The combination of creatine kinase-myocardial band isoenzyme and point-of-care cardiac troponin/ contemporary cardiac troponin for the early diagnosis of acute myocardial infarction

doi:10.5847/wjem.j.1920-8642.2022.033

Abstract

Abstract:

BACKGROUND: The early diagnosis of acute myocardial infarction (AMI) remains challenging, especially for institutions without the high-sensitive cardiac troponin (hs-cTn) assay. Herein, we aim to assess the value of creatine kinase-myocardial band isoenzyme (CK-MB) combined with different cardiac troponin (cTn) assays in AMI diagnosis.

METHODS: This multicenter, observational study included 3,706 patients with acute chest pain from September 1, 2015, to September 30, 2017. We classified the participants into three groups according to the cTn assays: the point-of-care cTn (POC-cTn) group, the contemporary cTn (c-cTn) group, and hs-cTn group. The diagnostic value was quantified using sensitivity and the area under the curve (AUC).

RESULTS: Compared to the single POC-cTn/c-cTn assays, combining CK-MB and POC-cTn/c-cTn increased the diagnostic sensitivity of AMI (56.1% vs. 63.9%, P<0.001; 82.7% vs. 84.3%, P=0.025). In contrast, combining CK-MB and hs-cTn did not change the sensitivity compared with hs-cTn alone (95.0% vs. 95.0%, P>0.999). In the subgroup analysis, the sensitivity of combining CK-MB and c-cTn increased with time from symptom onset <6 h compared with c-cTn alone (72.8% vs. 75.0%, P=0.046), while the sensitivity did not increase with time from symptom onset >6 h (97.5% vs. 98.3%, P=0.317). The AUC of the combination of CK-MB and POC-cTn significantly increased compared to the single POC-cTn assay (0.776 vs. 0.750, P=0.002). The AUC of the combined CK-MB and c-cTn/hs-cTn assays did not significantly decrease compared with that of the single c-cTn/hs-cTn assays within 6 h.

CONCLUSIONS: The combination of CK-MB and POC-cTn or c-cTn may be valuable for the early diagnosis of AMI, especially when hs-cTn is not available.

Key words: Creatine kinase-myocardial band isoenzyme, Cardiac troponin, Acute myocardial infarction, Emergency department

Guang-mei Wang, Yong Li, Shuo Wu, Wen Zheng, Jing-jing Ma, Feng Xu, Jia-qi Zheng, He Zhang, Jia-li Wang, Yu-guo Chen. The combination of creatine kinase-myocardial band isoenzyme and point-of-care cardiac troponin/ contemporary cardiac troponin for the early diagnosis of acute myocardial infarction[J]. World Journal of Emergency Medicine, 2022, 13(3): 163-168.

Figures/Tables 3

Table 1.

Basic characteristics of analyzed patients

Parameters	CK-MB-/cTn- (n=2,811)	CK-MB-/cTn+ (n=450)	CK-MB+/cTn- (n=127)	CK-MB+/cTn+ (n=318)	P-value
Age, years, mean±SD	62.9±13.8	67.7±12.9	66.2±11.4	65.0±12.8	<0.001
Male sex, n (%)	1,436 (51.1)	263 (58.4)	75 (59.1)	205 (64.5)	<0.001
Body mass index, kg/m², mean±SD	25.0±3.5	24.7±3.5	24.5±3.8	24.9±3.9	0.293
Medical history, n (%)
Hypertension	1,603 (57.0)	294 (65.3)	81 (63.8)	190 (59.7)	0.005
Diabetes	615 (21.9)	141 (31.3)	34 (26.8)	91 (28.6)	<0.001
Previous coronary heart disease	826 (29.4)	165 (36.7)	35 (27.6)	88 (27.7)	0.011
History of heart failure	77 (2.7)	33 (7.3)	5 (3.9)	14 (4.4)	<0.001
Chronic renal dysfunction	42 (1.5)	29 (6.4)	1 (0.8)	13 (4.1)	<0.001
Stroke	348 (12.4)	60 (13.3)	17 (13.4)	39 (12.3)	0.934
Smoking (previous or current)	924 (32.9)	210 (46.7)	46 (36.2)	133 (41.8)	<0.001
Family history	400 (14.2)	47 (10.4)	21 (16.5)	35 (11.0)	0.057
Clinical findings, mean±SD
Systolic BP (mmHg)^a	148.9±26.4	146.9±29.8	149.7±26.3	143.0±28.0	0.002
Heart rate, beats/min^b	79.9±18.2	84.8±21.1	79.6±20.2	82.8±22.1	<0.001
Initial electrocardiogram^c, n (%)					<0.001
Ischemic electrocardiogram	1,076 (39.3)	230 (52.8)	64 (51.6)	196 (64.1)
Non-diagnostic ST-T changes	393 (14.4)	74 (17.0)	24 (19.4)	49 (16.0)
Normal	767 (28.0)	52 (11.9)	19 (15.3)	16 (5.2)
Other	501 (18.3)	80 (18.3)	17 (13.7)	45 (14.7)
Time from onset of symptoms to the first blood sample^d, h, median (interquartile range)	3.9 (2.0-10.0)	3.9 (2.1-10.8)	4.7 (2.5-11.2)	7.3 (3.3-19.0)	<0.001
Medication in the first 24 h in the ED, n (%)
Aspirin	1,000 (35.6)	250 (55.6)	66 (52.0)	240 (75.5)	<0.001
Adenosine diphosphate inhibitors	602 (21.4)	205 (45.6)	38 (29.9)	222 (69.8)	<0.001
Low-molecular-weight heparin	285 (10.1)	130 (28.9)	30 (23.6)	146 (45.9)	<0.001
Statins	602 (21.4)	176 (39.1)	41 (32.3)	179 (56.3)	<0.001
Diagnosed with AMI, n (%)	154 (5.5)	233 (51.8)	27 (21.3)	272 (85.5)	<0.001
hs-cTn, n (%)	287 (10.2)	116 (25.8)	4 (3.1)	82 (25.8)	<0.001
POC-cTn, n (%)	935 (33.3)	122 (27.1)	46 (36.2)	90 (28.3)	<0.001

Table 1.

