|Year : 2017 | Volume
| Issue : 12 | Page : 1618-1621
Cardiac Troponin T and creatine kinase MB fraction levels among patients with acute ischemic stroke in Nigeria
HM Suleiman1, IS Aliyu1, SA Abubakar2, MS Isa1, JM El-Bashir1, R Adamu1, MZ Ibrahim3, A Mohammed4, R Yusuf1, M Manu1, AB Dogara1, SK Mustapha2, N Bello3, SA Ozovehe1
1 Department of Chemical Pathology, Ahmadu Bello University, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Medicine, Ahmadu Bello University, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Radiology, Ahmadu Bello University, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
4 Department of Chemical Pathology, FMC, Bida, Nigeria
|Date of Acceptance||12-Nov-2017|
|Date of Web Publication||29-Jan-2018|
Dr. H M Suleiman
Department of Chemical Pathology, Ahmadu Bello University, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Stroke has been a global burden, with increasing morbidity and mortality. Serum cardiac troponin t (cTnT) and creatine kinase (CK-MB) fraction are reported to be elevated in patients admitted with acute ischaemic stroke and high level of these biomarkers indicated more severe stroke and neurologic deficit in some of the patients. Objective: To evaluate the serum levels cardiac troponin t (cTnT) and creatine kinase MB fraction (CK-MB) in patients with acute ischaemic stroke and relate the analytes to severity of stroke. Method: Patients with clinical diagnosis of ischaemic stroke diagnosed, confirmed by brain Computerized Tomography scan and equal number of apparently healthy age and sex-matched were recruited. Serum cardiac troponin t (cTnT) and creatine kinase MB fraction (CK-MB) were analysed using ELISA method and Stroke severity was determined using National Institute of Health Stroke Score (NIHSS). Results: Mean serum cardiac troponin t (cTnT) and creatine kinase MB fraction (CK-MB) in stroke patients were found to be higher than age sex matched control (p<0.05). NIHS Score of 12.2 ± 5.43 and 9.78 ± 3.97 were observed in Patients with elevated and normal cTnT respectively (p=0.009) while NIHS Score were similar in patients with elevated and normal CK-MB (p = 0.772). Conclusion: The mean values of serum cTnT and CK-MB were higher in acute ischaemic stroke patients compared to controls. Serum cardiac Troponin t level may be a significant biomarker of the severity of stroke.
Keywords: Creatine kinase MB, Nigeria, serum cardiac troponin T, stroke
|How to cite this article:|
Suleiman H M, Aliyu I S, Abubakar S A, Isa M S, El-Bashir J M, Adamu R, Ibrahim M Z, Mohammed A, Yusuf R, Manu M, Dogara A B, Mustapha S K, Bello N, Ozovehe S A. Cardiac Troponin T and creatine kinase MB fraction levels among patients with acute ischemic stroke in Nigeria. Niger J Clin Pract 2017;20:1618-21
|How to cite this URL:|
Suleiman H M, Aliyu I S, Abubakar S A, Isa M S, El-Bashir J M, Adamu R, Ibrahim M Z, Mohammed A, Yusuf R, Manu M, Dogara A B, Mustapha S K, Bello N, Ozovehe S A. Cardiac Troponin T and creatine kinase MB fraction levels among patients with acute ischemic stroke in Nigeria. Niger J Clin Pract [serial online] 2017 [cited 2020 Aug 9];20:1618-21. Available from: http://www.njcponline.com/text.asp?2017/20/12/1618/224134
| Introduction|| |
Stroke is defined as a clinical syndrome of sudden onset of rapidly developing symptoms or signs of focal and at times global loss of cerebral function, with symptoms lasting more than 24 h or leading to death, with no apparent cause other than that of vascular origin. Stroke constitutes one of the main causes of morbidity and mortality worldwide. The World Health Organization estimates stroke to be one of the likely leading cause of death and disability worldwide by 2020. The current prevalence of stroke in Nigeria is 1.14/1000 while the 30-day case fatality rate is as high as 40%.
The identification of predictors of morbidity and mortality of stroke may contribute to reducing mortality and increasing functional outcome by allowing adaptation of prompt therapeutic management strategies to patients at risk. Heart-brain connections were described early in the 20th century and showed that changes in central nervous system metabolism influence cardiac function. There is considerable clinical and experimental evidence that cardiac changes in ischemic stroke result from excessive sympathetic nervous activity secondary to insular cortical damage. Cardiac troponin T (cTnT) is a new biochemical marker of myocardial damage with high specificity and sensitivity. Creatine kinase MB (CK-MB) which is also a cardiac enzyme increases in some patients with stroke, with no clear evidence of an acute coronary syndrome.
