Characterization of cardiac brain natriuretic peptide release in patients with paroxysmal atrial fibrillation undergoing left atrial ablation.

BACKGROUND: Paroxysmal atrial fibrillation (PAF) is associated with elevated levels of brain natriuretic peptide (BNP). The exact cardiac source and implications of this are currently unknown, as are the effects of left atrial ablation on cardiac BNP release. We sought to investigate BNP levels at different cardiac sites in PAF patients before and after left atrial ablation and compare these with a non-atrial fibrillation control cohort. METHODS AND RESULTS: Twenty PAF patients (52+/-10 years, 70% men; left ventricular ejection fraction, 55+/-3%) undergoing ablation were studied, BNP levels were measured at different cardiac sites before and after ablation and compared with a control cohort undergoing ablation for left lateral accessory pathways (10 patients, 41+/-11 years; left ventricular ejection fraction, 55+/-4%). In both cohorts, the coronary sinus BNP levels were the greatest. The PAF cohort had significantly greater BNP levels than the control cohort at all sites before and after ablation. Ablation of the left atrium was associated with a significant decrease in coronary sinus BNP levels (P=0.05) and transcardiac BNP gradient (P=0.03). This was not observed in the control cohort. CONCLUSIONS: BNP levels are elevated in PAF, with the highest levels in the coronary sinus. Ablation of the left atrium was associated with an immediate decrease of BNP levels, implicating this as the source.

Analytical evaluation of a newly developed ELISA mass assay for pancreatic amylase.

OBJECTIVE: To evaluate a newly developed ELISA mass assay for Pancreatic Amylase. METHODS: The serum levels of pancreatic amylase were measured by an in-house developed ELISA assay on microtitre plate and compared with two activity assays: immunoinhibition and electrophoresis. RESULTS: The proposed method was accurate and precise, as indicated by a recovery of 102% and coefficient of variation of less than 5% for within-run and less than 10% for between-run assay. The proposed assay showed good correlation with the activity assays (r = 0.98). The mass concentrations were three times higher than the activities. The relative values (mass or activity units/upper reference limits), however, were concordant in controls and in pancreatic and non-pancreatic conditions. CONCLUSION: Our results indicate that the activity measurements and mass concentrations of pancreatic amylase in serum are comparable and interchangeable after adjusting for the reference range.

Discordance between results for serum troponin T and troponin I in renal disease.

Two patients were investigated for unexplained increases in troponin T. In the first patient, who had rhabdomyolysis and acute renal failure, troponin T reached a peak value of 13.50 micrograms/L (67.5-fold the upper reference limit). The second patient had chronic renal failure and the troponin T peak value was 2.85 micrograms/L (14.3-fold the upper reference limit). Clinical investigations indicated no evidence of myocardial damage. Serum or plasma specimens were analyzed for total creatine kinase (CK), CK-2 mass, CK-2 isoform ratio, myoglobin, troponin T, troponin I, and myosin light chains; all except troponin I were at above-normal concentrations. We also investigated six additional renal patients with above-normal troponin T; troponin I was slightly increased in only one of these six patients. Our findings demonstrate discordance between results for troponin T and troponin I in renal patients.

Biochemical markers of myocardial damage.

