... and cross-linked fibrin degradation products containing D-dimer in EDTA whole blood and plasma...

download ... and cross-linked fibrin degradation products containing D-dimer in EDTA whole blood and plasma specimens. The test is used as an aid ... fibrin degradation ...

If you can't read please download the document

Transcript of ... and cross-linked fibrin degradation products containing D-dimer in EDTA whole blood and plasma...

  • English . . . . . . . . . . . . . Product Insert

    French / Franais . . . . . . Notice dutilisation

    German / Deutsch . . . . Packungsbeilage

    Italian / Italiano. . . . . . . Foglio illustrativo

    Spanish / Espaol. . . . . . Prospecto

    Portuguese / Portugus. . Folheto Informativo

    Greek / . . . . .

    Swedish / Svenska . . . . . Produktinformation

    Norwegian / Norsk . . . . Produktvedlegg

    Danish / Dansk . . . . . . . Produkttillg

    Dutch / Nederlands . . . . Bijsluiter

    22483 rev. G 2004/09/03

  • page 1 of 35 Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    EN

    GLI

    SH

    The Triage Profiler S.O.B. (Shortness of Breath) Panel is a fluorescenceimmunoassay to be used with the Triage MeterPlus for the quantitativedetermination of creatine kinase MB, myoglobin, troponin I, B-typenatriuretic peptide, and cross-linked fibrin degradation productscontaining D-dimer in EDTA whole blood and plasma specimens. Thetest is used as an aid in the diagnosis of myocardial infarction (injury), anaid in the diagnosis and assessment of severity of heart failure, an aid inthe assessment and evaluation of patients suspected of havingdisseminated intravascular coagulation or thromboembolic eventsincluding pulmonary embolism, and an aid in the risk stratification ofpatients with acute coronary syndromes.

    The diagnosis of acute myocardial infarction (AMI) in a patient presentingwith chest pain is difficult in many cases. The three major criteria outlined bythe World Health Organization for differentiating chest pain associated withAMI from chest pain due to other non-cardiac reasons are: 1) patient historyin addition to physical examination, 2) electrocardiographic data, and 3)changes in serum protein markers associated with myocardial infarction. Atleast two of these criteria must be fulfilled to appropriately diagnose an AMI.

    Frequently, physical examination cannot differentiate AMI from othercardiac abnormalities. The electrocardiogram is useful in diagnosing AMIbut is limited because it is diagnostic in only approximately 50% of AMIpatients. Typically, Q wave formation and changes in the ST segment,elevation or depression, are indicative of AMI. However, the results of theelectrocardiogram must be considered with the physical examination andclinical history of the patient. The electrocardiogram may be normal initiallyeven though the patient is truly presenting with AMI.

    Blood protein markers play an important role in the differential diagnosis ofAMI when other indicators may be negative or questionable. Markers usedin the diagnosis of myocardial infarction include: creatine kinase (CK), theMB isoenzyme of creatine kinase (CK-MB), lactate dehydrogenase, morespecifically, LDH-1 and LDH-2, myoglobin, isoforms of the MM and MBisoenzymes of CK and the structural proteins of the troponin complex, i.e.,troponin T and troponin I.

    Summary and Explanation of Test

    Intended Use

  • page 2 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Following an AMI, the appearance of protein markers in the blood resultsfrom cellular necrosis initiated by an ischemic event. Those proteins that arepresent in the highest concentrations and those that are most soluble appearin the blood first, e.g., myoglobin. The structural and mitochondrialproteins of the myocytes appear later following infarction, e.g., CK-MB andproteins of the troponin complex, including troponin I.

    Myoglobin is a cytoplasmic, soluble, heme protein present in muscle cellshaving a molecular weight of approximately 17,000 Daltons. Because of itsrelatively small size, high cellular concentration, and cytoplasmic location,myoglobin is released earlier than other cardiac markers following cellularnecrosis or injury. Blood concentrations of myoglobin increase above thereference range within the first 2 hours following injury, reaching a peakbetween 6 and 8 hours after the onset of symptoms. Myoglobin returns tobaseline or normal concentrations within 20-36 hours after tissue damage.Myoglobin is present in all types of muscle cells. Therefore, its appearancein blood is not necessarily associated with myocardial injury. Bloodmyoglobin concentrations may be elevated as a result of a variety ofconditions that produce muscle damage. These include trauma, ischemia,surgery, exercise and a variety of degenerative muscular diseases. In thisregard, myoglobin has its greatest value in the exclusion of myocardialinfarction in the early hours following chest pain. Due to the rapid increasein blood myoglobin concentrations, followed by moderately sustainedclearance, the utility of myoglobin is limited to the first 2-30 hoursfollowing tissue injury. Nevertheless, myoglobin is particularly useful whenthe clinical history of the patient is known.