Several conditions could result in elevated concentrations of these analytes during the acute phase of ischemic stroke; these include primary myocardial damage with secondary cardioembolic, cerebral damage or primary cerebral ischemia with secondary myocardial injury. The mechanism is unknown; however, some attributed it to central activation of the sympathoadrenal system resulting in cardiac sequelae including myocytolysis, serum enzyme elevation, and arrhythmia are known to develop in some ischemic stroke patients. It is also possible that the secondary rise in CK-MB seen might represent brain damage since the B subunit also exists in the brain as CK-BB. CTnT and CK-MB are not routinely requested in patients with ischemic stroke in our environment, and thus, there is paucity of data in the pattern of this analytes among stroke patients in our center.
This study is therefore aimed at determining the levels of cTnT and CK-MB in patients admitted with acute ischemic stroke in our environment.
| Subjects and Methods|| |
This study was carried out over 13 months. One hundred ischemic stroke patients confirmed by brain computerized tomography scan admitted in Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, within 72 h of onset of stroke and 100 apparently healthy age- and sex-matched controls from the community population were studied. However, patients with recent history (within 3 weeks) of myocardial infarction, long-standing hypertension, myopathies or muscular dystrophy, renal disease, previous stroke, recent surgery, or trauma were excluded from the study. Informed consent was obtained from the patient or their relation and the controls group. Approval was obtained from Ethical and Scientific committee of ABUTH, Zaria, before embarking on the study.
Blood samples were obtained from the antecubital fossa of each individual after disinfecting it with methylated spirit and allowed to dry. A tourniquet was applied 10 cm above the cubital fossa using 5 ml syringe, and a 21G needle was used to draw blood from anterior cubital vein. The blood was transferred into a plain bottle and allowed to stand for about 30 min for it to clot and retract. This was then centrifuged for 5 min at 10,000 rpm. The serum was separated from the cells and transferred into plain (sample) bottles and then frozen at −20°C until the time for analysis. Serum cTnT and CK-MB fraction concentrations were measured using commercial enzyme-linked immunosorbent assay kits and were procured from Wkea medical supplies corporation, Changchun, China, manufactured in November 2013 to expire in November 2017.
The chemicals and kits used for measurements of serum cTnT and CK-MB were procured from Wkea medical supplies corporation, Changchum China, and labkit, chemlex s.a. Barcelona Spain respectively. Data from the proforma were recorded and analysed using Statistical Program for Social Sciences 20.0 (SPSS 20.0) for windows (SPSS Inc. Chicago 20). Student's t-test was used to analyze continuous normally distributed variables. P < 0.05 was considered statistically significant.
| Results|| |
A total of 200 individuals were recruited, 100 cases and 100 age- and sex-matched controls between the age of 18–96 years with average of 59 years. The mean age of the patients and controls were 59 ± 14.08 and 59 ± 13.91 years, respectively (P = 0.9888). The majority were males (62%) in both patients and control groups. Ninety-one percent of the patients (n = 91) had hypertension while 8% (n = 8) had diabetes mellitus and 1% (n = 1) had sickle cell anemia. Both systolic and diastolic blood pressures were significantly higher among the cases (156 ± 32 mmHg vs 120 ± 20 mmHg) and controls (94 ± 20 vs. 76 ± 7 mmHg), respectively (P< 0.0001) as shown in [Table 1].
[Table 2] shows pattern of serum cTnT and CK-MB fraction of the acute ischemic stroke patients and controls. Stroke patients had significantly higher serum cTnT 90.40 ± 19.84 ng/L than the controls 61.16 ± 19.60 ng/L (P = 0.0000), while the CK-MB fraction was 25.41 ± 1.48 ng/mL and 17.33 ± 1.14 ng/ml among the patients and controls, respectively (P = 0.0000).
