World Heart Day (29th September)
Eminent Author, Medical Biochemist and Scientist, Technical Education consultant.
AGD Biomedicals (Pvt) LTD. Andheri East, Mumbai.
After decades of steady decline in heart failure mortality (1989-2009), rise in heart failure deaths have been on the increase with a dramatic increase among younger adults from 2012 to 2021(1). Indians present with Cardiovascular disease (CVD) a decade earlier compared to people of European ancestry. Nearly (62%) of all cardiovascular deaths in Indian populations are premature(2). Disruptions in health care caused by COVID-19 accelerated heart failure mortality rates dramatically in the last 5 years(3). Dietary risk factors, widespread obesity, rising rates of hypertension and diabetes mellitus are putting more people at risk for the cases of heart failure(4). It is estimated that up to 90% of CVDs could be preventable(5)(6). Therapeutic advances have reduced cardiovascular death rates in people with CVD. Similarly, routine and advanced fifth and fourth generation IVD tests with POCT-backed bed-side rapid technology provide accurate test results and facilitate personalised care and early medical decisions(7). Early determination of POCT screening tests could be useful to predict early stages of CVD and prevent major cardiac events(7) (Ref: Case study).
Q1. What are routine Cardiac risk evaluation laboratory tests and How advancements in IVD tests have impacted speed and accuracy of these tests?
ANS: Cardiac risk evaluation tests (CRET) are: Serum total cholesterol (TC) (<180), Triglycerides (<180), LDL-C(<90), VLDL-C (<38), TC/HDL-C ratio(<5.0), LDL-C/HDL-C ratio (<3.0). Advancements in the diagnostic technology, robotics, automation and artificial intelligence (AI) have facilitated generation of fast and accurate reports of CRET and reports could be available in 2-3 hours. Moreover, all these tests could be performed with speed and accuracy within few minutes at patient’s best side by improved POCT-testing facilities.
Q2. What are the Cardiac injury panel tests (CIPT), related Clinical significance and whether CIPT could be useful in the early detection of myocardial infarction (MI)?
CASE STUDY
A 37-year-old executive complained of retrosternal pain during a seminar at a hill station. After taking rest for about 2-3 hour; he was comfortable and took part in rest of the proceedings. After one week he resumed his duties and during the executive check-up in his office, his blood was collected. However, as he walked to his desk, he suffered massive MI and upon admission to the emergency ward of a hospital, he was declared dead. After 3 hrs his laboratory reports were available as follows:
| Parameters | Values | Normal values (Reference range) |
| Serum CK (Total) | 115 IU | 38 – 174 IU |
| Serum CK-MB | 7 IU | 5 – 13 IU |
| SGOT | 40 IU | 5 – 40 IU |
| LDH | 380 IU | 70 – 240 IU |
| SHBD | 410 IU | 65 – 165 IU |
| Cardiac Total Troponin (cTnT) | Present | Absent |
| Blood glucose (fasting) | 126 mg/dl | 70 – 110 mg/dl |
| Serum total cholesterol | 345 mg/dl | Absent |
Evaluation of the laboratory report
From the blood report of the patient, it appears that, normal CK, CK-MB and borderline SGOT, and high LDH and SHBD, with presence of serum cTnT, the patient had mild MI during the seminar one week back. After 7 days, serum CK-T, CK-MB and SGOT reports were normal Moderately elevated levels of LDH and SHBD confirmed the diagnosis. (Ref. Clinical significance of CIPT).
Although, the patient was not diabetic, he was suffering from hypercholesterolemia and atherosclerosis (lipid matrix deposition inside the arteries), which were responsible for the clinical events during the seminar at hill station. It was necessary for the patient to urgently consult a cardiologist to prevent future life-threatening MI. Unfortunately, life of this patient could not be saved, since he ignored early signs of MI and an early appointment with a cardiologist.