    Creatine Kinase MB (CK-MB) is an 82,000 Dalton cytosolic enzyme thatis present in high concentrations in the myocardium. This isoenzyme ofcreatine kinase is frequently used in the diagnosis of acute myocardialinfarction. Typically, CK-MB increases above normal within the first 4-8hours following acute myocardial infarction, reaching maximumconcentrations between 12 and 24 hours and returning to normal inapproximately 3 days. CK-MB, like myoglobin, is not specifically localizedin cardiac muscle. Blood concentrations of CK-MB can be elevated as aresult of acute or chronic muscle damage, including strenuous exercise andtrauma. Nonetheless, measurements of blood CK-MB concentrations arewidely relied on for the management of patients having an AMI.

    The contractile proteins of the myofibril have gained increased popularity ascardiac specific markers for acute myocardial infarction and myocardialdamage. These include two specific proteins of the contractile regulatory

  • page 3 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    complex, troponin I and troponin T. Troponin I and troponin T isolatedfrom cardiac muscle have unique amino acid sequences that enable thedevelopment of specific antibodies to the cardiac proteins. The aminoterminal amino acid sequence of the cardiac isotype of troponin I has 31amino acid residues that are not present in either of the two isotypes oftroponin I in skeletal muscle. Therefore, immunoassays specific for cardiactroponin I are used in the evaluation of patients suspected of experiencingan AMI. Blood troponin I concentrations become elevated between 4 and8 hours following an AMI. The concentration peaks between 12 and 16hours and remains elevated for 5-9 days following damage to themyocardium. Cardiac troponin I is primarily elevated as a result ofmyocardial infarction. However, cardiac troponin I also may be elevated asa result of minor cardiac injury that includes: unstable angina, cardiaccontusions, cardiac transplant, coronary artery bypass graft surgery, physicaltrauma to the heart, congestive heart failure and other conditions that maydamage the myocardium. Moreover, cardiac troponin I does not appear tobe elevated as a result of skeletal muscle injury. Due to the increasedanalytical specificity and the increased duration of elevation, cardiactroponin I has become an important marker in the diagnosis and evaluationof patients suspected of having an AMI. Simultaneous quantification ofmyoglobin, CK-MB and cardiac troponin I following AMI can greatly assistthe physician in the management of patients suspected of presenting withan AMI.

    It is estimated that 4.79 million people in the United States have heartfailure with approximately 550,000 new cases occurring each year.Congestive heart failure (CHF) occurs when the heart cannot deliver asufficient amount of blood to the body. This condition can occur at any agebut is most prevalent in an aged population. Symptoms of CHF includeshortness of breath, fluid retention and respiratory distress. These symptomsare often vague and nonspecific for detecting early stages of CHF.

    B-Type Natriuretic Peptide (BNP) is a member of a class of hormones thatregulate blood pressure. The heart is the main source of circulating BNP inhumans. The molecule is released into the blood in response to increasedheart pressure. Various studies have demonstrated that increased levels ofcirculating BNP are found in early stages of CHF. The level of BNP in theblood continues to increase as the CHF disease advances. Furthermore,BNP has been demonstrated to have utility as a prognostic indicator inpatients with acute coronary syndromes (ACS). The Triage Profiler S.O.B.Panel offers an objective, noninvasive measurement for assessing patients forCHF and risk stratification in patients with ACS.

  • page 4 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    During the coagulation process, thrombin converts fibrinogen to solublefibrin by the proteolytic removal of both fibrinopeptide A andfibrinopeptide B. Soluble fibrin spontaneously polymerizes, and the Dregions are covalently crosslinked through a process that is catalyzed byfactor XIIIa. Crosslinked fibrin is ultimately degraded via the fibrinolyticpathway. Plasmin cleaves bonds in the crosslinked fibrin lattice and liberatesfibrin degradation products (FDPs), including a 200 kDa crosslink of twofragment D molecules (D-dimer). Elevations of circulating D-dimer havebeen described in patients with venous thromboembolism, includingpulmonary embolism (PE) and deep venous thrombosis (DVT) (seeGoldhaber, S.Z. (1998) New Engl. J. Med. 339; 93-104).

