Document Type: Review Article


1 Department of Emergency Medicine, Tabriz University of Medical Science, Tabriz, Iran

2 Student’s Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran

3 Kerman Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran


Objective: Acute chest pain is an important and frequently occurring symptom in patients. Chest pain is often a sign of ischemic heart disease. Chest pain due to suspected Acute Coronary Syndrome (ACS) is responsible for a large and ijncreasing number of hospital attendances and admissions. Current practice for suspected ACS involves troponin testing 10–12 hours after symptom onset to diagnose Myocardial Infarction (MI). Patients with a negative troponin can be investigated further with Computed Tomographic Coronary Angiography (CTCA) or exercise Electrocardiography (ECG). A review of cardiac biomarkers as screening test in acute chest pain over 15 years was conducted. Separate searches were under taken for biomarkers. We Searched electronic databases up to 2004-2014, reviewed citation lists and contacted experts to identify diagnostic and prognostic studies comparing a relevant index test (biomarker, CTCA or exercise ECG) to the appropriate reference standard. We classified studies to two part early rise biomarkers, high sensitivity biomarkers.

Conclusion: Although presentation troponin has suboptimal sensitivity, measurement of a 10-hour troponin level is unlikely to be cost-effective in most scenarios compared with a high sensitivity presentation troponin. Measurement of cardiac troponin using a sensitive method was the best test for the early diagnosis of an Acute Myocardial Infarction (AMI). Measurement of myoglobin or Creatine Kinase-MB (CK-MB) in addition to a sensitive troponin test is not recommended. Heart-type Fatty Acid-Binding Protein (H-FABP) shows promise as an early marker and requires further study.


Main Subjects

1. Shams-Vahdati S, Vand-Rajavpour Z, Paknezhad SP, Piri R, Moghaddasi-Ghezeljeh E, Mirabolfathi S, et al. Cost-effectiveness of cardiac biomarkers as screening test in acute chest pain. J Cardiovasc Thorac Res 2014; 6(1): 29-33.

2. Goodacre S, Thokala P, Carroll C, Stevens JW, Leaviss J, Al Khalaf M, et al. Systematic review, meta-analysis and economic modelling of diagnostic strategies for suspected acute coronary syndrome. Health Technol Assess 2013;17 (1):v-vi, 1-188.

3. Goldberg RJ, Currie K, White K, Brieger D, Steg PG, Goodman SG, et al. Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (the Global Registry of Acute Coronary Events [GRACE]). Am J Cardiol 2004; 93(3): 288-93.

4. Thygesen K, Alpert JS, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007; 28(20): 2525-38.

5. Ebell MH, Flewelling D, Flynn CA. A systematic review of troponin T and I for diagnosing acute myocardial infarction. J Fam Pract 2000; 49(5): 550-6.

6. Ebell MH, White LL, Weismantel D. A systematic review of troponin T and I values as a prognostic tool for patients with chest pain. J Fam Pract 2000; 49(8): 746-53.

7. Cooper A, Calvert N, Skinner J, Sawyer L, Sparrow K, Timmis A, et al. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. NICE Clinical Guidelines, No. 95. London: Royal College of Physicians(UK); 2010.

8. Balk EM, Ioannidis JP, Salem D, Chew PW, Lau J. Accuracy of biomarkers to diagnose acute cardiac ischemia in the emergency department: A meta-analysis. Ann Emerg Med2001; 37(5): 478-94.

9. Kubasik NP, Guiney W, Warren K, D’Souza JP, Sine HE, Brody BB. Radioimmunoassay of serum myoglobin: evaluation and modification of a commercial kit and assessment of its usefulness for detecting acute myocardial infarction. Clin Chem 1978; 24(11):2047-9.

10. Roxin LE, Venge P, Friman G, Hallgren R. Radioimmunoassays of human myoglobin in serum and urine. Scand J Clin Lab Invest

1979; 39(1): 37-46.

11. Roxin LE, Venge P, Wide L. A fast and sensitive radioimmunoassay of human myoglobin for use in the early diagnosis of heart infarction. Clin Chim Acta1980; 107(1-2): 129-34.

12. Van Steirteghem AC, Zweig MH, Robertson EA, Bernard RM, Putzeys GA, Bieva CJ. Comparison of the effectiveness of four clinical chemical assays in classifying patients with chest pain. Clin Chem 1982; 28(6): 1319-24.

