarker testing may be in multimarker testing to better characterize each patient of ACS and thus tailor both short-term and long-term therapy accordingly. This novel concept, however, needs to be tested in clinical trials for its incremental value and cost-effectiveness.
C M Nagesh; Ambuj Roy
Related Documents :
11327226 - Cardiac damage in pediatric carbon monoxide poisoning.
6455136 - Clinical application of amplitude processing of echocardiographic images.
6180516 - Complete atrioventricular canal: current surgical technique.
11999086 - Predictive accuracy of commissural morphology and its role in determining the outcome f...
16820556 - Counterpulsation from the skeletal muscle ventricle and the intraaortic balloon pump in...
19222616 - Management of patients with unstable angina / non-st-elevation myocardial infarction: a...
Publication Detail:
Type:  Journal Article; Review    
Journal Detail:
Title:  The Indian journal of medical research     Volume:  132     ISSN:  0971-5916     ISO Abbreviation:  Indian J. Med. Res.     Publication Date:  2010 Nov 
Date Detail:
Created Date:  2010-12-14     Completed Date:  2011-03-29     Revised Date:  2013-07-03    
Medline Journal Info:
Nlm Unique ID:  0374701     Medline TA:  Indian J Med Res     Country:  India    
Other Details:
Languages:  eng     Pagination:  627-33     Citation Subset:  IM    
Department of Cardiology, Cardio-Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Acute Coronary Syndrome / diagnosis*,  physiopathology*
Biological Markers*
C-Reactive Protein / diagnostic use
Cystatin C / diagnostic use
Individualized Medicine / methods*,  trends
Natriuretic Peptide, Brain / diagnostic use
Risk Assessment
Troponin / diagnostic use
Reg. No./Substance:
0/Biological Markers; 0/Cystatin C; 0/Troponin; 114471-18-0/Natriuretic Peptide, Brain; 9007-41-4/C-Reactive Protein

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Indian J Med Res
Journal ID (publisher-id): IJMR
ISSN: 0971-5916
ISSN: 0971-5916
Publisher: Medknow Publications, India
Article Information
© The Indian Journal of Medical Research
Received Day: 30 Month: 4 Year: 2009
Print publication date: Month: 11 Year: 2010
Volume: 132 Issue: 5
First Page: 627 Last Page: 633
ID: 3028962
PubMed Id: 21150016
Publisher Id: IJMR-132-627
DOI: 10.4103/0971-5916.73419

Role of biomarkers in risk stratification of acute coronary syndrome
C.M. NageshAF0001
Ambuj RoyAF0001
Department of Cardiology, Cardio-Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
Correspondence: Reprint requests: Dr Ambuj Roy, Assistant Professor, Department of Cardiology, 7th Floor, Cardio-Thoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India e-mail:


Acute coronary syndrome (ACS) is an umbrella term for a wide spectrum of clinical sign and symptoms suggestive of myocardial ischaemia. The ultimate clinical implication of ACS may therefore vary from assuredly benign to potentially fatal. Thus further risk stratification of this syndrome complex is imperative. It has been seen that 50 per cent of patients hospitalized for suspected ACS ultimately leave the hospital with other diagnoses1. Further management of ACS is resource-intensive and thus proper risk stratification is mandatory to avoid needless hospitalizations and interventional procedures. The traditional clinical tools for risk stratification such as history, physical examination, and ECG though undoubtedly important may prove to be inadequate in the majority of cases. This has led to the search for circulating markers that better establish diagnosis and thus aid in appropriate and rapid patient triage. The cardiac necrosis markers creatine phosphokinase and its isoenzymes and especially troponin have come to the forefront in the past decade to better identify high-risk individuals suitable for the most resource-intensive treatment. This is reflected in the various management guidelines of ACS where cardiac enzymes are the cornerstone in decision making. In addition, the success and usefulness of these biomarkers has led to intense research in this field resulting in several newer biomarkers emerging on the horizon of clinical use in ACS.

In this review we discuss the role of these cardiac biomarkers; established and emerging in ACS (Table I) and also the growing evidence of support for the use of multiple biomarkers, each representative of a different facet of the pathophysiology of ACS (Table II).

