Physical Examination And Ecg Findings At The Emergency Department Of Any Hospital

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Chest pain is a common presenting complaint to the emergency department of any hospital and, given that ischemic heart disease is considered the world 's biggest killer1, it is imperative to investigate such patients at length to exclude coronary artery disease (CAD). Physicians commonly rely on the measurement of cardiac biomarkers such as creatine kinase (CK) and its isoenzymes for such a differential diagnosis. Despite the determination of Troponin levels in the evaluation of myocardial ischemia, an elevated CK-MB can provide diagnostic uncertainty as it rises earlier than troponin in myocardial injury. Thus, it is important to remember the other causes of an elevated CK, and by extension it isoenzymes when investigating such …show more content…

These are known as macro-enzymes and carry a molecular weight of greater than 200 kDa3,4. Macro molecular forms of not only creatine kinase have been described but also that of lactate dehydrogenase, amylase and aspartate aminotransferase6. These molecules provide diagnostic challenges for physicians as they often lead to an interference in the biochemical assay for their respective enzymes, resulting in false positive diagnosis such as acute myocardial ischemia or even acute pancreatitis.
This discussion will focus on the macro-molecular forms of creatine kinase: macro-CK type 1 and macro-CK type 2. Macro-CK type 1 is a complex formed by one of the CK isoenzymes and immunoglobulin in an antigen - (auto) antibody reaction7. Most often, it 's components entail CK-BB and monoclonal IgG3. Its prevalence is estimated at 0.9-1.2% 3. Albeit, very rare, researchers have shown its association with various disorders including hypothyroidism, neoplasia, autoimmune conditions, myositis and cardiovascular disease8. Persuasively, Lee et al (1994) showed that more than 50% of his patients with macro CK type 1 had some form of myositis, whether it was autoimmune, malignancy associated or drug induced (PBrien, J.The Macroenzymes: A Clinical Review. Mayo Clinic Proceedings. 1993; 68(4):349-354.
7. Stein, W., Bohner, J., Krais, J.,

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