3

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 2
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 1
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 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF MEDICINE
DEPARTMENT OF BIOCHEMISTRY
AUGUST 5, 2010

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 Barsaga, Mark Lester A.

Basilio, Rhealyn G.

Baui, Bernard Jr. G.

Bañas, Philip Gideon T.

Belada, Ralph Patrick G.

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 Specific Objective
– To understand myocardial infarction, and the
biochemical events that lead to it.
– To identify enzymes that are significant in the
diagnosis of MI.
– To identify isoenzymes and how can they be
use in diagnosis of MI.
– To determine the initial rise, peak and descent
of serum levels of enzymes.
– To know the significance of proper timing of
enzymes assays in the diagnosis of MI.

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 Specific Objective
– To know the other proteins not enzymatic in
nature and its significance to MI diagnosis.
– To determine enzymes which are of
“therapeutic” value to MI and their mechanism
of actions.
– To cite examples of anti-thrombotic drugs that
can be use in MI and their mechanism of action.
– To define repurfusion injury and its relation to
thrombolytic theraphy.

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 INTRODUCTION:
 Acute myocardial infarction (MI) is defined as the death
or necrosis of myocardial cells due to occlusion in the
coronary artery by a thrombus that result to the
insufficient or cease of blood flow. (Guyton and Hall 11th
edition, pp. 231)
 Commonly known as “heart attack”
 Derived from the words “myocardium” or heart muscle,
and “infarction,” which means tissue death due to
oxygen insufficiency.
 Approx. 90% occlusion in the blood vessel , blood flow
through the affected vessel may cease (total ischemia)
and the 02 supply of to myocardium is compromised.
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 Ascending Aorta

• Diagram :
• 1. occlussion of a branch of the left coronary artery
• 2. myocardial infarction resulting from #1 at the anterior wall of the heart
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 Ascending Aorta

• Diagram :
• 1. occlussion of a branch of the left coronary artery
• 2. myocardial infarction resulting from #1 at the anterior wall of the heart
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 2 Types of Myocardial
Infarction

• Transmural - characterized by ischemic

necrosis of the full thickness of the
affected muscle segment(s).

• Non Transmural – as an area of ischemic

necrosis that does not extend through the
full thickness of the myocardial wall
segment(s)

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 Classic Symptoms of MI
• Chest pain (angina pectoris)
- the most common symptom of acute
myocardial infarction due to ischemia.
• Shortness of breath (dyspnea)
occurs when the damage to the heart
limits the output of the left ventricle
resulting to low cardiac output and less
venous return.
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 Biochemical Events

In Myocardial Infarction

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 Development of atherosclerosis Plaque Rupture

Deprivation of blood supply

Formation of large thrombus in a
(ischemia) to an area of
coronary artery
myocardium
Shift to anaerobic glycolysis> NADH due to terminal electron
synthesis of ATP, depletion of transport chain; due to lack of O2
adenine nucleotide pool

Accumulation of lactic acid and

pH in heart muscle cells other metabolites in myocardium
causing cellular osmolarity &
altered membrane permeability
Inefficient of heart muscles
Cessation of contraction
Activation of membrane
Death of affected are of heart phospholipases, degradation of
muscles proteins by proteases, influx of
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3 ++ >> 4 >>
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 Development of atherosclerosis Plaque Rupture

Deprivation of blood supply

Formation of large thrombus in a
(ischemia) to an area of
coronary artery
myocardium
Shift to anaerobic glycolysis> NADH due to terminal electron
synthesis of ATP, depletion of transport chain; due to lack of O2
adenine nucleotide pool

Accumulation of lactic acid and

pH in heart muscle cells other metabolites in myocardium
causing cellular osmolarity &
altered membrane permeability
Inefficient contractiion of heart
muscles Cessation of contraction
Activation of membrane
Death of affected area of the phospholipases, degradation of
heart muscles proteins by proteases, influx of
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3 ++ >> 4 >>
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 ENZYME
ISOENZYME
(ISOZYME)

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 ENZYMES
• Enzymes are very important molecules in
biology. Enymes are proteins that help to
speed up chemical reactions in the body
• Accelerates reactions in cells
• Break old covalent bonds and form new
covalent bonds
• Regulate metabolic reaction rates
• Biologic catalyst

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 ENZYMES

• Catalyst
• Substance that increase the rate of a
chemical reaction. It is not change by the
reaction. It does not alter the equilibrium
constant of a reaction.

