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CPK-MB test
Kinetics of cardiac markers in myocardial infarction with or without reperfusion treatment
Reference range2 to 19.5 U/L (at 37 C in adults),[1]
some places 5 to 25 IU/L[2]
LOINC49551-5, 51506-4, 2154-3, 13969-1, 32673-6, 38482-6

The CPK-MB test (creatine phosphokinase-MB), also known as CK-MB test, is a cardiac marker[3] used to assist diagnoses of an acute myocardial infarction, myocardial ischemia, or myocarditis. It measures the blood level of CK-MB (creatine kinase myocardial band), the bound combination of two variants (isoenzymes CKM and CKB) of the enzyme phosphocreatine kinase.[citation needed]

In some locations, the test has been superseded by the troponin test. However, recently, there have been improvements to the test that involve measuring the ratio of the CK-MB1 and CK-MB2 isoforms.[4]

The newer test detects different isoforms of the B subunit specific to the myocardium whereas the older test detected the presence of cardiac-related isoenzyme dimers.[citation needed]

Many cases of CK-MB levels exceeding the blood level of total CK have been reported, especially in newborns with cardiac malformations, especially ventricular septal defects. This reversal of ratios is in favor of pulmonary emboli or vasculitis. An autoimmune reaction creating a complex molecule of CK and IgG should be taken into consideration.[5]

See also

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References

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CPK-MB test

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from Grokipedia
The CPK-MB test, also known as the creatine kinase-MB (CK-MB) test, is a that measures the level of , an isoenzyme of primarily found in heart muscle cells. This test detects elevated CK-MB concentrations in the bloodstream, which indicate damage to cardiac tissue, and is historically significant for aiding in the diagnosis of acute (heart attack). CK-MB levels typically begin to rise 3 to 6 hours after the onset of heart muscle injury, peak between 12 and 24 hours, and return to baseline within 48 to 72 hours. Normal CK-MB values vary by laboratory but are generally 3% to 5% of total CK activity, with elevations above these thresholds suggesting cardiac damage, though non-cardiac factors like strenuous exercise or skeletal muscle injury can also influence results. Although the CPK-MB test was once a cornerstone for confirming myocardial infarction due to its specificity for heart tissue—estimated at around 90% accuracy in isoenzyme analysis—it has been largely replaced by more sensitive and specific cardiac biomarkers like troponin I and T, which detect damage earlier and with greater precision. Today, CK-MB may still be used in conjunction with other tests to differentiate cardiac from non-cardiac causes of enzyme elevation or in settings where troponin assays are unavailable.

Background

Creatine kinase overview

(CK), also known as creatine phosphokinase, is an that catalyzes the reversible transfer of a group from (ATP) to , forming (PCr) and (ADP). This reaction plays a crucial role in cellular energy metabolism, particularly in tissues with high and fluctuating energy demands, by facilitating the rapid regeneration of ATP from PCr during periods of intense activity. The enzyme enables the storage and quick mobilization of high-energy phosphates, supporting sustained cellular function in energy-intensive environments. CK is predominantly active in high-energy tissues such as , , and the , where it maintains ATP levels to meet metabolic needs. In these locations, CK helps buffer energy fluctuations by shuttling groups between sites of ATP production (mitochondria) and consumption (myofibrils or ion pumps). Under normal conditions, CK remains largely intracellular, but damage—such as from , ischemia, or trauma—leads to the release of the into the bloodstream, resulting in elevated serum levels that can indicate tissue disruption. Structurally, CK is a dimer composed of two subunits: the muscle-specific M subunit and the brain-specific B subunit, which combine to form three main isoenzymes—CK-MM (predominant in ), CK-MB (found in ), and CK-BB (primarily in the ). These isoenzymes differ in their tissue distribution and substrate affinities, allowing for specialized roles in energy transfer within distinct cell types. CK-MB, in particular, serves as a marker of cardiac involvement due to its relative abundance in heart tissue.

