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Serum creatine kinase MB in ischaemic stroke: a case control study.

INTRODUCTION

The word "Stroke" is used to refer to a clinical syndrome of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral functions lasting more than twenty four hours or leading to death. (1) (World health organization 1978).

For years, strokes have been subdivided pathologically into infarcts (thrombotic or embolic) and haemorrhages & clinical criteria for distinguishing between these possibilities have been emphasized. (2)

It effects between 174 & 216 people per 100000 population in UK each year (Man et al 2004) and accounts for 11% of all deaths in England & Wales. It is accepted that 85% of strokes are due to cerebral infarction, 10% due to primary haemorrhage 5% due to subarachnoid haemorrhage. The risk of recurrent stroke is 26% within 5 years of a first stroke and 39% by 10 years (Mohan et al 2011). (3)

Thus, the definition of stroke is clinical and laboratory studies including brain imaging are used to support the diagnosis. (4)

Brain is a rich source of a variety of enzymes and any injury like stroke to brain tissue could similarly result in an increase in activity of these enzymes in cerebrospinal fluid and serum. It was in this context that the present study was done to assess the levels of enzymes like aspartate aminotransferase (AST), creatine kinase (CK) and isoenzyme of creatine kinase (CK-MB) in serum. CK has three isoenzymes CK-MM, CK-MB, CK-BB. Myocardial damage has been shown to be associated with cerebrovascular accident and in present study overall raised values of CK was consistent with routine ECG and Holter monitor changes and may be an indicator of associated myocardial damage.

Uric acid is the end product of purine metabolism. Increased uric acid levels have been found to be associated with established risk factors of stroke such as hypertension, dyslipidaemia, obesity and diabetes mellitus. (5) Also significantly higher risk of stroke incidence and mortality was reported in cases of hyperuricemia. (6)

Evaluation of enzyme levels and easily available method for the evaluation of severity, course, prognosis, and to some extent in the differential diagnosis of various types of cerebrovascular accidents. (7)

Serum creatine kinase, creatine kinase-MB and aspartate aminotransferase levels were raised above normal in stroke patients. The values of CPK and CPK-MB were well above normal limits in 72%, and 54% of patients respectively on day

1. Aspartate aminotransferase levels were marginally raised. The present study aims to estimate serum SGOT, CK (total) and CK-MB and uric acid. In addition, other parameters estimated are fasting plasma glucose, cholesterol, triglycerides, serum HDL cholesterol, serum LDL cholesterol, serum VLDL cholesterol.

MATERIALS AND METHODS

The present study was conducted on fifty (50) patients of ischaemic stroke admitted in medical wards and casualty of NRI Hospital, Vishakapatnam (With mean age 56.5 years) during the period of 2015. Out of Fifty (50) cases, Thirty Three (33) are men and Seventeen (17) are women.

The study included Thirty (30) healthy control subjects who are age matched and sex matched with patients. Out of Thirty (30), Twenty (20) are men and Ten (10) are women.

Blood samples for serum enzymes were taken within 24-72 hours of onset of symptoms and serum enzymes, uric acid were estimated. Fasting blood sample collected for lipid profile and blood sugar on the next day of admission. Blood pressure recorded in right upper limb in supine position with Hg Sphygmomanometer. Creatine Kinase (Total), Creatine Kinase-MB, Aspartate Transaminase, lipid profile, Fasting Blood Sugar were estimated in control group also.

A detailed history was taken considering various risk factors for stroke like hypertension, smoking, diabetes mellitus, alcoholism, and previous stroke from study group. CT scan was done to differentiate various causes of stroke. Only ischaemic causes showing CT scans were taken into consideration and 50 cases showing positive findings for ischaemic stroke were taken for evaluation of present study. CT scans were done immediately after admission. Parameters were analysed immediately after collection of sample.

Inclusion Criteria

Patients clinically diagnosed to have ischaemic stroke were selected for the study.

Exclusion Criteria

Traumatic and space occupying lesions of cerebrovascular disease are excluded form study by history and Computed Tomography Scan impression. Patients with previous myocardial infarction or present myocardial infarction and patients with recent infections, liver disease, and renal failures are excluded.