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 ENZYMES as CATALYST
Its qualities include:

• Enzymes are very specific - chemical catalysts can react with

a variety of substrates. Enzymes catalyze only a single type
of reaction, and work only in one or few substrate compounds
• Enzymes are often regulated by (1)concentration of
substratres,by binding small molecules or other proteins. (2)
By covalent modification of the enzmes amino acids side
chain.
• Enzymes are stereo specific - chemical catalyst of a reaction
usually leads to a mixture of stereoisomers either the D or L
isomer, but not both

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 ENZYMES as CATALYST

• Enzymes are Macromolecules - Composed of protein, or in

a few cases, RNA.
• Enzymes work under mild conditions – chemical catalyst
often require high temperature and/ or pressure to. These
conditions of temperature , pressure , and pH characterize
enzymatic catalysis, especially with in cells.

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 Terminologies
• Coenzymes - small non protein ligands that
catalyze reactions
• Cofactors – small inorganic ions which act as
activators and/or inhibitors of activity. Mostly
metal ions: Cu, Mg, Mn, Fe.
• Active site – portion of enzyme which folds to
precisely fit the contours of a substrate via weak
electrostatic interactions and facilitates bond
reactivity.
• Prosthetic group – large complex organic
molecules, which may have catalytic activity.
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 ENZYMES
What are the Mechanism used by enzyme to get it
easier to the transition state?

• Proximity- enzymes can bring 2 molecules together in

solution.

• Orientation - even when two molecules collide with

enough energy to cause reaction, they don’t necessarily
form the products, they have to be oriented properly.
Enzymes bind substrates so that the reactive groups are
steered to the reaction that can lead to a reaction.

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 ENZYMES
• Reactive amino acid groups – the side chains of amino
acids contain a variety of reactive residues.

• Induced fit – enzymes as a flexible. In this regard they

are different form solid catalyst, like the metal catalyst s
used in chemical hydrogenation.

• Coenzymes and metal ions - coenzymes are bio

molecules that provide chemical groups that help
catalysis. They are not change during catalysis. Metal
ions which act as a activators and or inhibitors of activity.
Eg. Cu, Mg, Mn, Fe.

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 TYPES of Enzyme Catalayst
• Oxidoreductases – catalyzes oxidation reduction
reactions, often using coenzyme as NAD/ FAD
• Transferases- catalyze the transfer of functional group
• Hydrolyases – catalyzes hydrolytic reactions adds water
across C-C bonds
• Lyases – cleave C-C, C-O, C-N and other bonds
generating a C=C bond or ring
• Isomerases- the position of a functional group is change
w/ in molecule, but the molecule itself contains the same
number and kind of atoms that it did in the beginning.
The catalyze the isomerizations.
• Ligases- condensation of two substrate with splitting of
ATP. Removes the elements of water from two fuctional
>> groups
0 to form1a single
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 How are Enzymes Regulated
Anchoring enzymes in membranes – in plasma
membrane,membrane of mitochondria and chloroplast s,
endoplasmic reticulum and nuclear envelop.
Inactive precursor
Allosteric regulation – change in kinetic property of an
enzyme cause by binding to another molecule. The binding
of a small molecule to the enzyme alters it conformation so
that it carries catalysis more or less efficiently. The first
conformation is termed T (tense ) state, the second is
called R (relax) state. The higher the concentration of
substrate favor the conversion of T to R state.
Covalent modification
Regulation of enzyme synthesis

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 ISOENZYMES
also known as isozymes
are enzymes that differ in amino acid sequence but
catalyze the same chemical reaction. These enzymes
usually display different kinetic parameters (e.g. different
KM values), or different regulatory properties. The
existence of isozymes permits the fine-tuning of
metabolism to meet the particular needs of a given tissue
or developmental stage (for example lactate
dehydrogenase (LDH)).
In biochemistry, isozymes are isoforms (closely related
variants) of enzymes. In many cases, they are coded for
by homologous genes that have diverged over time.

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 Aspartate Aminotransferase
• sensitivity progressively decay and higher degree of
specificity
• Highest concentration found in cardiac tissue, liver, and
skeletal muscle
• Involved in the transfer of amino group between aspartate
and alpha keto acids
• Low levels of AST are normally found in the blood

– Appears in blood 6-10 hours

– peaks at 12-48 hours
– returns to normal in 3-4 days

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 Lactate Dehydrogenase
• Lactate dehydrogenase catalyses the conversion of
pyruvate to lactate.
• Lactate Dehydrogenase levels are also high in tissue
breakdown or hemolysis. It can mean cancer, meningitis,
encephalitis, or HIV.

