Elsevier

American Heart Journal

Volume 134, Issue 4, October 1997, Pages 622-630
American Heart Journal

Myoglobin, creatine kinase MB, and cardiac troponin-I to assess reperfusion after thrombolysis for acute myocardial infarction: Results from TIMI 10A,☆☆,,★★,

https://doi.org/10.1016/S0002-8703(97)70044-9Get rights and content

Abstract

Background The availability of a reliable, noninvasive serum marker of reperfusion may permit early identification of patients with occlusion after thrombolysis who might benefit from further interventions.

Methods We measured myoglobin, creatine kinase MB (CK-MB), and cardiac troponin-I (cTnI) concentrations in sera obtained just before thrombolysis (T0) and 60 minutes later (T60) in 30 patients given TNK-tPA for acute myocardial infarction as part of the Thrombolysis in Myocardial Infarction (TIMI) 10A trial.

Results Angiography at T60 showed reperfusion (TIMI flow grade 2 to 3; n = 19) or occlusion (TIMI flow grade 0 to 1; n = 8). The median serum T60 concentration, the ratio of the T60 and T0 serum concentration, and the slope of increase over a 60-minute period for each serum marker were significantly higher in patients with patent arteries compared with patients with occluded arteries. The areas under the receiver operator characteristics curve for diagnosis of occlusion were 0.96, 0.91, and 0.87 for the T60 concentration of myoglobin, CK-MB and cTnI, respectively. Although the T60 levels of <469 ng/ml for myoglobin, <11.5 ng/ml for CK-MB, and <1.1 ng/ml for cTnI identified all patients with occlusion, the specificity of myoglobin (94%) was higher than that of CK-MB (61%) and cTnI (67%). Similar results were obtained for the 60-minute ratios and 60-minute slopes for each marker, with indexes for myoglobin having the highest specificity.

Conclusions In this pilot study, noninvasive diagnosis of occlusion 60 minutes after thrombolysis was achieved with a high degree of sensitivity and specificity with the myoglobin, CK-MB, and cTnI concentrations measured at that time point. These preliminary findings may permit a new strategy for assessment of the success of reperfusion, with triage to rescue angioplasty for patients in whom the 60-minute cardiac marker values or indexes are consistent with occlusion of the infarct-related artery. (Am Heart J 1997;134:622-30.)

Section snippets

Study population

The TIMI 10A trial, a phase I, dose-ranging, pilot trial was conducted in the United States between January and November 1995. It evaluated a new thrombolytic agent, TNK-tissue plasminogen activator (TNK-tPA), in patients with AMI, as previously reported. 32 The study patients were between the ages of 19 and 69, had episodes of pain lasting ≥30 minutes and within 12 hours from symptom onset, associated with ST-segment elevation ≥0.1 mV in two or more contiguous electrocardiogram leads, or new

Patient characteristics

Table I summarizes the baseline clinical characteristics of the 27 patients included in the study. There were 21 men and six women with a mean age of 55.6 years. The time interval from the onset of chest pain to start of thrombolytic therapy averaged 3 ± 1.3 hours. In 19 patients (group A), angiography at 60 minutes revealed TIMI flow grade 2 or 3. In the remaining eight patients, the TIMI flow grade was 0 or 1 (group B). Angiography at 60 minutes identified the left anterior descending

Discussion

The aim of this study was to investigate the diagnostic performance of serum myoglobin, CK-MB, and cTnI concentrations obtained 60 minutes after initiation of thrombolysis in assessing the infarct-related artery patency, the most important aspect of early AMI care.41

Our findings indicate that at the diagnostic cutoffs optimized to identify all patients with occluded coronary arteries (i.e., 100% sensitivity for vessel occlusion), a single myoglobin concentration measured 60 minutes from

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    *See Appendix.

    ☆☆

    Supported by Dade International, Miami, Fla. The TIMI 10A Clinical Centers were supported by Genentech, South San Francisco, Calif.

    Reprint requests: Milenko J. Tanasijevic, MD, Clinical Laboratories, Brigham and Women’s Hospital, Amory Building, 215 A, 75 Francis St., Boston, MA 02115.

    ★★

    E-mail: [email protected]

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