Established biomarkers
Cardiac troponin (cTn)

Cardiac troponin is a well established biomarker for diagnosis and prognosis of ACS25. The data for troponins in ACS is robust even at minimally elevated levels. Measurement of cTnT and cTnI is now the crucial step in new diagnostic criteria for MI6. With current high quality analytic methods, cardiac troponin measurements are highly sensitive and specific for myocardial injury7. In the appropriate clinical setting (high certainty that the troponin is due to acute coronary syndrome) even minor elevations of troponin identify high risk underlying coronary morphology like patients with plaque rupture, large thrombus burden and distal embolisation8. These patients clearly benefit from aggressive anti-platelet, anti-thrombotic and revascularization therapy9.

cTn typically increases more than 20 times above the upper limit of the reference range in myocardial infarction as compared to creatine kinase-myocardial band (CK-MB) which usually increases 10 times above the reference range. This provides an improved signal - to - noise ratio, enabling the detection of even minor degree of necrosis with troponin. The cTn begins to elevate 3 h from the onset of chest pain in MI. Because of the continuous release, cTn elevation persists for days (cTnI: 7-10 days, cTnT: 10-14 days). This prolonged course of release with troponin is advantageous for the late diagnosis of MI, however, it limits the diagnosis of early reinfarction.

The cardiac troponin especially cTnT pose diagnostic challenges in patients of chronic renal failure10, 11. Frequent cTnT elevations (30 to 70% of end stage renal disease (ESRD) patients compared with <5% in similar patients of cTnI) are seen in patients of renal failure in the absence of clinical suspicion of ACS10, 11. The putative mechanisms for chronic elevation of troponin in chronic renal disease patients include endothelial dysfunction, acute cardiac stretch, microinfarction and left ventricular hypertrophy12. However, it is important to understand that in the setting of acute coronary syndrome these patients should be treated as if renal failure were not present13as the short term prognostic value of troponin T for cardiovascular event is similar in patients with and without renal failure.

Data comparing the two cTn suggest that cTnI may be slightly more sensitive. However, this may be due to different release kinetics of the two biomarkers and to different limits of detection of the currently available assays14. The other advantage of cTnI may be its greater specificity in patients of ESRD. However, the important advantage of cTnT is that due to international patent restrictions there is only one assay for its measurement, thus cTnT demonstrates a high degree of precision at the low end of measurement range and a relatively uniform cut-off concentration. In contrast, at least 18 different commercial assays for cTnI are available leading to considerable variation in the cut-off concentrations in the definition of a myocardial infarction by cTnI values15, 16. Thus, a clinician should be aware of the cTnI cut-off values specifically associated with the particular assay used by the laboratory.

Brain natriuretic peptide (BNP)

Brain natriuretic peptide is a neurohormone synthesized in ventricular myocardium and released in response to cardiac stretch. NT-ProBNP is the N-terminal fragment of the prohormone BNP. These natriuretic peptides have prognostic value across the full spectrum of acute coronary syndrome patients.

Patients with elevated BNP or NT-proBNP are at significantly increased risk for subsequently developing heart failure and death both in the short- and long-term. This is seen regardless of their troponin levels and even when there is no clinical evidence of heart failure17, 18. The prognostic value of these peptides is over and above the conventional risk factors like age, Killip class and left ventricular ejection fraction. Studies have shown that BNP predicts high risk features in ACS, such as more severe underlying atherosclerosis, left ventricular dysfunction, left ventricular hypertrophy, and the burden of the ischaemic insult16. Thus it may be prudent to conclude that in patients with ACS, the higher the BNP, the more severe the haemodynamic insult due to ischaemia and the worse the prognosis.

C-reactive protein (CRP)

C-reactive protein is a nonspecific inflammatory marker that is released by the liver in response to the acute phase injury. CRP can be measured by multiple assays in acceptable precisions down to or below 0.3 mg/l and most give comparable results (designated as high-sensitive CRP or hsCRP).