The Following Investigations Were Performed

1. Estimation of Fasting Blood Sugar.

2. Serum Total Cholesterol, Triglycerides, HDL, LDL, and VLDL cholesterol.

3. Creatine Kinase (CK)-Total.

4. Creatine Kinase-MB (CPK-MB).

5. Serum Glutamate Oxaloacetate Transaminase (SGOT).

6. Uric Acid.

7. Also E.C.G. and C.T. Scan brain were considered for study.

Blood glucose was estimated by glucose oxidase peroxidase method. Creatine kinase was assayed by UV kinetic (IFCC) method & creatine kinase-MB was assayed by following procedure. This procedure involves measurement of creatine kinase activity in the presence of an antibody completely inhibits the activity of creatine kinase-MM and half of the B subunit activity of creatine kinase-MB and creatine kinase-BB. Then, we use the creatine kinase method to quantitatively determine creatine kinase-B activity, the creatine kinase-MB activity is obtained by multiplying the creatine kinase-B activity by two. Serum aspartate aminotransferase was estimated by UV kinetic (IFCC) method. Estimation of cholesterol and HDL cholesterol was done by CHOD--POD phosphotungstate method. Low density lipoprotein cholesterol (LDL-C) was calculated indirectly by Friedewald formula. Uric acid was estimated by enzymatic uricase method.

Statistical Analysis

It was done by applying the "z" test. Significance between cases and controls values estimated by "p" value.

RESULTS

Normal Values:--20-170 IU/L

In the present study, mean value of creatine kinase among cases (Average) is 227.51U/1 [+ or -] 240.54 (Mean [+ or -] SD) and that of controls is 70.43 [+ or -] 35.803. The increase in serum creatine kinase among cases is highly significant with a p value of <0.001.

In the present study, mean value of CPK-MB among cases (Average is 49.56 [+ or -] 35.15 (Mean [+ or -] SD) and that of controls is 10.3 [+ or -] 4.90. The increases in serum CPK-MB among cases is highly significant with a p value of <0.001.

Normal Values: 3-6 mg/dL

Normal Values: 8-20 IU/L

In the present study mean value of serum SGOT among cases (average) is 45.42 IU/1 [+ or -] 25.47 (mean [+ or -] SD) and that of controls is 27.77 [+ or -] 3.682. The increase in SGOT among cases is highly significant with a p value of <0.001.

In the study, it is shown that uric acid constitutes 80%, hypercholesterolemia 78%, LDL 74%, HTN 70%, smoking 56%, & DM 10%. So, it has been inferred that ischaemic stroke is associated positively with HTN, hypercholesterolemia, LDL, hyperuricemia, smoking, and DM as shown above.

DISCUSSION

Fifty (50) Ischaemic stroke patients were studied for Serum Enzymes, that is Creatine Kinase, Creatine Kinase-MB and Aspartate Transaminase. Thirty (30) age matched controls were taken for comparison. Present study included thirty three (33) male patients and seventeen (17) female patients. Age group varied from 41-70 years, majority falling between 51-60 years.

CPK-MB and total CK values in cases were increased significantly when compared to controls. The value of mean and SD of CPK-MB in cases is 49.56 and 35.15 respectively and in controls it is 10.3 and 4.90 respectively. The value of mean and SD of total CK in cases is 227.5 and 240.54 respectively and in controls it is 70.43 and 35.8 respectively. The above values indicate that CPK-MB and total CK are significantly elevated in ischaemic stroke patients.

The rise in CPK-MB in males was greater than the rise in females indicating that gender has a significant role in CPK-MB levels in ischaemic patients. CT scan was done to categorise the patients into ischaemic or haemorrhagic lesion.

History of hypertension was taken. Out of 50 cases 35 (70%) had high blood pressure (Systolic more than 140 mm and diastolic more than 80 mm Hg). At the time of diagnosis CPK-MB to CK levels were high in patients having high blood pressure when compared to normotensive group (30%). The rise in CPK-MB and CK levels in the present study is in correlation with previous study of J.W. Norris, Hakan Ay. (8,9)

The rise in CPK-MB and CK levels are in correlation with the CT scan findings, indicating that the origin of CPK-MB is of brain related injury rather than cardiac. However, as a limitation troponin T levels, which is a sensitive indicator of myocardial injury was not taken in this study.

In the present study uric acid was elevated in 40 cases out of 50 (80%).

The mean value of uric acid in cases was 6.48 mg/dL with SD of 1.94. The mean value of uric acid in controls was 5.09 with SD 1.07, which is statistically significant.

These findings are in agreement to those of Mehrpour et al who found a higher prevalence of hyperuricemia in patients of acute stroke as compared to the normal population. (10) Millionis. (11) et al observed that serum uric acid levels were significantly higher in stroke patients compared with controls (5.6 +- 1.7 mg/dL vs 4.8 +- 1.4 mg/dL, P<0.001). Shrikrishna R and Suresh DR. (12) found that serum uric acid levels were significantly higher in cases as compared to controls (6.56 +- 0.73 vs 4.66+-0.47, P<0.05). In the Rotterdam study. (3), higher serum uric acid levels were associated with risk of stroke.

Out of the 50 cases, 30 cases (60%) showed increase in SGOT levels and 20 cases showed normal SGOT levels. In 1987 Nand N, Gupta S in the study showed that SGOT levels were elevated in ischaemic stroke patients. (14) The present study is in correlation with the above study.