|Table 2: Pattern of serum troponin T and creatine kinase MB fraction mean±standard deviation in stroke patients and controls|
Click here to view
[Table 3] shows the relationship between the levels of cardiac markers (cTnT and CK-MB) and National Institute of Health Stroke Score (NIHS) score. NIHS score of 12.2 ± 5.43 and 9.78 ± 3.97 was observed in patients with elevated and normal cTnT, respectively (P = 0.009), while NIHS score was similar in patients with elevated and normal CK-MB (P = 0.772).
|Table 3: Relationship between the levels of cardiac markers (cardiac troponin T and creatine kinase MB fraction) and National Institute of Health Stroke Score score (mean±standard deviation) in stroke patients|
Click here to view
| Discussion|| |
This shows that certain age groups are more at risk of ischemic stroke than others and therefore requires more medical attention for the prevention of stroke. Patients with ischemic stroke present around their fifth to sixth decade of life in this environment. The mean ages of the patients and controls were similar and comparable with those patients and controls of University of Benin and University of Lagos Teaching Hospitals. Stroke was more common in males than females in this study; however, the male to female ratio in this study was slightly higher than the findings in the united states  but similar to the report from Sokoto. It has been reported that male sex is a risk factor, especially for thrombotic stroke, until the eighth and ninth decades when the risk becomes equal for both sexes. It may be due to protective effect of female sex hormones before menopause. The other possibilities include the influence of cultural factors such as the easy accessibility of males to health care and the greater life expectancy in women. However, a report from South Western Nigeria in 2005 reported higher females than males and suggested that this is due to the changing pattern in sub-Saharan Africa. Awareness of oral contraceptives use and obesity which is more common in southern Nigeria may be another explanation as it is one of the modifiable risk factors of stroke worldwide. Other risk factors that are more common in males than females are hypertension, heart diseases such as atrial fibrillation and heart failure, hyperlipidemia, cigarette smoking, excess alcohol consumption, and polycythemia.
In the present study, the serum levels of cTnT and CK-MB of ischemic stroke patients were significantly higher than those in the apparently healthy controls. This is similar to the findings of other studies.,,
In a study in Turkey, serum CK-MB was elevated above the normal cutoff value in patients with acute ischemic stroke. It has been suggested that the elevated levels of cardiac markers in acute ischemic stroke patients could be related to cardiac myocytolysis that occurred as a result of activation of the sympathetic nervous system. The presumed cause for this elevation in acute neurologic disease is related to an increase in systemic catecholamines. It is also possible that the secondary rise in CK-MB seen might represent brain damage since the B subunit also exists in the brain as CKBB. Several studies have also suggested that cTnT could be a valuable marker for evidence of myocardial injury in ischemic stroke patients. Another study demonstrated elevation of noradrenaline and adrenaline, followed by elevation of troponin T and CK-MB, associated with decrease in cardiac output and new left ventricular wall motion abnormalities in stroke. Several other studies have confirmed the presence of troponin elevation in high catecholamine states such as in ischemic stroke. The high concentration of catecholamines in the myocardium would bring about a calcium overload of myocardial cells which can cause a reduction of myocardial contractility and can lead to an impairment of cardiac function due to the perfusion disturbance at the level of capillaries caused by an enhanced platelet aggregation.
The current study demonstrated relationship between cTnT, CK-MB, and severity of stroke using NIHS score. Severity of stroke relates positively with cTnT but not with CK-MB. This is in agreement with the findings of other studies were Severity of stroke relates positively with cTnT but not with CK-MB., The mean values of NIHS score was significantly higher in patients with elevated cTnT, while the mean NIHS score was similar in those with elevated and normal CK-MB values. This implies that stroke patients with elevated cTnT presented with more severe neurologic deficits than patients with normal cTnT values. However, CK-MB could not assess the severity of acute ischemic stroke in patients as shown above. A similar study in 2013 demonstrated that patients with elevated cTnT presented with more severe neurologic deficits (mean NIHS score 10.1) than patients with normal cTnT values (mean NIHS score 7.4) Similarly, research conducted in Berlin, Korea, and Iraq all found that elevated serum cTnT in patients with acute ischemic stroke was associated with severe neurological deficits. On the other hand, the level of CK-MB activity did not show significant association with stroke severity. This is probably because CK-MB is less specific than cTnT and/or signifies the noncardiac source of CK-MB.
| Conclusion|| |
The mean values of serum cTnT and CK-MB were higher in acute ischemic stroke patients than in the apparently healthy controls. cTnT levels increase with severity of stroke using NIHS score; thus, cTnT may be a good marker of severity of stroke.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Katsiki N, Ntaios G, Vemmos K. Stroke, obesity and gender: A review of the literature. Maturitas 2011;69:239-43.