CRP in addition to BNP and troponin does appear to provide some additional value in the prognostication of ACS20; however, the incremental value is modest. In terms of the association of CRP and ACS it is important to distinguish cases without (unstable angina) and with necrosis (acute MI). In cases of AMI, CRP release is triggered as an acute phase reactant secondary to necrosis and levels of CRP are much higher and these have been correlated with infarct size. Though infarct size is the major determinant of long term prognosis after AMI; mortality has been shown to be related to CRP levels independent of left ventricular systolic function21, 22. In the absence of infarction, CRP levels correlate to the extent of atherosclerosis and some studies have shown that it predicts coronary events in patients of unstable angina independent of troponin levels23, 24. However, a more recent large prospective study showed only a weak association of CRP levels and future coronary events in patients of ACS and even this disappeared once adjusted for other common clinical variables. This study included about two-thirds of AMI patients and one-third unstable angina patients25.

Another interesting implication of CRP in ACS has been in terms of treatment: in a study of ACS patients, those with low CRP levels after statin therapy had better clinical outcomes than those with higher CRP levels, regardless of the resultant level of LDL cholesterol. Thus implying that statin therapy in these high risk patients of ACS should be driven not only by the target lipid levels but also the CRP levels achieved26.

These data suggest that CRP levels in ACS may be of prognostic significance but their incremental value over conventional factors and biomarkers may be modest.

Emerging biomarkers
Myeloperoxidase (MPO)

Myeloperoxidase is a haemoprotein and lysosomal enzyme released from neutrophilic granules and monocytes27. MPO is released into the extracellular fluid and general circulation during inflammatory conditions. This enzyme has been associated with oxidation of lipids contained within LDL, dysfunctional HDL and consumption of nitric oxide thus rendering the normally anti-thrombotic endothelial surface thrombogenic via expression of various pro-thrombotic and anti-fibrinolytic factors28. MPO elevation has been associated with adverse ventricular modeling after MI and with progression to heart failure29. MPO is responsible for fibrous cap disintegration making it a marker of plaque instability and inflammation. A recent study revealed that elevated MPO levels were marker of cardiac death independent of troponins, CRP in patients of ACS thus highlighting its utility in these patients30. However, increased MPO is not likely to be specific to cardiac diseases, as activation of neutrophil and macrophages can occur in any infectious, inflammatory or infiltrative disease process.

Soluble CD40 ligand

Soluble CD40 ligand (sCD40L) is expressed on platelets and released from them on activation. It has biological activity that can trigger an inflammatory reaction in vascular endothelial cells by the secretion of cytokines and chemokines31. Membrane bound CD40L and sCD40L forms interact with the CD40 receptor molecule, which is present not only on B cells but also on monocytes, macrophages, and endothelial and smooth muscle cells in atheroma, leading to release of matrix MMPs and subsequent destabilization of the plaque32. Thus upregulation of the CD40L system may play a pathogenic role also in triggering ACS.

Increased sCD40L concentrations have been demonstrated in other inflammatory disorders, e.g., autoimmune diseases, multiple sclerosis, and inflammatory bowel disease, as well as in stroke, hypercholesterolaemia, and diabetes32, 33.

In OPUS-TIMI16 trial increased sCD40L was associated with a higher risk for future death and recurrent myocardial infarction independent of other variables including cTnI and CRP. Importantly in combination with cardiac troponin I it significantly improved risk prediction for future death and MI34. Similarly in the CAPTURE study of ACS, increased sCD40L concentrations were associated with a higher risk of death and non-fatal MI. Notably elevation of soluble CD40 ligand identified the subgroup of patients likely to benefit from anti-platelet treatment with abciximab35. Therapeutic benefits of sCD40L were also seen in MIRACL Study wherein patients with acute coronary syndromes and high sCD40L had a significant reduction in the risk of recurrent cardiovascular events with early statin therapy36. However, recent studies have flagged doubts on the influence of pre-analytical and analytical conditions on measurement of sCD40L and thus additional studies are warranted before implementing wider clinical use37.

Ischaemia modified albumin

Ischaemia induces a conformational change in albumin, so that it can no longer bind to transitional metals such as cobalt or copper. Using the albumin cobalt binding (ACB) test, the quantum of ischaemia modified albumin can be estimated and this serves as an index of ischaemia.