Out of 50 cases, 39 cases (78%) had abnormal lipid profile and 10 had normal lipid profile. The mean and SD value for cholesterol are 215.9 and 26.955 and in controls it is 184.7 and 25.7. The mean and SD value for triglycerides are 146.76 and 16.04. The values of cholesterol and triglycerides indicate that they are important risk factor for ischaemic stroke. Anuradha, Vivek, Debaprity conducted a study in 2014, which indicated the effect of lipid profile in ischaemic stroke patients. (15) The present study is in correlation with above study and also with study done by JF Albucher, J Ferrieres. (16)

Fasting blood sugar was taken at time of diagnosis. Out of 50 cases, 5 patients had blood sugar level more than 130 mg/dL and 45 patients had levels in the normal range. High values in the cases may indicate either a risk factor for ischaemic stroke or may have raised due to stress related injury to brain.

CONCLUSION

In the present study, CPK-MB levels were elevated in stroke patients indicating the importance of measuring the CPK-MB levels in the diagnosis and prognosis of ischaemic stroke patients. SGOT assays may be important indicator in the prognosis of stroke patients. In the present study, uric acid, cholesterol, and triglycerides were elevated in the cases indicating that they are important risk factor and control of the same may help in preventing stroke. In 10% cases showed high blood sugar values, which indicate that diabetes is an important risk factor, which should be regulated and treated to prevent ischaemic stroke.

REFERENCES

(1.) Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. 4th Edition. London, chapter 1.4, 2012:Pg 4.

(2.) Stephen J, McPhee, Maxine A, et al. Current medical diagnosis and treatment. 52nd Edition. USA Chapter 24, 2013:p 979.

(3.) Colledge NR, Walker B, Ralston SH, et al. Davidson's principles & practice of medicine. 21st edn. UK Chapter 26, 2010:p 1180.

(4.) Longo DL, Fauci AS, Kasper DL, et al. Claiborne Johnston Harrison's principal of Internal Medicine. 18th edition. USA Chapter 370, 2012:p 3270.

(5.) Dimitroula HV, Hatzitolios AI, Karvounis HI. The role of uric acid in stroke: the issue remains unresolved. Neurologist 2008;14(4):238-42.

(6.) Kim SY, Guvera JP, Kim KM, et al. Hyperuricemia and risk of stroke: a systematic review and meta analysis. Arthritis Rheum 2009;61(7):885-92.

(7.) Di Napoli M, Papa F, Baocola V. Prognostic influence of increased C-reactive protein and fibrinogen levels in ischaemic stroke. Stroke 2001;32(1):133-8.

(8.) Norris JW, Hachinski VC, Myers MG, et al. Serum cardiac enzyme in stroke. Stroke 1979;10(5):548-53.

(9.) Ay H, Arsava EM, Saribas O. Creatine kinase-MB elevation after stroke is not cardiac in origin: comparison with troponin T levels. Stroke 2002;33(1):286-9.

(10.) Mehrpour M, Khuzan M, Najimi N, et al. Serum uric acid level in acute stroke patients. Medical Journal Islamic Republic of Iran 2012;26(2):66-72.

(11.) Millionis HJ, Kalantzi KJ, Goudevenos JA, et al. Serum uric acid levels and risk for acute ischaemic non-embolic stroke in elderly subjects. J Intern Med 2005;258(5): 435-41.

(12.) Shrikrishna R, Suresh DR. Biochemical study of antioxidant profile in acute ischaemic stroke. British Journal of Medical Practitioners 2009;2(1):35-7.

(13.) Bos MJ, Koudstaal PJ, Hofman A, et al. Uric acid is a risk factor for myocardial infarction and stroke: Rotterdam study. Stroke 2006;37(6):1503-7.

(14.) Nand N, Gupta S, Sharma M, et al. Evaluation of enzymes in serum and cerebrospinal fluid in cases of cerebrovascular accident. Angiology 1987;38(10):750-5.

(15.) Bharosay A, Bharosay VV, Bandyopadhyay D, et al. Effect of lipid profile upon prognosis in ischaemic and haemorrhagic cerebrovascular stroke. Indian Journal of Clinical Biochemistry 2014;29(3):372-6.

(16.) Albucher J, Ferrieres J, Ruidavets J, et al. Serum lipids in young patients with ischaemic stroke-a case control study. J Neurol Neurosurgery Psychiatry 2000;69(1): 29-33.

B. Preethi [1], C. Ramakrishna [2], M. Roopa [3], Sanjeevi Rao [4]

[1] Assistant Professor, Department of Biochemistry, NRI Institute of Medical Sciences, Sangivalasa, Vishakapatnam.

[2] Assistant Professor, Department of Biochemistry, NRI Institute of Medical Sciences, Sangivalasa, Vishakapatnam.