Lynn S. Cardiovascular news, The American Heart Association. Circulation 2000;102:502-4.
Kolawole WW. The burden of stroke in Nigeria; international Journal of stroke 2008;3:290-292.
Song HS, Back JH, Jin DK, Chung PW, Moon HS, Suh BC, et al.
Cardiac troponin T elevation after stroke: Relationships between elevated serum troponin T, stroke location, and prognosis. J Clin Neurol 2008;4:75-83.
Levy A. The exiting causes of ventricular fibrillation in animals under chloroform anesthesia. Heart 1993;4:319-78.
Barber M, Morton JJ, Macfarlane PW, Barlow N, Roditi G, Stott DJ, et al.
Elevated troponin levels are associated with sympathoadrenal activation in acute ischaemic stroke. Cerebrovasc Dis 2007;23:260-6.
The World Health Organization MONICA project (monitoring trends and determinants in cardiovascular disease): A major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol 1988;41:105-14.
Etgen T, Baum H, Sander K, Sander D. Cardiac troponins and N-terminal pro-brain natriuretic peptide in acute ischemic stroke do not relate to clinical prognosis. Stroke 2005;36:270-5.
Bell RD, Alexander GM, Nguyen T, Albin MS. Quantification of cerebral infarct size by creatine kinase BB isoenzyme. Stroke 1986;17:254-60.
Amu E, Ogunrin O, Danesi M. Re-appraisal of risk factors for stroke in Nigerian Africans-a prospective case-control study. African Journal of Neurological Sciences 2005;24(2).
Ralph LS, Emelia JB, Joseph P, Broderic M, Dyken J, Donald E, et al
. Risk factor, public health burden of stroke. Stroke 1997;28:1507-17.
Abubakar SA, Sabir AA. Profile of stroke patients seen in a tertiary health care center in Nigeria. Ann Niger Med 2013;7:55.
Dubey RK, Oparil S, Imthurn B, Jackson EK. Sex hormones and hypertension. Cardiovasc Res 2002;53:688-708.
Ogun SA, Ojini FI, Ogungbo B, Kolapo KO, Danesi MA. Stroke in South West Nigeria: A 10-year review. Stroke 2005;36:1120-2.
Newby DE, Grubb NR, Bradbury A. Davidson's Principle and Practice of Medicine. 20th
ed., Ch. 14. Elsevier China; 2006. p. 974-1000.
Haider AH, Al-Khefaji DK, Abbase AH, Kadum Khadim MA, Al-Gazally ME, Al-Jeborry MM, et al
. Prognostic Significance of Troponin T and Creatine Kinase-MB Activity in Sera of Acute Ischaemic Stroke Patients. Medical Journal of Babylon 2010;7:469-79.
Ay H, Arsava EM, Saribaş O. Creatine kinase-MB elevation after stroke is not cardiac in origin: Comparison with troponin T levels. Stroke 2002;33:286-9.
Apak I, Iltumur K, Tamam Y, Kaya N. Serum cardiac troponin T levels as an indicator of myocardial injury in ischemic and hemorrhagic stroke patients. Tohoku J Exp Med 2005;205:93-101.
Myers MG, Norris JW, Hachinski VC, Weingert ME, Sole MJ. Cardiac sequelae of acute stroke. Stroke 1982;13:838-42.
Batal O, Jentzer J, Balaney B, Kolia N, Hickey G, Dardari Z, et al.
The prognostic significance of troponin I elevation in acute ischemic stroke. J Crit Care 2016;31:41-7.
Jensen JK, Kristensen SR, Bak S, Atar D, Høilund-Carlsen PF, Mickley H, et al.
Frequency and significance of troponin T elevation in acute ischemic stroke. Am J Cardiol 2007;99:108-12.
Scheitz JF, Endres M, Mochmann HC, Audebert HJ, Nolte CH. Frequency, determinants and outcome of elevated troponin in acute ischemic stroke patients. Int J Cardiol 2012;157:239-42.
Král M, Šaňák D, Veverka T, Hutyra M, Vindiš D, Kunčarová A, et al.
Troponin T in acute ischemic stroke. Am J Cardiol 2013;112:117-21.
[Table 1], [Table 2], [Table 3]