CK-MB isoenzyme specifics

The CK-MB isoenzyme is a dimeric protein composed of one M (muscle) subunit and one B () subunit, forming a heterodimer with a molecular weight of approximately 86 . This structure distinguishes it from the other cytosolic isoenzymes, MM-CK and BB-CK, and enables its enzymatic activity in catalyzing the reversible transfer of a phosphate group from to ADP, generating ATP. CK-MB is typically quantified in laboratory assays either by enzymatic activity, reported in units per liter (U/L), or by mass concentration, reported in nanograms per milliliter (ng/mL), depending on the method employed. In terms of tissue distribution, CK-MB is present in highest concentrations in myocardial tissue, where it constitutes 20-30% of the total activity, compared to less than 5% in . This disparity arises because expresses a balanced mix of M and B subunits, allowing significant heterodimer formation, whereas predominantly produces the M subunit, favoring the MM-CK homodimer. The elevated proportion of CK-MB in the heart thus provides a biochemical basis for distinguishing cardiac injury from damage, as the relative index of CK-MB to total CK shifts markedly in favor of cardiac origin following myocardial events. Regarding , CK-MB has a plasma of approximately 10-18 hours after release into circulation. Following cardiac injury, serum levels of CK-MB typically rise within 4-6 hours, peak at 12-24 hours, and return to baseline within 48-72 hours, reflecting its rapid clearance and the transient nature of release from damaged tissue.

Clinical applications

Diagnosis of

The serves as a key in diagnosing acute (AMI), especially in cases where electrocardiogram (ECG) results are nondiagnostic or equivocal. Following the onset of AMI symptoms, CK-MB levels typically begin to elevate within 4-6 hours, reach a peak at approximately 24 hours, and normalize within 48-72 hours, providing a temporal window for confirming myocardial . This pattern distinguishes CK-MB from other isoenzymes due to its higher cardiac specificity. Diagnosis relies on detecting CK-MB elevations exceeding 2-3 times the upper limit of normal, which supports the presence of myocardial injury when correlated with clinical symptoms. To enhance specificity for cardiac origin, the relative index—calculated as CK-MB divided by total CK, expressed as a —is commonly used; values greater than 2.5-3% indicate likely AMI rather than damage. This combined approach was integral to AMI diagnostic protocols in the late 20th century. Serial CK-MB measurements, often performed at baseline and intervals such as 6 and 12 hours post-symptom onset, enable clinicians to monitor the temporal evolution of release, estimate infarct size based on peak levels and area under the , and assess reperfusion following thrombolytic therapy. A rapid rise and early peak in CK-MB post-reperfusion suggest successful restoration of blood flow, while delayed or prolonged elevations may signal incomplete reperfusion or larger infarct extent. Prior to the introduction of cardiac assays in the , CK-MB held the status of the gold standard for AMI confirmation and reinfarction detection in clinical guidelines. Its utility in early protocols facilitated timely interventions, though it has since been largely supplanted by more sensitive markers.

Monitoring cardiac injury in other conditions

The CK-MB test plays a role in assessing perioperative myocardial damage following , such as coronary artery bypass grafting (CABG). Elevations in CK-MB levels indicate myocardial necrosis occurring during the procedure, with levels exceeding five times the upper limit of normal associated with an increased risk of death or in the postoperative period. Specifically, CK-MB release greater than five to eight times the upper limit of the after CABG correlates with elevated mortality risk extending beyond three years postoperatively. Postoperative CK-MB elevations above 40 ng/mL the morning after surgery further predict higher long-term mortality. In the context of (PCI), CK-MB monitoring helps detect procedural complications, including myocardial injury from or . Routine surveillance shows CK-MB elevations in 10% to 40% of cases post-PCI, which are linked to increased mortality risk. Levels between 30 and 50 ng/mL post-procedure identify patients with at least a twofold increase in one-year mortality, providing prognostic insights into the extent of periprocedural damage. Elevated CK-MB after elective PCI also correlates with adverse long-term outcomes, emphasizing its utility in risk stratification. CK-MB elevations occur in various non-ischemic cardiac conditions, aiding in the evaluation of myocardial injury. In , heart muscle damage leads to detectable CK-MB release, serving as an indicator of disease severity despite lower sensitivity compared to troponins. For cardiac contusion due to blunt chest trauma, CK-MB demonstrates moderate specificity (75.8%) in detecting acute myocardial injury, though its sensitivity is limited at 55.2%. CK-MB levels can rise after , particularly with cumulative shock energies exceeding 1000 J, reflecting potential myocardial stress or minor injury. To distinguish cardiac from sources in these scenarios, the CK-MB relative index—calculated as (CK-MB / total CK) × 100—is employed; an index greater than 2.5–3% supports a cardiac origin, enhancing diagnostic specificity. Beyond acute events, CK-MB holds prognostic value in stable angina and exacerbations. In patients with stable angina undergoing elective , elevated CK-MB levels post-procedure predict reduced long-term event-free survival over five years, correlating with larger areas of myocardial involvement. Higher CK-MB peaks in exacerbations following are associated with increased risk of subsequent heart failure development, underscoring its role in outcome prediction.