Ischaemia-modified albumin (IMA) has been shown to be an independent predictor of short- and long-term adverse outcomes over and above conventional known risk in patients with ACS38. Increased IMA values may be found in patients with cancer, infections, end-stage renal disease, liver disease, and brain ischaemia also39, 40.

The commercially available IMA test appears to be relatively sensitive for identifying unstable angina. However, the test’s specificity is relatively poor and the assay is cumbersome to use. With greater refinement it may be a useful test in the emergency department (ED) to rule out ischaemia which is more important at that stage.

Pregnancy-associated plasma protein-A

Pregnancy-associated plasma protein-A (PAPP-A) is a large, zinc binding proteinase produced by different cell types, including fibroblasts, vascular smooth muscle cells, male and female reproductive tissues and belongs to the insulin-like growth factor family.

It is thought to be released when neovascularization occurs and thus may be a marker of incipient plaque rupture. Its level has been shown to be elevated in unstable plaques and in circulation in patients of ACS41. In study of patients with angiographically confirmed acute coronary syndrome, elevated serum PAPP-A was a strong independent predictor of death or recurrent MI, even in patients with normal serum troponin T42. Thus preliminary data suggest a possible novel role of PAPP-A in identifying vulnerable plaques, however, additional studies are needed. Moreover, standardized assays for PAPP-A are not available.

Cystatin C

Cystatin C is a low molecular weight basic protein that is freely filtered and metabolized after tubular reabsorption. There is a U.S. Food and Drug Administration-(FDA) cleared assay that is analytically robust. Some studies have revealed the usefulness of the cystatin C as a prognostic marker in heart failure43, 44and acute coronary syndrome45. This protein is less influenced by age, gender, and muscle mass than serum creatinine and thus may be better indicator of cardiovascular risk than serum creatinine especially in elderly.

Fatty acid binding protein

It is one of the proteins which is rapidly released after myocardial infarction and is considered as alternative to myoglobin. It is an extremely valuable marker of myocardial necrosis in the early hours of ACS and more sensitive than CK-MB, CK-MB mass and cTn46.

Placental growth factor (PlGF)

It is one of the families of platelet-derived proteins that function as potent chemoattractants for monocytes and are involved in the regulation of vascular endothelial growth47. It has a high homology with vascular endothelial growth factor. Plasma PlGF measurements have been shown to be an independent biomarker of adverse outcome in patients with suspected ACS48. Plasma PlGF appears to extend the predictive and prognostic information gained from traditional biomarkers of necrosis, platelet activation, and systemic inflammation, and has great potential as an independent biomarker for plaque disruption, ischaemia, and thrombosis.

Multiple biomarker testing: will this be the future norm?

The emergence of different biomarkers in ACS provides insight into the varied pathophysiology of this disease. The future of ACS management would probably shift from single to multimarker testing leading to better characterization of each individual case and thus aid to singularize the stratagem of management of each case in the short- and long-term. In a study to assess the role of multi-marker testing cTnI, CRP and BNP were measured in 450 patients of ACS20. It was seen that the mortality was independently related to each biomarker tested and there was a near doubling of mortality rate for each additional biomarker that was positive. Similarly the short term and intermediate cardiac event rates were also strongly related to the number of biomarker positive at admission.

The role of the multiple testing of emerging biomarkers over and above that of the currently established ones needs to be tested in a study and more importantly the impact of a biomarker highlighting a specific pathophysiologic mechanism of ACS in tailoring therapy for an individual patient needs to be established. Although there is still a long way till we reach this destination, it is a noble goal, and the desired direction for the future of cardiac medicine.


Importance of biomarkers, both in diagnosis and prognosis, of ACS is now well established. Biomarkers like troponin, BNP and CRP are in wide clinical use and substantial evidence of their utility in ACS is present. In addition, several newer biomarkers have recently emerged and may soon be in clinical use as these exemplify different facets of the pathophysiology of ACS and thus may have important therapeutic and prognostic implication over and above that of the established biomarkers. Moreover, these biomarkers would be mutually complementary to each other and thus multi-marker testing would help in better characterizing each case of ACS and may be the future norm.