13. Gibler WB, Gibler CD, Weinshenker E, Abbottsmith C, Hedges JR, Barsan WG, et al. Myoglobin as an early indicator of acute myocardial infarction. Ann Emerg Med 1987; 16(8): 851-6.

14. Kontos MC, Anderson FP, Hanbury CM, Roberts CS, Miller WG, Jesse RL. Use of the combination of myoglobin and CK-MB mass for the rapid diagnosis of acute myocardial infarction. Am J Emerg Med1997; 15(1): 14-9.

15. McCord J, Nowak RM, McCullough PA, Foreback C, Borzak S, Tokarski G, et al. Ninety-minute exclusion of acute myocardial infarction by use of quantitative point-of-care testing of myoglobin and troponin I. Circulation2001; 104(13): 1483-8.

16. Duma RJ, Siegel AL. Serum creatine phosphokinase in acute myocardial infarction. Arch Intern Med1965; 115: 443-51.

17. Rosalki SB. An improved procedure for serum creatine phosphokinase determination. J Lab Clin Med 1967; 69(4): 696-705.

18. Rokos JA, Rosalki SB, Tarlow D. Automated fluorometric procedure for measurement of creatine phosphokinase activity. ClinChem 1972; 18(3):193-8.

19. Vaidya HC, Maynard Y, Dietzler DN, Ladenson JH. Direct measurement of creatine kinase-MB activity in serum after extraction with a monoclonal antibody specific to the MB isoenzyme. Clin Chem 1986;32(4): 657-63.

20. Youens JE, Calvin J, Price CP. Clinical and analytical validation of an enzymometric assay for creatine kinase-MB isoenzyme. Ann Clin Biochem1986; 23 (Pt 4): 463-9.

21. Rosalki SB, Roberts R, Katus HA, Giannitsis E, Ladenson JH, Apple FS. Cardiac biomarkers for detection of myocardial infarction: perspectives from past to present. Clin Chem2004; 50(11): 2205-13.

22. Bakker AJ, Gorgels JP, van Vlies B, Haagen FD, Smits R. The mass concentrations of serum troponin T and creatine kinase-MB are elevated before creatine kinase and creatine kinase-MB activities in acute myocardial infarction. Eur J Clin Chem Clin Biochem1993; 31(11): 715-24.

23. Azzazy HM, Pelsers MM, Christenson RH. Unbound free fatty acids and heart-type fatty acid-binding protein: diagnostic assays and clinical applications. Clin Chem 2006; 52(1): 19-29.

24. Pagani F, Bonora R, Bonetti G, Panteghini M. Evaluation of a sandwich enzyme-linked immunosorbent assay for the measurement of serum heart fatty acid-binding protein. Ann Clin Biochem

2002; 39(Pt 4): 404-5.

25. Alansari SE, Croal BL. Diagnostic value of heart fatty acid binding protein and myoglobin in patients admitted with chest pain. Ann Clin Biochem2004; 41 (Pt 5): 391-6.

26. Colli A, Josa M, Pomar JL, Mestres CA, Gherli T. Heart fatty acid binding protein in the diagnosis of myocardial infarction: wheredo we stand today? Cardiology2007; 108(1): 4-10.

27. Collinson PO, Stubbs PJ, Kessler A. Multicentre evaluation of the diagnostic value of cardiac troponin T, CK-MB mass, and myoglobin for assessing patients with suspected acute coronary syndromes in routine clinical practice. Heart2003; 89(3): 280-6.

28. Eggers KM, Oldgren J, Nordenskjöld A, Lindahl B. Diagnostic value of serial measurement of cardiac markers in patients with chest pain: limited value of adding myoglobin to troponin I for exclusion of myocardial infarction. Am Heart J 2004; 148: 574-81.

29. Collinson PO, Gaze DC, Thokala P, Goodacre S. Randomised Assessment of Treatment using Panel Assay of Cardiac markers--Contemporary Biomarker Evaluation (RATPAC CBE). Health Technol Assess 2013; 17(15): 1-122.

30. Christ M, Popp S, Pohlmann H, Poravas M, Umarov D, Bach R, et al. Implementation of high sensitivity cardiac troponin t measurement in the emergency department. Am J Med 2010; 123(12): 1134–42.