Test procedure

Blood sample collection

The CPK-MB test requires a draw, typically collecting 5-10 mL of from a peripheral in the using standard techniques. The sample is collected into a serum separator tube (SST, such as a red-top or gel-barrier tube) for serum preparation or a green-top tube containing or sodium for plasma. Some labs recommend avoiding EDTA or citrate anticoagulants due to potential interference with the ; plasma or serum is preferred. No is required prior to the blood draw, but patients should avoid strenuous physical exercise for at least 48 hours beforehand to prevent transient elevations in baseline levels that could confound results. Additionally, supplementation should be discontinued at least 72 hours prior to collection to avoid interference. The procedure is performed by a trained phlebotomist or healthcare professional, and patients may experience minor discomfort from the needle insertion. In cases of suspected acute , an initial sample is drawn upon patient presentation to establish a baseline. Serial samples are then collected every 6-8 hours for up to 24-48 hours to detect any rise and fall in CPK-MB levels indicative of cardiac injury. This timing aligns with the enzyme's release kinetics, where levels typically begin to rise 3-6 hours after symptom onset. After collection, the sample must be allowed to clot for 15-30 minutes at if using a serum tube, followed by at greater than 2500 × g for 10 minutes within 2 hours to separate serum or plasma from cells. The separated specimen should be transferred to a transport tube and refrigerated at 2-8°C if analysis is not immediate; it remains stable for up to 72 hours under these conditions. must be strictly avoided during collection and handling, as it can falsely elevate CPK-MB results due to release of intracellular enzymes from red blood cells.

Laboratory measurement methods

The laboratory measurement of CK-MB primarily relies on two main approaches: immunoassays for mass concentration and enzymatic assays for catalytic activity. Immunoassays, which are the most widely used method due to their high , employ monoclonal or specific to the MB isoform in a two-site sandwich format. These assays, such as enzyme-linked immunosorbent (ELISA) or chemiluminescent immunoassays, quantify CK-MB mass in nanograms per milliliter (ng/mL) and are typically automated for rapid processing. Enzymatic activity assays, an older but still utilized technique, measure the catalytic activity of CK-MB in international units per liter (U/L) through coupled enzymatic reactions involving , ATP, and detection of NADH production via . These methods often incorporate immunoinhibition, where antibodies inhibit the M subunit of CK-MM, allowing measurement of approximately half the CK-MB activity, or for prior isoenzyme separation. While less specific than assays, enzymatic methods remain valuable in resource-limited settings for their . To enhance diagnostic specificity, laboratories report both absolute CK-MB values and the relative index, calculated as the percentage of CK-MB activity or mass relative to total CK (CK-MB%). The relative index helps distinguish cardiac from non-cardiac sources by identifying elevations where CK-MB exceeds 2.5-3% of total CK, though absolute measurements provide direct quantification without requiring total CK assay. Quality control in CK-MB testing involves calibration against international reference standards, such as those from the International Federation of Clinical Chemistry (IFCC), and daily analysis of control materials to verify accuracy and precision. Turnaround times in stat laboratories typically range from 1 to 2 hours, facilitated by point-of-care or automated analyzers.