1. Storrow AB,Gibler WB. Chest pain centers: diagnosis of acute coronary syndromesAnn Emerg MedYear: 2000354496110783407
2. Alpert JS,Thygesen K,Antman E,Bassand JP. Myocardial infarction redefined - a consensus document of The Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarctionJ Am Coll CardiolYear: 2000369596910987628
3. Antman EM,Tanasijevic MJ,Thompson B,Schactman M,McCabe CH,Cannon CP,et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromesN Engl J MedYear: 1996335134298857017
4. Ohman EM,Armstrong PW,Christenson RH,Granger CB,Katus HA,Hamm CW,et al. Cardiac troponin T levels for risk stratification in acute myocardial ischemia. GUSTO IIA InvestigatorsN Engl J MedYear: 19963351333418857016
5. Galvani M,Ottani F,Ferrini D,Ladenson JH,Destro A,Baccos D,et al. Prognostic influence of elevated values of cardiac troponin I in patients with unstable anginaCirculationYear: 199795205399133515
6. Panteghini M,Pagani F,Yeo KT,Apple FS,Christenson RH,Dati F,et al. Evaluation of imprecision for cardiac troponin assays at low-range concentrationsClin ChemYear: 2004503273214656904
7. Jaffe AS,Ravkilde J,Roberts R,Naslund U,Apple FS,Galvani M,et al. It’s time for a change to a troponin standardCirculationYear: 200010212162010982533
8. Wong GC,Morrow DA,Murphy S,Kraimer N,Pai R,James D,et al. Elevations in troponin T and I are associated with abnormal tissue level perfusion: a TACTICS-TIMI 18 substudy. Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial InfarctionCirculationYear: 2002106202712105159
9. Morrow DA,Cannon CP,Rifai N,Frey MJ,Vicari R,Lakkis N,et al. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trialJAMAYear: 200128624051211712935
10. Freda BJ,Tang WH,Van Lente F,Peacock WF,Francis GS. Cardiac troponin in renal insufficiency: review and clinical implicationsJ Am Coll CardiolYear: 20024020657112505215
11. De Zoysa JR. Cardiac troponins and renal diseaseNephrology (Carlton)Year: 2004983815056267
12. Ooi DS,Isotalo PA,Veinot JP. Correlation of antemortem serum creatine kinase, creatine kinase-MB, troponin I, and troponin T with cardiac pathologyClin ChemYear: 2000463384410702520
13. Aviles RJ,Askari AT,Lindahl B,Wallentin L,Jia G,Ohman EM,et al. Troponin T levels in patients with acute coronary syndromes, with or without renal dysfunctionN Engl J MedYear: 200234620475212087140
14. 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 IN Engl J MedYear: 19973371648539385123
15. Higgins JP,Higgins JA. Elevation of cardiac troponin I indicates more than myocardial ischemiaClin Invest MedYear: 2003261334712858947
16. Christenson RH,Duh SH,Apple FS,Bodor GS,Bunk DM,Dalluge J,et al. Standardization of cardiac troponin I assays: round robin of ten candidate reference materialsClin ChemYear: 200147431711238293
17. De Lemos JA,Morrow DA,Bentley JH,Omland T,Sabatine MS,McCabe CH,et al. The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromesN Engl J MedYear: 200134510142111586953
18. Omland T,Persson A,Ng L,O’Brien R,Karlsson T,Herlitz J,et al. N-terminal pro-B-type natriuretic peptide and long-term mortality in acute coronary syndromesCirculationYear: 20021062913812460871
19. Sabatine MS,Morrow DA,de Lemos JA,Omland T,Desai MY,Tanasijevic M,et al. Acute changes incirculating natriuretic peptide levels in relation to myocardial ischemiaJ Am Coll CardiolYear: 20044419889515542281
20. Sabatine MS,Morrow DA,de Lemos JA,Gibson CM,Murphpy SA,Rifai N,et al. Multimarker approach to risk stratification in non-ST elevation acute coronary syndromes: simultaneous assessment of troponin I, C-reactive protein, and B-type natriuretic peptideCirculationYear: 20021051760311956114
21. Suleiman M,Aronson D,Reisner SA,Kapelovich MR,Morkiewics W,Levy Y,et al. Admission C-reactive protein levels and 30-day mortality in patients with acute myocardial infarctionAm J MedYear: 200311569570114693321
22. Suleiman M,Khatib R,Agmon Y,Mehamid R,Boulos M,Kapeliovich M,et al. Early inflammation and risk of long-term development of heart failure and mortality in survivors of acute myocardial infarction predictive role of C-reactive proteinJ Am Coll CardiolYear: 200647962816516078
23. Rebuzzi AG,Quaranta G,Liuzzo G,Caligiuri G,Lanza GA,Gallimora JR,et al. Incremental prognostic value of serum levels of troponin T and C-reactive protein on admission in patients with unstable angina pectorisAm J CardiolYear: 19988271599761079
24. Morrow DA,Rifai N,Antman EM,Weiner DL,McCabe CH,Cannon CP,et al. C-reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes: a TIMI 11A substudy. Thrombolysis in Myocardial InfarctionJ Am Coll CardiolYear: 199831146059626820