    The Triage Profiler S.O.B. Panel is a fluorescence immunoassay for thequantitative determination of the proteins D-dimer, CK-MB, myoglobin,troponin I, and BNP in whole blood and plasma specimens using EDTA asthe anticoagulant. After addition of the sample to the sample port, the cellsare separated from the plasma via a filter contained in the device. Apredetermined quantity of plasma is allowed to react with fluorescentantibody conjugates within the reaction chamber. After sufficientincubation has occurred, the reaction mixture flows down the devicedetection lane. Complexes of the analytes and fluorescent antibodyconjugates are captured on discrete zones resulting in binding assays that arespecific for each analyte. The concentration of the analyte in the specimenis directly proportional to the fluorescence detected.

    The Triage Profiler S.O.B. Test Device contains all the reagents necessaryfor the simultaneous quantification of the proteins D-dimer, CK-MB,myoglobin, troponin I, and BNP in plasma and whole blood.

    The Test Device contains:

    Murine monoclonal and polyclonal antibodies against CK-MB, murinemonoclonal and polyclonal antibodies against myoglobin, murinemonoclonal and goat polyclonal antibodies against troponin I, murinemonoclonal antibodies against D-dimer, and murine monolonal andpolyclonal antibodies against BNP labeled with a fluorescent dye andimmobilized on the solid phase, and stabilizers.

    Reagents

    Principles of Procedure

  • page 5 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    For In Vitro Diagnostic Use. Carefully follow the instructions and procedures described in this insert. Patient specimens, used test devices and transfer pipettes may be

    potentially infectious. Proper handling and disposal methods should beestablished by the laboratory director in accordance with local, state andfederal regulations.

    Proper laboratory safety techniques should be followed at all times whenworking with blood specimens because they are potentially infectious.

    The Triage Profiler S.O.B. Panel should not be used as absolute evidencefor AMI, CHF, PE, or DVT. As with all in vitro diagnostic tests, the testresults should be interpreted by the physician in conjunction with clinicalfindings and other test results.

    Blood concentrations of BNP may be elevated in patients who areexperiencing a heart attack, patients that are candidates for renal dialysis,and patients that have had renal dialysis.

    The transfer pipette should be used for one specimen only. Discard aftersingle use.

    Keep the Test Device in the sealed pouch until ready to use. Discard aftersingle use.

    The Triage Profiler S.O.B. Test Device is stable (while in the sealed pouch)up to the expiration date when stored refrigerated at 2 - 8C (35 - 46F).Once removed from refrigeration, the pouched Triage Profiler S.O.B. TestDevice is stable for up to 14 days, but not beyond the expiration date printedon the pouch. If not used on the same day of removal from refrigeration,gently write the date of removal from the refrigerator and the date to discardon the foil pouch and/or the kit box (use a soft, felt tip marker).

    Once removed from refrigeration, allow a minimum of 30 minutes forTest Device to reach room temperature while in the sealed pouch.

    Do not remove the Test Device from the pouch until ready for use.

    Storage and Handling Requirements

    Warnings and Precautions

  • page 6 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Whole blood or plasma using EDTA as the anticoagulant is the specimenrequired for testing with this product. Other blood specimen types have notbeen evaluated.

    Test blood specimens on the Triage Profiler S.O.B. Test Deviceimmediately or within 6 hours of sample collection. If testing cannot becompleted within 6 hours, the plasma should be separated and stored at-20 C until it can be tested.

    Transport specimens at room temperature or chilled and avoid extremetemperatures.

    The specimen must be at room temperature and be homogeneous beforetesting.

    Mix the blood specimen by gently inverting the tube several times beforetransferring blood to the Test Device.

    It is recommended to avoid using severely hemolyzed specimenswhenever possible. If a specimen appears to be severely hemolyzed,another specimen should be obtained and tested.