Result interpretation

Normal reference ranges

The normal reference range for CK-MB in adults using mass assays is typically 0–5 ng/mL, while activity assays yield 5–25 U/L, though these values can vary by laboratory and are often expressed as less than 3–5% of total (CK) activity. Laboratories commonly establish upper limits based on the 99th of a healthy to account for method-specific variations. In pediatric populations, CK-MB levels show age-related variations, with higher total CK in infants (up to 308 U/L in males over 3 months and 192 U/L in females) but CK-MB mass remaining low, typically under 3.36 ng/mL in boys and 2.71 ng/mL in girls as upper limits. Newborns and infants exhibit elevated total CK (214–1175 U/L in the first day), yet the CK-MB fraction stays proportionally low at 0–6% of total CK, reflecting immature cardiac and contributions. For older children and adolescents, CK-MB stabilizes near adult levels, with sex differences emerging after age 12, where males show slightly higher values due to greater muscle mass. In the elderly, CK-MB reference ranges do not show significant increases; instead, total CK often declines slightly due to age-related muscle loss (), maintaining CK-MB mass below 5 ng/mL similar to younger adults, though individual labs adjust for comorbidities. Factors such as , race, and physical condition influence normal CK-MB levels. Males generally have higher CK-MB (mean 3.49 ng/mL) compared to females (mean 2.55 ng/mL), with 99th upper limits of 7.13 ng/mL and 5.40 ng/mL, respectively, attributable to greater . Racial differences primarily affect total CK, with Black individuals exhibiting 70% higher levels (upper limits 520–810 U/L in males) than Caucasians or Asians (227–440 U/L), potentially elevating the CK-MB percentage indirectly, though cardiac-specific MB remains comparable across groups when indexed to total CK. Conversion between mass and activity units for CK-MB is approximate, with 1 ng/mL corresponding to roughly 1–2 U/L activity at 37°C, depending on conditions and ; however, direct equivalence is not precise due to variations in molecular weight and catalytic efficiency. assays are now preferred over activity assays because they offer greater sensitivity for early detection of cardiac injury, reduced interference from non-cardiac sources, and improved stability for monitoring reinfarction, as supported by clinical studies showing earlier peak elevations and higher diagnostic accuracy.
PopulationCK-MB Mass (ng/mL)CK-MB Activity (U/L)Notes
Adults (Male)0–7.13 (99th percentile)5–25 (<3–5% total CK)Higher due to muscle mass
Adults (Female)0–5.40 (99th percentile)5–25 (<3–5% total CK)Lower baseline
Children (>3 months, Male)0–3.36 (upper limit)5–25 (<3–5% total CK)Stabilizes with age
Children (>3 months, Female)0–2.71 (upper limit)5–25 (<3–5% total CK)Sex differences post-puberty
Infants (Newborn)0–55–25 (<6% total CK)Elevated total CK, low MB fraction
Elderly0–55–25 (<3–5% total CK)Slight total CK decline

Clinical significance of elevations

Elevated CK-MB levels above the 99th percentile of the reference range, typically greater than 5 ng/mL in mass assays or 25 U/L in activity assays, indicate possible myocardial injury, particularly when confirmed by clinical context. A relative index of CK-MB to total CK exceeding 5% further supports a cardiac origin, distinguishing it from skeletal muscle contributions and aiding in the identification of acute cardiac damage. The temporal pattern of CK-MB elevation provides key diagnostic insights: levels begin to rise 4-6 hours after symptom onset, peak around 24 hours, and return to baseline within 48-72 hours in acute events, reflecting the dynamics of myocardial necrosis. A rapid rise and subsequent fall characterize an acute insult, such as myocardial infarction, while persistent elevations suggest ongoing cardiac injury, allowing clinicians to monitor the evolution of damage over time. Prognostically, higher peak CK-MB levels correlate with larger infarct size and increased mortality risk; for instance, peaks exceeding 100 U/L are associated with moderate to large infarcts and adverse outcomes in ST-elevation myocardial infarction patients. These elevations serve as a surrogate for myocardial damage extent, with studies showing independent associations between peak values and both short- and long-term cardiovascular mortality. In clinical practice, elevated CK-MB is integrated with electrocardiogram (ECG) findings and patient symptoms, such as chest pain, to confirm acute myocardial infarction, enhancing diagnostic accuracy when troponin results are pending or inconclusive. This multimodal approach ensures comprehensive evaluation, particularly in early presentations where CK-MB's kinetics provide timely evidence of injury.