25. Bogaty P,Boyer L,Simard S,Danwe F,Dupuis R,Verret B,et al. Clinical utility of C-reactive protein measured at admission, hospital discharge, and 1 month later to predict outcome in patients with acute coronary disease. The RISCA (recurrence and inflammation in the acute coronary syndromes) studyJ Am Coll CardiolYear: 20085123394618549920
26. Ridker PM,Cannon CP,Morrow D,Rifai N,Rose LM,McCabe CH,et al. C-reactive protein levels and outcomes after statin therapyN Engl J MedYear: 200535220815635109
27. Apple FS,Wu AH,Mair J,Ravkilde J,Panteghini M,Tale J,et al. Future biomarkers for detection of ischemia and risk stratification in acute coronary syndromeClin ChemYear: 2005518102415774573
28. Nicholls SJ,Hazen SL. Myeloperoxidase and cardiovascular diseaseArterioscler Thromb Vasc BiolYear: 20052511021115790935
29. Askari AT,Brennan ML,Zhou X,Drinko J,Morehead A,Thomas JD,et al. Myeloperoxidase and plasminogen activator inhibitor 1 play a central role in ventricular remodeling after myocardial infarctionJ Exp MedYear: 20031976152412615902
30. Baldus S,Heeschen C,Meinertz T,Zeiher AM,Eiserich JP,Mungel T,et al. Myeloperoxidase serum levels predict risk in patients with acute coronary syndromesCirculationYear: 20031081440512952835
31. Andre P,Nannizzi-Alaimo L,Prasad SK,Phillips DR. Platelet-derived CD40L: the switch hitting player of cardiovascular diseaseCirculationYear: 2002106896912186789
32. Scho¨nbeck U,Libby P. CD40 signaling and plaque instabilityCirc ResYear: 200189109210311739273
33. Szmitko PE,Wang C-H,Weisel RD,de Almeida JR,Anderson TJ,Verma S. New markers of inflammation and endothelial cell activation. Part 1CirculationYear: 200310819172314568885
34. Varo N,de Lemos JA,Libby P,Morrow DA,Murphy SA,Nuzzo R,et al. Soluble CD40L risk prediction after acute coronary syndromesCirculationYear: 200310810495212912804
35. Heeschen C,Dimmeler S,Hamm CW,Van den Brond MJ,Boersma E,zeiher AM,et al. CAPTURE Study Investigators. Soluble CD40 ligand in acute coronary syndromesN Engl J MedYear: 200334811041112646667
36. Kinlay S,Schwartz GG,Olsson AG,Rifai N,Sasiela WJ,Szarek M,et al. Effect of atorvastatin on risk of recurrent cardiovascular events after an acute coronary syndrome associated with high soluble CD40 ligand in the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) StudyCirculationYear: 20041103869115262833
37. Olenchock BA,Wiviott SD,Murphy SA,Cannon CP,Rafai N,Braunwald E,et al. Lack of association between soluble CD40L and risk in a large cohort of patients with acute coronary syndrome in OPUS TIMI-16J Thromb ThrombolysisYear: 200726798417917707
38. Consuegra-Sanchez L,Bouzas-Mosquera A,Sinha MK,Collinson PO,Gaze DC,Kaski JC. Ischemia-modified albumin predicts short-term outcome and 1-year mortality in patients attending the emergency department for acute ischemic chest painHeart VesselsYear: 2008231748018484160
39. Aslan D,Apple FS. Ischemia modified albumin: clinical and analytical updateLab MedYear: 20043515
40. Wu AH. The ischemia-modified albumin biomarker for myocardial ischemiaMLO Med Lab ObsYear: 200335368 40. 12841070
41. Bayes-Genis A,Conover CA,Overgaard MT,Bailey KR,Christiansen M,Holmes DR Jr,et al. Pregnancy-associated plasma protein A as a marker of acute coronary syndromesN Engl J MedYear: 20013451022911586954
42. Heeschen C,Dimmeler S,Hamm CW,Fichtscherer S,Simoons ML,Zeiher AM. CAPTURE Study Investigators. Pregnancyassociated plasma protein-A levels in patients with acute coronary syndromes: comparison with markers of systemic inflammation, platelet activation, and myocardial necrosisJ Am Coll CardiolYear: 2005452293715653020
43. Sarnak MJ,Katz R,Stehman-Breen CO,Fried LF,Jenny NS,Pasty BM,et al. Cystatin C concentration as a risk factor for heart failure in older adultsAnn Intern MedYear: 200514249750515809461
44. Shlipak MG,Katz R,Fried LF,Jenny NS,Stehman-Breen CO,Newman AB,et al. Cystatin-C and mortality in elderly persons with heart failureJ Am Coll CardiolYear: 2005452687115653026
45. Jernberg T,Lindahl B,James S,Larsson A,Hansson LO,Wallentin L. Cystatin C: a novel predictor of outcome in suspected or confirmed non-ST-elevation acute coronary syndromeCirculationYear: 20041102342815477399
46. Ruzgar O,Bilge AK,Bugra Z,Umman S,Yilmaz E,Ozben B,et al. The use of human heart-type fatty acid-binding protein as an early diagnostic biochemical marker of myocardial necrosis in patients with acute coronary syndrome, and its comparison with troponin-T and creatine kinase-myocardial bandHeart VesselsYear: 2006213091417151819
47. Maglione D,Guerriero V,Viglietto G,Delli-Bovi P,Persico MG. Isolation of a human placenta cDNA coding for a protein related to the vascular permeability factorProc Natl Acad Sci USAYear: 1991889267711924389
48. Heeschen C,Dimmeler S,Fichtlscherer S,Hamm CW,Berger J,Simoons ML,et al. Prognostic value of placental growth factor in patients with acute chest painJAMAYear: 20042914354114747500