OBJECTIVE: To assess various biochemical markers of myocardial damage. METHODS AND RESULTS: Before routinely using any test as a biochemical marker of myocardial damage, the published evidence for its diagnostic utility must be critically assessed. Such assessment includes receiver operator curve (ROC) curve analyses, confidence interval estimates of claimed sensitivity and specificity values, and the effects of testing in serial and parallel modes. It is also necessary to establish the test's rule-in (high specificity) and rule-out (high sensitivity) decision thresholds that may vary with time after the onset of symptoms. The spectrum of ischemic heart disease includes acute (sudden death, non-Q- and Q-wave infarctions) and chronic (stable, unstable, and variant angina) conditions. Biochemical markers of myocardial damage are of most value in the diagnosis of acute ischemic heart disease, although increasingly some of these markers are being found to possess a prognostic value in chronic ischemic heart disease. The markers of enzymatic activity include aspartate aminotransferase, creatine kinase (together with isoenzymes and isoforms), and lactate dehydrogenase and isoenzymes. Creatine kinase isoenzyme-2 may also be measured immunologically, and this type of assay is in increasing use both because of its speed and because its blood levels rise earlier than the corresponding activities. The commercially available nonenzymatic markers are myoglobin and troponin T; troponin I is expected to become available in late 1995. While myoglobin is a nonspecific indicator of myocardial damage, its diagnostic value is due to its early appearance in blood. Troponin T is more cardiac specific, but the published data appears to suggest that the cardiac specificity of troponin I is superior. Troponin levels become abnormal at about the same time after the onset of symptoms as mass assays of creatine kinase isoenzyme-2; therefore, they are not useful as early markers of myocardial damage. CONCLUSION: The availability of these nonenzymatic markers of myocardial damage must force a reassessment of the continued use of the enzymatic markers. Are they necessary, and if so, which ones should be retained?

Combination (multiple) testing for myocardial infarction using myoglobin, creatine kinase-2 (mass), and troponin T.

We retrospectively determined the mass concentrations of myoglobin, creatine kinase-2 (CK-2), and troponin T in serial samples from 80 patients with confirmed myocardial infarction (MI) and 60 non-MI patients. Results from receiver operating characteristic curve analyses show that all three tests are comparable in their diagnostic utility within the first 12 h of infarction. Decision thresholds were selected at a constant rule-in specificity of 95% and rule-out sensitivities of 95% at, respectively, 3-6, 6-9, and 9-12 h intervals after the onset of symptoms. Test sensitivities and specificities were compared for each, used as: a single test; two-test parallel combination; three-test parallel combination; two-test series combination; and three-test series combination. Our results from combination testing indicate what for the early diagnosis of MI, a single serum myoglobin measurement has diagnostic utility at 3 h after the onset of symptoms, and myoglobin and CK-2 (mass) in combination later than 3 h following the onset of symptoms. Serum troponin T is diagnostically similar to CK-2 (mass), although it has superior cardiac-tissue specificity, but it is not as yet commercially available as a "stat" test. Therefore, we recommend using troponin T as a confirmatory test 9 h after the onset of MI. Based on our findings, we suggest a testing algorithm for the early biochemical diagnosis of MI.

Diagnostic evaluation of creatine kinase-2 mass and creatine kinase-3 and -2 isoform ratios in early diagnosis of acute myocardial infarction.

The diagnostic efficacy of creatine kinase (CK) isoforms (CK-3 and CK-2) was compared with measurement of CK-2 mass concentrations for the early diagnosis of myocardial infarction (MI). Serial serum samples drawn from 76 patients with confirmed MI and 55 non-MI patients were used for determining CK-2 mass concentrations and the MM3/MM1 (CK-3 isoforms) and MB2/MB1 (CK-2 isoforms) ratios. We compared the diagnostic utility of each by receiver-operating-characteristic (ROC) curve and likelihood ratio analyses. Our results indicate that all three tests were ineffective within the first 4 h after the onset of chest pain. All three were most effective at 4-18 h after onset, but both CK-3 and CK-2 isoform ratios were less effective than CK-2 mass concentrations in the next 6-h period (18-24 h). In the critical time between 3 and 6 h, the diagnostic performance of all three was comparable.

Triiodothyronine uptake measurement in serum by time-resolved fluorescence immunofluorometry.

A solid phase competition-type fluoroimmunoassay for triiodothyronine (T3) uptake in serum is described. In the assay, exogenous free T3 binds to the unoccupied binding sites on serum thyroxine binding proteins while the remaining unbound T3 competes with immobilized T3 for binding to a soluble biotinylated anti-T3 monoclonal antibody. The bound biotinylated antibody is quantitated by the addition of streptavidin labeled with the europium chelator 4,7-bis(chlorosulfophenyl-1,10 phenanthroline-2,9-bicarboxylic acid (BCPDA) in the presence of excess europium. The fluorescence signal of the final complex, which is directly proportional to the number of unoccupied binding sites on thyroxine binding proteins, is then measured on the dried solid-phase with a pulsed-laser time-resolved fluorometer. The assay requires a 10 microliters serum sample and a total incubation time of 90 minutes. The coefficients of variation for within-run and between-run assays ranged from 2.0 to 5.7%. Results obtained by the present method compared well with those determined by two commercial radioimmunoassays (r greater than 0.9).