Limitations and alternatives

Sources of non-cardiac elevations

Elevated levels of CK-MB can arise from various non-cardiac sources, primarily due to the presence of CK-MB isoforms in tissues beyond the myocardium, which limits the test's specificity for cardiac injury. Skeletal muscle is a major contributor to non-cardiac CK-MB elevations, as it contains small but detectable amounts of the CK-MB isoform, typically 1-3% of total CK, though this can increase to up to 25% in regenerating skeletal muscle fibers following injury or during myopathic processes. Conditions such as trauma, rhabdomyolysis, strenuous exercise, and intramuscular injections can release CK-MB from damaged or stressed skeletal muscle, leading to transient elevations that mimic cardiac patterns. Other non-cardiac conditions also elevate CK-MB through mechanisms like tissue damage, metabolic disturbances, or impaired clearance. Hypothyroidism can retard CK clearance and cause muscle involvement, resulting in higher CK-MB levels; pulmonary embolism may trigger release from pulmonary or associated muscle tissues; carbon monoxide poisoning induces systemic hypoxia and muscle injury; and renal failure delays CK-MB clearance, prolonging elevations even without ongoing damage. These factors contribute to false positive rates of up to 20-30% for CK-MB in patients presenting with non-cardiac chest pain, often leading to unnecessary cardiac evaluations. To mitigate these non-specific elevations and improve diagnostic accuracy, clinicians can employ the CK-MB relative index (calculated as CK-MB divided by total CK, multiplied by 100), where values below 3% suggest skeletal muscle origin and above 5% indicate cardiac source; additionally, mass assays for CK-MB offer higher specificity compared to activity-based methods by directly measuring the protein rather than enzymatic activity.

Comparison with cardiac troponin tests

The CPK-MB (creatine kinase-MB) test, while historically significant for diagnosing acute myocardial infarction (AMI), has been largely supplanted by cardiac troponin tests due to the latter's superior diagnostic performance. Cardiac troponins, specifically troponin I and T, offer greater sensitivity and specificity for detecting myocardial injury, allowing for earlier identification of even small infarcts. In contrast, CK-MB, an isoform of creatine kinase, is less precise because it can originate from non-cardiac tissues, leading to potential false positives. Key differences lie in their analytical performance metrics. Cardiac troponin assays achieve sensitivities exceeding 95% and specificities around 90-95% for AMI diagnosis, outperforming CK-MB's typical sensitivity of approximately 85% and specificity of 85-90%. Troponins enable detection of myocardial necrosis within 2-3 hours of symptom onset, compared to 4-6 hours for CK-MB, making them invaluable for rapid triage in emergency settings. Additionally, troponins remain elevated for 5-14 days post-infarction, aiding diagnosis in late presenters, whereas CK-MB levels normalize within 2-3 days, limiting its utility for timing events.
AspectCK-MBCardiac Troponin
Time to elevation4-6 hours post-onset2-3 hours post-onset
Peak time24 hours12-24 hours
Duration elevated2-3 days5-14 days
Sensitivity for AMI~85%>95%
Specificity for AMI85-90%90-95%
Clinical guidelines from the (ACC) and (AHA) endorse high-sensitivity cardiac as the first-line biomarker for AMI evaluation, recommending CK-MB only as an adjunct in equivocal cases, such as suspected reinfarction post-percutaneous coronary intervention (PCI) or when results are inconclusive. This shift reflects 's prognostic value in risk stratification, where elevations correlate more strongly with adverse outcomes than CK-MB. Regarding practicality, CK-MB testing remains somewhat less expensive due to simpler enzymatic assays, but high-sensitivity tests are now widely available, automated, and integrated into point-of-care systems globally, minimizing turnaround times and costs in high-volume laboratories. Routine CK-MB use adds unnecessary expense without enhancing diagnostic accuracy beyond troponin alone.