[TableWrap ID: T0001] Table I 

Biomarkers in acute coronary syndrome

Established biomarkers Emerging biomarkers
Troponin I Myeloperoxidase
Troponin T Metalloproteinase
Brain natriuretic peptide (BNP) Soluble CD40 ligand
NT-Pro BNP Ischemia modified albumin
C-reactive protein (CRP) Pregnancy-associated plasma
Cystatin C
Fatty acid binding protein
Placental growth factor (PlGF)

[TableWrap ID: T0002] Table II 

Various biomarkers underscoring different facets of the pathophysiology and outcomes of ACS

  C-reactive protein
  Matrix metalloproteinase
  Soluble CD40 ligand
Platelet activation
  Soluble CD40 ligand
Vulnerable plaque
  Pregnancy-associated plasma protein-A
  Placental growth factor
  Matrix metalloproteinase
Myocardial necrosis
  Creatine phophokinase and isoenzymes
  Troponin I and T
  Fatty acid binding protein
  Ischaemia modified albumin
Pump failure
  Brain natriuretic peptide
  NT-pro brain natriuretic peptide

Article Categories:
  • Review Article

Keywords: Acute coronary syndrome, brain natriuretic peptide, cardiac biomarkers, CRP, cystatin C, troponin.

Previous Document:  Clinical judgement & evidence-based medicine: time for reconciliation.
Next Document:  Surveillance of cardiovascular disease risk factors in India: the need & scope.