[3] Associate Professor, Department of Biochemistry, NRI Institute of Medical Sciences, Sangivalasa, Vishakapatnam.

[4] Professor and HOD, Department of Biochemistry, NRI Institute of Medical Sciences, Sangivalasa, Vishakapatnam.

Financial or Other, Competing Interest: None.

Submission 20-04-2016, Peer Review 07-06-2016, Acceptance 13-06-2016, Published 29-06-2016.

Corresponding Author:

Dr. C. Ramakrishna, Door No. 48-6-33, Srinagar, Vishakapatnam-530016 Andhra Pradesh

E-mail: ramjeerk@gmail.com

DOI: 10.14260/jemds/2016/782
Table I: Serum Creatine Kinase Levels in Cases and Controls

                  Mean      SD         Mean
                                    Difference

Cases n=50       227.5    240.54      157.07
Controls n=30    70.43    35.803

                  SE     Z Static     P Value

Cases n=50       6.30      24.93     P <0.001
Controls n=30

Table II: Serum Creatine Kinase--MB Levels of Cases and Controls

                  Mean      SD        Mean
                                   Difference

Cases n=50       49.56    35.15       39.26
Controls n=30     10.3     4.90

                  SE     Z Statistic     P Value

Cases n=50       6.45        6.08       P <0.001
Controls n=30

Table III: Serum Uric Acid Levels of Cases and Controls

                 Mean     SD        Mean
                                 Difference

Cases n=50       6.48    1.94       1.39
Controls n=30    5.09    1.07

                 SE (d)    Z Statistic     P Value

Cases n=50        0.36         3.65       P < 0.001
Controls n=30

Table IV: Serum SGOT Levels of Cases and Controls

Normal Values:--8-20 IU/L

                  Mean      SD        Mean
                                   Difference

Cases n=50       45.42    25.47       18.15
Controls n=30    27.77    3.682

                 SE (d)   Z Static     P value

Cases n=50       4.676      3.88      P <0.001
Controls n=30

Table V: Risk Factors in Ischaemic Stroke

Risk Factor              Male N=33    Females N=17        Total
                                                      Patients N=50

Uric acid               30 (90.90)     10 (58.82)       40 (80.00)
Hypertension            24 (72.72)     11 (64.70)       35 (70.00)
Smoking                 27 (81.81)      01 (5.88)       28 (56.00)
Hypercholesterolemia    28 (84.84)     11 (64.70)       39 (78.00)
DM                      01 (03.03)     04 (23.52)       05 (10.00)
LDL                     28 (84.84)     09 (52.94)       08 (10.00)
No risk factor          01 (03.03)     04 (23.52)       05 (10.00)

Table VI: Serum Cholesterol and Triglycerides
Levels in Cases and Controls

                       Cholesterol             Triglycerides
                     Mean [+ or -] SD         Mean [+ or -] SD

Cases n=50        215.92 [+ or -] 26.95    146.76 [+ or -] 16.04
Controls n=30      184.7 [+ or -] 24.76     95.8 [+ or -] 15.12
1. Mean (d)               31.22                    50.96
2. SE (d)                  6.02                     3.61
3. Z Statistic             5.73                    14.11
4. P value               P <0.001                 P <0.001

Fig. 1: Serum Creatine Kinase Levels in Cases and Controls

               CASES    CONTROLS

Sample Size     50       30
Means          227.5     70.43
SD s           240.54    35.8

Note: Table made from bar graph.

Fig. 2: Serum Creatine Kinase--MB Levels
of Cases and Controls

               CASES    CONTROLS

Sample Size     50       30
Means           49.56    10.3
SD s            35.15     4.9

Note: Table made from bar graph.

Fig. 3: Serum Uric Acid Levels in Cases and Controls

               CASES    CONTROLS

Sample Size     50       30
Means            6.48     5.09
SD s             1.94     1.07

Note: Table made from bar graph.

Fig. 4: Serum SGOT Levels of Cases and Controls

               CASES    CONTROLS

Sample Size     50       30
Means           45.42    27.77
SD s            25.47     3.68

Note: Table made from bar graph.

Fig. 5: Risk Factors in Ischaemic Stroke

                           Male      Female

Uric Acid                  90.9      58.82
HTM                        72.72     64.7
Smoking                    81.81     64.7
Hyper Cholesterolemia      84.84     64.7
DM                          3.03     23.52
LDL                        84.84     52.94

Note: Table made from bar graph.

Fig. 6: Mean Serum Cholesterol and Triglycerides
in Cases and Controls
              Cholesterol   Triglycerides
Cases           215.92         146.76
Controls        184.7           95.8

Note: Table made from bar graph.
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Author:Preethi, B.; Ramakrishna, C.; Roopa, M.; Rao, Sanjeevi
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Jun 30, 2016
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