Historical development

Discovery and early use

The (CK) isoenzymes were first in the late through electrophoretic separation techniques applied to human tissues, with the MB fraction specifically in , revealing distinct patterns of CK in cardiac versus . Following its identification in the early 1970s, researchers recognized CK-MB as predominantly cardiac-specific, with elevated serum levels observed in patients with acute (AMI), establishing its potential as a diagnostic over total CK measurements. In the 1970s, early assays for CK-MB evolved from labor-intensive to more practical methods, including radioimmunoassays developed in 1976 for precise isoenzyme quantification. A key advancement was the immuno-inhibition technique introduced around 1977, which used antibodies to selectively inhibit the M subunit of CK, allowing routine measurement of CK-MB activity in clinical laboratories without requiring full isoenzyme separation. Key studies from the , such as those evaluating CK-MB in confirmed AMI cases, reported elevations in approximately 90% of patients, demonstrating high sensitivity for detecting myocardial when sampled appropriately after symptom onset. By the , CK-MB had become a standard test in emergency departments for AMI diagnosis, enabling earlier identification that supported timely thrombolytic interventions and contributed to reduced mortality rates in acute coronary events. The formalized its inclusion in AMI diagnostic criteria in , solidifying its clinical role.

Shift to modern biomarkers

During the 1990s, the development of cardiac assays revolutionized (MI) diagnostics, offering greater specificity and sensitivity compared to CK-MB. Initial and I immunoassays emerged in the late 1980s and early 1990s, with refinements such as the second-generation assay in 1997 eliminating skeletal muscle cross-reactivity. High-sensitivity assays, introduced toward the end of the decade via techniques, demonstrated superior prognostic value in clinical trials. For instance, in the GUSTO-IIa substudy involving 855 patients with acute myocardial ischemia, elevated levels (>0.1 ng/mL) were a stronger independent predictor of 30-day mortality (11.8% vs. 3.9% for normal levels; chi-square = 21, P<0.001) than CK-MB, providing incremental risk stratification even when adjusted for ECG and CK-MB findings. Guideline shifts accelerated the transition, establishing troponin as the preferred biomarker. In 2000, the joint European Society of Cardiology (ESC)/American College of Cardiology (ACC) consensus redefined MI, designating elevated cardiac troponin levels (exceeding the 99th percentile of a reference population with <10% coefficient of variation) as the biochemical gold standard, requiring accompaniment by clinical evidence such as ischemic symptoms or ECG changes. This redefinition increased apparent MI incidence in studies, from 29% to 40% in one cohort of chest pain patients using high-sensitivity troponin I versus conventional CK-MB criteria, enabling earlier intervention. By the 2010s, major guidelines and laboratory practices phased out routine CK-MB testing, reserving it for select scenarios like research or post-percutaneous coronary intervention (PCI) monitoring, as troponin proved more accurate for diagnosis and risk assessment. CK-MB retains limited niches despite its decline. In resource-limited settings, where high-sensitivity assays may be unavailable or costly, CK-MB continues to serve as an accessible marker for MI detection and in acute coronary syndromes. Additionally, peak CK-MB levels remain useful for estimating infarct size, correlating linearly with myocardial necrosis extent in post-PCI patients and predicting outcomes like left . As of 2025, CK-MB is largely obsolete for routine MI diagnosis, with guidelines explicitly recommending against its use in favor of or T, which offer superior ; CK-MB testing is non-reimbursable in many outpatient settings for evaluation. It persists in some laboratories for legacy protocols or specialized applications, but troponin's dominance reflects broader advancements in precision.

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