Fancy new ACS tests

It’s hard to keep track of all new proposed biomarkers that may be useful in the work up of acute coronary syndrome (ACS) patients. We’re all used to troponin now – so we really want to know how novel tests measure up against the existing standard, in particular for the timeframe in which troponin is less helpful, namely the first six hours.
A systematic review examine the evidence for the following biomarkers in the early assessment (ie, within 6 h of symptom onset) of suspected ACS:

  • CK-MB: CK-MB and 2 h ΔCK-MB have potential in diagnosing AMI in the first hours after symptom onset. Whether CK-MB has value in the early diagnostic assessment of ACS in addition to clinical symptoms, ECG or other markers has rarely been studied.
  • myoglobin: myoglobin might be of value in early ruling out of AMI and ACS in suspected patients because of the relatively high NPV; its PPV, however, is low. However, it is not yet known whether myoglobin has diagnostic value in addition to symptoms, signs and other diagnostic tests (eg, ECG), because of the lack of multivariable analysis
  • heart-type fatty acid binding protein (H-FABP): H-FABP seems to have some potential as an early diagnostic marker of AMI or ACS, but its value in addition to clinical features and other markers has not been studied
  • ischemia modified albumin (IMA): IMA could be a potential marker for early ruling out of ACS in chest pain patients because of its relatively high NPV, especially combined with cTn and ECG. However, its PPV is low. Importantly; IMA seems to add relevant diagnostic information to more readily available diagnostic parameters. However, problems with the stability of IMA and its lack of cardiospecificity have been reported
  • pregnancy-associated plasma protein A: contradictory results indicate that the diagnostic value of PAPP-A in patients suspected of having ACS has not been evaluated properly
  • glycogen phosphorylase isoenzyme BB: GPBB might be a marker for myocardial ischaemia and myocardial necrosis, although the available research is limited and does not assess the added value of the marker.
  • myeloid-related protein 8/14: more research is needed to evaluate the (added) diagnostic value of MRP 8/14 in patients suspected of having ACS.

The authors also point out the introduction of high-sensitivity troponin assays may further improve diagnosis of ACS. They refer to a study in patients with suspected AMI presenting at the emergency department, which showed that a sensitive cTnI assay had a higher NPV than a standard cTnT assay and comparable PPV for detecting AMI within 6 h of symptom onset. The PPV was 79.3% and 80.7%, respectively; the NPVs were 95.3% and 88%. The Full Text of this high-sensitivity troponin paper is here

The review makes the following conclusions:

  • current guidelines advocate the use of cardiac troponin or CK-MB when cTn is not available, and myoglobin in the first 6 h in addition to cTn
  • IMA and H-FABP seem to be promising diagnostic biomarkers in the early diagnostic assessment of patients suspected of having ACS
  • There is an urgent need for adequately designed studies of (novel) ACS markers and their combinations against contemporary troponin assays

Novel biochemical markers in suspected acute coronary syndrome: systematic review and critical appraisal
Heart. 2010 Jul;96(13):1001-1