Table 2.

Diagnostic performance of cTn alone and in combination with CK-MB for the first detection

Parameters	Sensitivity (95% CI)	P-value	Specificity (95% CI)	PPV (95% CI)	NPV (95% CI)
All patients (n=3,706)
cTn	73.6% (70.3%-76.9%)		91.3% (90.3%-92.3%)	65.8% (62.4%-69.1%)	93.8% (93.0%-94.7%)
cTn+CK-MB	77.6% (74.4%-80.7%)	<0.001	88.0% (86.8%-89.1%)	59.4% (56.2%-62.7%)	94.5% (93.7%-95.4%)
POC-cTn	56.1% (50.3%-61.9%)		94.0% (92.4%-95.5%)	74.1% (68.2%-80.0%)	87.5% (85.4%-89.5%)
POC-cTn+CK-MB	63.9% (58.3%-69.6%)	<0.001	91.3% (89.5%-93.2%)	69.4% (63.8%-75.0%)	89.2% (87.2%-91.2%)
c-cTn	82.7% (78.4%-86.9%)		93.9% (92.8%-95.0%)	70.7% (66.0%-75.4%)	96.8% (96.0%-97.7%)
c-cTn+CK-MB	84.3% (80.2%-88.4%)	0.025	89.7% (88.3%-91.1%)	59.3% (54.7%-63.9%)	97.0% (96.1%-97.8%)
hs-cTn	95.0% (90.7%-99.3%)		73.5% (69.1%-77.9%)	48.0% (41.0%-54.9%)	98.3% (96.8%-99.8%)
hs-cTn+CK-MB	95.0% (90.7%-99.3%)	>0.999	72.5% (68.1%-76.9%)	47.0% (40.1%-53.9%)	98.3% (96.7%-99.8%)
Onset of symptoms <6 h (n=2,231)
cTn	63.4% (58.8%-67.9%)		91.8% (90.5%-93.0%)	65.0% (60.5%-69.6%)	91.2% (89.9%-92.5%)
cTn+CK-MB	67.3% (62.9%-71.7%)	<0.001	89.0% (87.5%-90.4%)	59.6% (55.2%-63.9%)	91.8% (90.6%-93.1%)
POC-cTn	47.2% (40.3%-54.2%)	<0.001	94.1% (92.3%-95.9%)	71.2% (63.5%-78.9%)	85.3% (82.7%-87.9%)
POC-cTn+CK-MB	53.8% (46.8%-60.7%)		91.7% (89.5%-93.8%)	66.5% (59.2%-73.8%)	86.6% (84.0%-89.1%)
c-cTn	72.8% (66.4%-79.3%)		93.6% (92.1%-95.2%)	68.7% (62.2%-75.2%)	94.7% (93.3%-96.1%)
c-cTn+CK-MB	75.0% (68.7%-81.3%)	0.046	90.4% (88.5%-92.3%)	60.0% (53.7%-66.3%)	95.0% (93.5%-96.4%)
hs-cTn	92.2% (84.8%-99.5%)		74.3% (68.2%-80.5%)	49.0% (39.0%-59.0%)	97.3% (94.6%-99.9%)
hs-cTn+CK-MB	92.2% (84.8%-99.5%)	>0.999	72.8% (66.5%-79.1%)	47.5% (37.6%-57.3%)	97.2% (94.5%-99.9%)
Onset of symptoms ≥6 h (n=1,368)
cTn	91.0% (87.4%-94.6%)		90.2% (88.5%-92.0%)	66.9% (61.8%-71.9%)	97.9% (97.0%-98.8%)
cTn+CK-MB	95.1% (92.4%-97.8%)	0.002	86.3% (84.3%-88.3%)	60.1% (55.2%-65.0%)	98.8% (98.1%-99.5%)
POC-cTn	76.6% (67.2%-86.1%)		93.5% (90.5%-96.6%)	78.7% (69.4%-87.9%)	92.8% (89.6%-96.0%)
POC-cTn+CK-MB	88.3% (81.1%-95.5%)	0.003	90.7% (87.1%-94.3%)	74.7% (65.8%-83.7%)	96.2% (93.7%-98.6%)
c-cTn	97.5% (94.7%-100.0%)		94.0% (92.2%-95.8%)	74.1% (67.2%-80.9%)	99.5% (99.0%-100.0%)
c-cTn+CK-MB	98.3% (96.0%-100.0%)	0.317	88.7% (86.3%-91.1%)	60.5% (53.7%-67.4%)	99.7% (99.2%-100.0%)
hs-cTn	97.9% (93.7%-100.0%)		72.8% (66.6%-79.1%)	46.5% (36.6%-56.3%)	99.3% (97.9%-100.0%)
hs-cTn+CK-MB	97.9% (93.7%-100.0%)	>0.999	72.3% (66.0%-78.6%)	46.0% (36.2%-55.8%)	99.3% (97.9%-100.0%)

Table 2.

Figure 1.

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