Clinical significance of CIPT
The cardiac enzymes remain elevated, following MI as follows: (CK total and CK-MB: About 2hrs to 3 days), SGOT: About 4 hrs 7 days), LHD (about 8 hrs to 15 days), SHBD (About 10 hrs to 21 days) and cTnT (Within 1 hr to 15 days).
Q3. What are the 4th and 5th generation IVD POCT blood cardiac markers useful in identifying risk for patients with acute coronary syndrome?
ANS: Reference 8:
- Cardiac Troponin T (cTnT): Detection of MI within 2-3 minutes.
- Cardiac Troponin I (cTnI): Detection of MI within 2-3 minutes.
- Myoglobin: Detection of MI within 2-3 minutes.
- Brain natriuretic peptide (BNP) and NT-ProBNP: Increase indicates acute congestive heart. failure (CHF) and asymptomatic or symptomatic left ventricular dysfunction.
- Heart fatty acid-binding protein: Rapid rise in acute myocardial infarction (AMI).
- High sensitivity hsCRP: Increased values indicate cardiovascular disease (CVD).
- Small dense LDL: High values indicate increased risk of MI.
- Homocysteine: Increased levels indicate vascular and cardiovascular disease.
Q4. How do latest IVD tests impact patient outcomes and overall healthcare costs?
ANS: A report of the World Economic Forum and Harvard School of Public Health in 2023 estimated the economic losses India would suffer due to CVD between the years 2012 and 2030 to be approximately $2.17 trillion(9, 10). Latest IVD tests along with Therapeutic advances could decrease the cardiovascular death rates in people with CVD and overall healthcare costs.
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| Cardiac panel | Lipid panel |
| CK-MB | Cholesterol |
| CK-NAC | Triglyceride |
| Homocysteine | HDL |
| LDH-P | LDL |
References
(1) Marat Fudim, MD, Associate professor in the Duke Department of Medicine and lead author of the study published April 24, 2024, JAMA.
(2) Jadhav U.M., Cardio-metabolic disease in India-the up-coming tsunami. Ann Transl Med. 2018; 6: 295.
(3) Daniel Ayoubkhani, Kamlesh Khunti, Vahé Nafilyan, Thomas Maddox, Ben Humberstone, Ian Diamond, Amitava Banerjee. Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study. BMJ. 2021 Mar 31:372:n693.
(4) Michael Drozd, Mar Pujades‐Rodriguez, Kevin N. Franks, Patrick J. Lillie, Klaus K. Witte, Mark T. Kearney, Richard M. Cubbon. Causes of Death in People with Cardiovascular Disease: A UK Biobank Cohort Study. Journal of the American Heart Association. Volume 10, Number 22.
(5) McGill HC, McMahan CA, Gidding SS (March 2008). “Preventing heart disease in the 21st century: implications of the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study”. Circulation. 117 (9): 1216–27.
(6) Shanthi M, Pekka P, Norrving B (2011). Global Atlas on Cardiovascular Disease Prevention and Control (PDF). World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization. pp. 3–18.
(7) Annette Plüddemann, Matthew Thompson, Christopher P Price, Jane Wolstenholme, Carl Heneghan. Point-of-care testing for the analysis of lipid panels: primary care diagnostic technology update. Br J Gen Pract (2012), Mar;62(596).
(8) Godkar PB, Godkar DP. Text book of Medical laboratory technology (4th edition, 2024), Bhlani Publishers, Mumbai. India.
(9) Ankur Kalraa,j, Arun Pulikkottil Joseb,j, Poornima Prabhakaranc,j, Ashish Kumard, Anurag Agrawale, Ambuj Royf. The burgeoning cardiovascular disease epidemic in Indians–perspectives on contextual factors and potential solutions. The Lancet Regional Health (May, 2023), Volume 12100156. Open access.
(10) [accessed on August 3, 2023]. World Heart Federation. World heart vision 2030: Driving policy change. Available from: https://www.world-heart-federation.org/wp-content/uploads/World-Heart-Vision-2030.pdf.