A double monoclonal time-resolved immunofluorometric assay of carcinoembryonic antigen in serum.

A non-isotopic heterogeneous non-competitive immunoassay for carcinoembryonic antigen is described. CEA present in serum binds simultaneously to two monoclonal antibodies specific for different antigenic determinants of CEA. One antibody is immobilized on a solid-phase (microtiter well) and the other is biotinylated. The amount of biotinylated antibody bound is measured on the dried solid-phase by time-resolved fluorometry after adding streptavidin labeled with the europium chelate 4,7-bis(chlorosulfophenyl)-1,10 phenanthroline-2, 9-dicarboxylic acid (BCPDA) in the presence of excess Eu3+. The assay is simple to perform, its characteristics are similar to those of other isotopic and non-isotopic techniques, and it is suitable for routine clinical use.

A simple time-resolved fluoroimmunoassay of total thyroxine in serum.

We describe a non-isotopic heterogeneous competitive immunoassay of total thyroxine in serum. Thyroxine, released from its binding proteins by merthiolate (thimerosal), competes with immobilised thyroxine (thyroxine-bovine globulin conjugate) for binding to a monoclonal biotinylated antibody. The amount of biotinylated antibody bound, which is inversely related to the amount of thyroxine in the sample, is then quantified by adding streptavidin labelled with the europium chelator 4,7-bis(chlorosulphophenyl)-1,10-phenanthroline-2,9-dicarboxylic acid (BCPDA) in the presence of excess Eu3+. The complex formed (bovine globulin-thyroxine-antibody-biotin-streptavidin-BCPDA-Eu3+) is measured on the solid-phase by time-resolved fluorescence. The assay is simple to perform and its characteristics are similar to those of other currently used immunoassay techniques.

Time-resolved fluoroimmunoassay of cortisol in serum with a europium chelate as label.

A non-isotopic heterogeneous competitive immunoassay of serum cortisol is described. Cortisol present in the sample competes with immobilised cortisol (cortisol-thyroglobulin conjugate) for binding to a monoclonal anti-cortisol biotinylated antibody. The amount of antibody bound is measured on the dry solid-phase by time-resolved fluorometry after adding streptavidin labeled with the Eu3+ chelate 4,7-bis(chlorosulfophenyl)-1,10 phenanthroline-2,9-dicarboxylic acid (BCPDA), in the presence of excess Eu3+. The assay is simple to perform, its characteristics are similar to those of radioimmunoassay techniques, and is suitable for routine clinical use.

Amino acid sequence of Escherichia coli citrate synthase.

Detailed evidence for the amino acid sequence of allosteric citrate synthase from Escherichia coli is presented. The evidence confirms all but 11 of the residues inferred from the sequence of the gene as reported previously [Ner, S. S., Bhayana, V., Bell, A. W., Giles, I. G., Duckworth, H. W., & Bloxham, D. P. (1983) Biochemistry 22, 5243]; no information has been obtained about 10 of these (residues 101-108 and 217-218), and we find aspartic acid rather than asparagine at position 10. Substantial regions of sequence homology are noted between the E. coli enzyme and citrate synthase from pig heart, especially near residues thought to be involved in the active site. Deletions or insertions must be assumed in a number of places in order to maximize homology. Either of two lysines, at positions 355 and 356, could be formally homologous to the trimethyllysine of pig heart enzyme, but neither of these is methylated. It appears that E. coli and pig heart citrate synthases are formed of basically similar subunits but that considerable differences exist, which must explain why the E. coli enzyme is hexameric and allosterically inhibited by NADH, while the pig heart enzyme is dimeric and insensitive to that nucleotide.