– Appears in blood 8-10 hours

– Peaks at 72 hours
– Back to normal in 8-12 days

• It is not as specific as troponin.

• Has 2 monomers: H (for heart) M (for muscle)

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 Lactate Dehydrogenase Isozyme
• 5 isozymes: HHHH (I1) predominates heart tissue
HHHM (I2) blood serum
HHMM (I3)
HMMM (I4)
MMMM (I5) liver
• Lactate Dehydrogenase 1 (LDH-1) isozyme is
normally found in the heart muscle and Lactate
Dehydrogenase-2 (LDH-2) is found predominately in
blood serum.
• A high LDH-1 level to LDH-2 suggest MI.

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 Creatine Kinase
 Also known as creatine phosphokinase
 Creatine kinase is released when any muscle cell undergoes
necrosis, which makes it a specific and sensitive marker for any
muscle injury.
 An enzyme that catalyzes the muscle reaction between creatine
phosphate and adenosine diphosphate (ADP), yielding adenosine
triphosphate (ATP) and creatine. Adenosine triphosphate, along with
magnesium, provides the energy for muscle contraction. Creatine
phosphate, the substrate of CK, is a rather unstable compound that
is autohydrolyzed to creatinine. Although creatinine has no real
function, its predictable concentration in muscle, as well as its known
rate of excretion by the kidney, makes it a valuable marker for renal
function measurements.
 The sensitivity of the CK determination is limited because the
increase in serum CK is relatively small, lasts only a short time after
the onset of pain and may be obscured by differences in normal
serum levels.
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 Creatine Kinase Isozyme
• This enzyme is found in heart muscle (CK-MB),
skeletal muscle (CK-MM), and brain (CK-BB). 
• Creatine kinase is increased in over 90% of
myocardial infarctions. However, it can be
increased in muscle trauma, physical exertion,
postoperatively, convulsions, delirium tremens and
other conditions.
• Time sequence after myocardial infarction
– begins to rise 4-6 hours
– Peaks at 24 hours
– returns to normal in 2-3 days
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 Creatine Kinase Isozyme
CK-MB resides in the cytosol and facilitates high energy
phosphates into and out of mitochondria. It is distributed in a
large number of tissues even in the skeletal muscle. Since it
has a short duration, it cannot be used for late diagnosis of
acute MI but can be used to suggest infarct extension if
levels rise again. This is usually back to normal within 2–3
days.
It is relatively specific when skeletal muscle damage is not
present.
CK-MB is the most sensitive and specific marker of MI. The
blood levels of CK-MB rise by 6-8 hrs and peak at 12-48 hrs
later.

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 Creatine Kinase
• Creatine kinase isozymes.Combine at
random to give three isozymes:
– • CK-MM (primarily muscle)
– • CK-MB (hybrid)
– • CK-BB (primarily brain)

• The CK-MB has its highest concentration in

heart muscle
• CK-MB >5% of total CPK strongly suggests
myocardial infarction
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 Creatine Kinase

• This test is becoming more popular. MB2 is

released from heart muscle and converted in
blood to MB1.

– A level of MB2 equal or greater than 1.0 U/L and

an MB2/MB1 ratio equal or greater than 1.5
indicates myocardial infarction.

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 Comparison
ENZYMES Initial Rise Peak Level Descent

Aspartate 6-10 Hrs 12-48 Hrs 3-4 Days

Aminotransferase

Lactate 8-10 Hrs 72 Hrs 8-12 Days

dehydrogenase

Creatinine Kinase 4-6 Hrs 24 Hrs 2-3 days

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 The Importance
of the timing of Enzyme
Assays in the Diagnosis
of MI

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 >>>
Enzyme assays are laboratory methods for
measuring enzymatic activity. They are
vital for the study of enzyme kinetics and
enzyme inhibition.
A rapid laboratory turn around time for
cardiac markers is essential.
Once a sample is drawn from a patient,
structural changes in the enzymes can take
place, which can alter the result of a test,
therefore, a quick turnaround time must be
practiced to avoid these changes.
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 NON-ENZYME
PROTEIN
Significant to MI diagnosis

