European Heart Journal Advance Access originally published online on August 3, 2007
European Heart Journal 2007 28(18):2297-2298; doi:10.1093/eurheartj/ehm317
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High-risk ACS patients and cardiac biomarkers in the emergency department: any role for new biomarkers of myocardial ischaemia? Reply
University of Arkansas for Medical Sciences
Little Rock
AR 72205
USA
University of Arkansas for Medical Sciences
Little Rock
AR 72205
USA
Division of Cardiovascular Medicine
University of Arkansas for Medical Sciences
4301 W Markham, Slot 532
Little Rock
AR 72205
USA
Tel: +1 501 296 1401 Fax: +1 501 686 6180 E-mail address: mehtajl{at}uams.edu
Roy et al. have raised an interesting question of the role of additional biomarkers like ischaemia-modulated albumin (IMA) for the early detection of myocyte injury in the setting of acute coronary syndrome. Indeed, many such markers including, unbound free fatty acids, glycogen phosphorylase isoenzyme BB and choline have been proposed for early detection of cardiac ischaemia.1 Everyone is interested in finding the next biomarker that will be more specific and possibly cheaper than the current biomarkers in the diagnosis and prediction of coronary atherosclerosis in general, and acute coronary syndrome in particular.2,3
The fundamental issue with all markers of ischaemia is that there is no gold standard for the diagnosis of cardiac ischaemia. Specifically with respect to IMA, low specificity (the test is positive in many conditions like cancer, infections, end-stage renal disease, liver disease, and brain ischaemia), need for standardization of the test assay, adjustment for baseline albumin, and frequent overlap between normal and abnormal values renders this test difficult to interpret in many patients.4 IMA has been evaluated in differentiating non-cardiac from cardiac chest pain in the emergency department only in a few studies. The utility of IMA still remains to be tested in a wide array of patients presenting with chest pain including those with coronary vasospasm and chronic stable angina.
Overall, based on current evidence, the ACB test (designed to test for IMA) seems best for evaluating patients with low-intermediate risk factors for coronary artery disease, negative troponin, and negative ECG at presentation. We agree that further objective assessment of markers like IMA hold promise as an exciting modality because they may detect myocardial ischaemia before necrosis.
Somehow, one gets a feeling that the authors of the paper wanted more to advertise their work with IMA than to be specific about the role of cardiac troponins and other biomarkers.
References
- Ridker PM, Brown NJ, Vaughan DE, Harrison DG, Mehta JL. Established and emerging plasma biomarkers in the prediction of first atherothrombotic event. Circulation (2004) 109(25 Suppl. 1):IV6–IV19.[Medline]
- Apple FS, Wu AH, Mair J, Ravkilde J, Panteghini M, Tate J, Pagani F, Christenson RH, Mockel M, Danne O, Jaffe AS. Future biomarkers for detection of ischemia and risk stratification in acute coronary syndrome. Clin Chem (2005) 51:810–824.
[Abstract/Free Full Text] - Mehta JL. Oxidized or native LDL-cholesterol-Which is more important in atherogenesis? (Editorial). J Am Coll Cardiol (2006) 48:980–982.
[Free Full Text] - Parikh SV, de Lemos JA. Biomarkers in cardiovascular disease: integrating pathophysiology into clinical practice. Am J Med Sci (2006) 332(4):186–197.[CrossRef][Web of Science][Medline]
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