myocardial infarction and CRP
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Transcript of myocardial infarction and CRP
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CRP AND MYOCARDIAL INFARCTION
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Myocardial Infarction
Ischemic necrosis of myocardium due to sudden occlusion of coronary artery due to atheromatous plaque.
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Signs and symptoms
prolong cardiac pain radiating to chest, arms, throat and back.
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Signs and symptoms……
Increased Erythrocyte Sedimentation Rate.
Chest x rays shows pulmonary edema.
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Atherosclerosis A form of arteriosclerosis where the
tunica intima of large and medium sized arteries is affected due to formation of fibrofatty plaques or atheromas.
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RISK FACTORS
ATHEROSCLEROSIS
Oral contraceptiv
e pills
Diabetes mellitus
smoking
Hypertension
Myocardial
Infarction
Inflammation
Infections
obesity
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RISK ACCORDING TO AGE AND SEX
Ages
Myocard
ial in
farc
tion
p
er
1000
pers
on
s y
ears
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INFLAMMATION
A complex reaction in tissues that consist mainly of responses of blood vessels and leucocytes.
-Robbins and Cotrans
A protective response triggered by inflammatory mediators (interleukins, tumor necrosis factor).
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Inflammation …..
One of the main cause of atherosclerosis.
Inflammation as a main cause of myocardial infarction has been a subject of studies for years as conformed by various studies .
-Ross 1999, Semeri etal 1992, Thompson etal 1995
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Some predisposing factors like Diabetes,Hypertension,Hyperlipidemia can intensify inflammation of coronary arteries.
Indicators of inflammation (ICAM-1, VCAM-1, IL-1, IL-6, TNF, CRP).
C- reactive protein (CRP)- an important inflammatory marker.
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Measuring inflammatory indicators other than screening plasma lipid is a useful prediction of myocardial infarction.
In case inflammation is cause,CRP may reveal the etiology and can be guide for management strategy.
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C-Reactive Protein An acute phase protein , the level
rises in response to inflammation. It is a pentraxin , each subunit
having MW -33kDa. Synthesized by hepatocytes in
response to factors released by fat cells (adipocytes).
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Structure of CRP
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Binds to phosphocholine and activate complement system and also enhance phagocytosis by macrophages.
Increased level of CRP may be induced by metabolic, infective, immunologic or other processes.
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Normal concentration - >10 mg/L, slightly increases with aging.
Higher levels are found in late pregnancy, bacterial infections , viral infections, mild inflammations and burns.
Increased CRP level indicate tissue damage and inflammation.
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CRP levels: - Decreased by : Statins, aspirin, α-tocopherol (vitamin E) and loss of weight - Increased by : hormonal therapy will increase CRP
levels.
CRP is more sensitive and accurate reflection of acute phase response than ESR (Erythrocytes Sedimentation Rate)
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CRP relationship with Myocardial infarction
CRP is a prognostic marker of cardiovascular events.
Predict myocardial infarction, stroke, peripheral arterial disease and sudden cardiac death.
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CRP is an indirect marker of increased cytokine response to inflammation.
Person with high CRP level had relative risk of myocardial infarction 3 to 4 times higher than those with low level.
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CRP levels and the risk group
S.No.
CRP level (mg/L)
Risk group
1. < 1 Low
2. 1 – 3 Moderate
3. > 3 High
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CRP is stronger predictor of myocardial infarction than LDL cholesterol.
In clinical practice; even LDL cholesterol level below 130mg/dl and with c-RP level >3mg/L represent high risk group.
Because of less specificity of CRP, highly sensitive CRP(hsCRP) has been used these days.
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Advantage of CRP over other inflammatory indicators like Interleukins, Tumor Necrosis Factor:
Easy Effective Inexpensive to measure.
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Should not be measured within 3 weeks of acute inflammation
CRP measured within 12 hours of onset of symptom is not related to long term prognosis.
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CRP and hsCRP Measurement and
Clinical Recommendation
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Clinical laboratory methods to measure
serum CRP level :
1.Latex Agglutination method - Qualitative latex agglutination
method - Semiquantitative latex agglutination
method
2.Quantitative Method -ELISA -Immunoflourescence Quantitative test
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Qualitative Latex Agglutination Method
1st laboratory method to measure CRP level.
Agglutination and precipitation indicates the presence of CRP in the serum sample.
A positive result indicate a CRP level greater than 10mg/L.
Can be performed within 10 to 20 minutes.
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Semi quantitative Latex Agglutination Method
Dilution of serum
Mixed with latex reagent
Agglutination was observed
Highest dilution in which agglutination is observed
corresponds to approximate concentration of CRP-ligand complex
This method detects CRP level in between 6-10 mg/L.
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Quantitative Method
Most rapid, sophisticated and sensitive method.
2 types: - ELISA - Immunoflourescence Quantitative
Test
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Processing of ELISA:
Monoclonal Anti-CRP Antibodies conjugated with an
Enzyme
Diluted human serum is added
Formation of CRP-ligand complexes
Removal of unbound Antibodies
Florescent marked CRP-ligand complex is measured under Radio Immune Assay(RIA)
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Clinical Application It is a strong predictor of CVS
events than cholesterol.
It adds prognostic information at all level of metabolic syndrome.
Prediction of risk group of CVS problem:
CRP level< 1mg/L: low risk group CRP level 1-3mg/L:moderate risk
group CRP level>3mg/L:High risk group
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Interpretation Biochemical and pathological components are responsible for
formation of Atherosclerotic plaque
Manifests as myocardial infarction
hsCRP and CRP are useful diagnostic and prognostic marker of myocardial infarction.
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Various methods are still on the way for the prognostic and diagnostic purpose of MI.
Latex agglutination method , ELISA and
immunofluorescence test commonly used for measurement of CRP.
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ACKNOWLEDGEMENT
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Thank you