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 Troponin
Troponin - protein involve in muscle contraction in
skeletal and cardiac but not in smooth muscle.
- normally it is tightly bounded to
contractile apparatus of muscle protein with minimal
amount presence in the blood.
- 0-0.1 ug/L
Troponin I - prevents binding of myosin and actin
Troponin C- calcium ion accceptor
Troponin T- binds Troponin C and Troponin I to
tropomyosin

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 Troponin
The most sensitive and specific test for
myocardial damage. Because it has increased
specificity compared with CK-MB, troponin is a
superior marker for myocardial injury
The troponin T and troponin I of cardiac muscle
differ structurally, and therefore antigenically,
from their skeletal muscle counterparts.
Skeletal troponin is not detected by cardiac
troponin assay.
Troponin C of both cardiac and skeletal muscle
have the same structure.
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 Troponin

• Troponin I (cTnI) or T (cTnT) are the forms

frequently assessed. 
– appears in blood 2 - 6
– Peaks in 12 - 16 hours
– Returns to normal 5-9 days

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 Myoglobin
Myoglobin is a monomeric protein of red muscle,
stores O2 as a reserve against O2 deprivation.
Elevated when muscle tissue is damaged but it
lacks specificity.
earliest marker for myocardial injury.
Used together with cardiac troponin and CK-MB
assays, the myoglobin assay can give valuable
clinical information as to the time of injury and the
presence of re-injury.

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 Myoglobin
A negative test is useful 1-2 hours after the onset of
symptoms to rule out myocardial necrosis. But
because the same myoglobin is present in all types
of muscle, many conditions can produce a positive
myoglobin test.

• Time sequence after myocardial infarction

– Rises fast (2 hours) after myocardial infarction
– Peaks at 6 - 8 hours
– Returns to normal in 20 - 36 hours

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 Comparison
ENZYMES Initial Rise Peak Level Descent

Troponin 4-8 Hrs 12-16 Hrs 5-9 days

Myoglobin 2 Hrs 6-8 Hrs 20-36 Hrs

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 Thrombolytic Drugs

Used in MI

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Classification
Mechanism of Action sample
of Drugs
It is a substance stops
Heparin,
blood from clotting or
Anticoagulant Coumadin,
limits the ability of the
LMWH
platelets to clot
They decreases
platelet aggregation Aspirin,
Antiplatelet
and inhibits thrombus Clopidogrel
formation

used in medicine to Streptokinase,

Thrombolytic tPA, Urokinase
dissolve blood clots

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 Heparin

Heparin is a biological substance,

usually made from pig intestines.

It works by activating antithrombin III,

which blocks thrombin from clotting
blood.

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 Aspirin

Irreversibly inhibits the enzyme COX,

resulting in reduced platelet production of
TXA2 (thromboxane - powerful
vasoconstrictor which lowers cyclic AMP
and initiates the platelet release reaction)

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 Streptokinase
• a protein secreted by several species of streptococci
(group C, ß-hemolytic streptococci) can bind and
activate human plasminogen.

• Streptokinase belongs to a group of medications known

as fibrinolytics, and complexes of streptokinase with
human plasminogen can hydrolytically activate other
unbound plasminogen by activating through bond
cleavage to produce plasmin.

• It is used as an effective and inexpensive clot-dissolving

medication.

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 Tissue Plasminogen Activator tPA PLAT
• Derived by recombinant genetics from human DNA

• It s a protein involved in the breakdown of blood clots.

It activates plasminogen associated with fibrin directly
by enzymatic action.

• As an enzyme, it catalyzes the conversion of

plasminogen to plasmin, the major enzyme responsible
for clot breakdown. Because it works on the clotting
system, tPA is used in clinical medicine to treat only
embolic or thrombotic stroke

• Recombinant tissue plasminogen activator (Alteplase,

Reteplase, Tenecteplase)
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 Thrombolytic Theraphy
• It is the drugs use to dissolve clot

• The primary goal of treatment is to quickly open

the blocked artery and restore blood flow to the
heart muscle, a process called reperfusion

• When the blood clot forms in the blood vessel,

it may cut off and reduced the blood flow to the
parts of the body that are served by the blood
vessels. This can cause a severe damage to
that part of the body

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 Repurfusion Injury

• Refers to damage to tissue caused when blood

supply returns to the tissue after a period of
ischemia.

• The absence of oxygen and nutrients from

blood creates a condition in which the
restoration of circulation results in
inflammation and oxidative damage through the
induction of oxidative stress rather than
restoration of normal function.

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 END

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