    Biosite Triage Profiler S.O.B. Panel, Catalog No. 97300Kit contains:Test Devices 25Transfer Pipettes 25Reagent Code Chip 1Printer Paper 1 roll

    Triage MeterPlus U.S. Catalog # 55040or

    International Catalog # 55041

    Triage Profiler S.O.B. Controls Catalog # 97301

    Using the Transfer Pipette1.Depress the larger (top) bulb completely and insert the tip into the

    specimen.2.Release the bulb slowly. The tube should fill completely. Some fluid must

    remain in the smaller (lower) bulb.

    Procedure

    Materials Required But Not Provided

    Materials Provided

    Sample Collection and Preparation

  • page 7 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    3.Place the tip of the pipette into the sample port of the Test Device anddepress larger bulb completely. The entire amount of sample in thepipette tube must be dispensed. The sample in the smaller (lower) bulbwill not be expelled.

    4.Remove the tip from the sample port and then release the bulb.

    Test ProcedureSTEP 1. Add Sample to Triage Profiler S.O.B. Test Device

    Open the pouch, write the patient ID number on the label of theTest Device, and add EDTA-anticoagulated whole blood orplasma into the sample chamber using the transfer pipetteprovided (refer to pipette instructions).

    STEP 2. Insert Test Device into Triage MeterPlusAllowing a moment for the sample to absorb into the sample portof the device, insert the Triage Profiler S.O.B. Test Device intothe Triage MeterPlus. This step must be completed no longerthan 30 minutes after step 1.

    STEP 3. Read the Results on the Triage MeterPlus Display ScreenThe test results are displayed when the test is complete. After thedevice has been analyzed, it is released by the TriageMeterPlus.

    The results of the Triage Profiler S.O.B. Panel are calculated automaticallyby the Triage MeterPlus. The concentrations of all five analytes aredisplayed on the screen. The operator has the option to print the results. Foradditional information, refer to the User Guide for the Triage MeterPlus.

    The Triage Profiler S.O.B. Panel has been standardized using purifiedprotein preparations of D-dimer, CK-MB, myoglobin, cardiac troponin I,and BNP based on the mass (concentration) of analyte present in EDTA-anticoagulated plasma.

    The use of positive and/or negative controls is recommended to assess eachshipment of product, and at least every 30 days, or whenever thelaboratorian wishes to verify the performance of the controls or the test.Biosite provides two external control solutions for this purpose. Onecontains analyte concentrations near the diagnostic cut-off. The othercontains concentrations of analytes that are observed in samples from

    Quality Control and Acceptability of Results

    Standardization

    Results

  • page 8 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    patients experiencing an AMI or having heart failure. It is recommendedthat these controls be used to test each new shipment or lot of product andto verify the system integrity and operator proficiency.

    Each Triage Profiler S.O.B. Test Device contains two internal controls thatsatisfy routine quality control requirements. These controls indicate thatsufficient sample was applied to the Test Device, the unbound fluorescentlabel was washed sufficiently from the detection zone, and the Test Devicewas inserted and read properly by the meter. An unacceptable result fromeither control causes the display of a warning message on the Triage MeterPlus indicating that the test should be repeated.

    For further information regarding the complete quality control of the systemrefer to the User Guide for the Triage MeterPlus.

    The QC Device (may also be named QC Simulator) provided with theTriage MeterPlus should be tested each day of patient testing to verifyinstrument performance. Alternately, the QC Device should be tested uponset-up of the Triage MeterPlus and whenever required by local, state andfederal regulations. Refer to the User Guide for a description of the QCDevice.

    The results of the Triage Profiler S.O.B. Panel should be evaluated in thecontext of all the clinical and laboratory data available. In those instanceswhere the laboratory results do not agree with the clinical evaluation,additional tests should be performed accordingly.

    This test has been evaluated with whole blood and plasma using EDTA asthe anticoagulant. Serum and blood or plasma specimens obtained usingother anticoagulants have not been evaluated and should not be used (e.g.heparin or citrate).

    There is the possibility that factors such as technical or procedural errors, aswell as additional substances in blood specimens that are not listed below,may interfere with the test and cause erroneous results.

    Limitations of the Procedure

  • page 9 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Analytical SensitivityThe analytical sensitivity or lowest detectable concentration that isdistinguishable from zero for the five analytes was determined by testing azero calibrator 20 times each using 3 lots of reagents and 5 meters on 3 days.The analytical sensitivity of each assay on the Triage Profiler S.O.B. TestDevice is presented below:

    D-dimer: 100 ng/mLTroponin I: 0.05 ng/mLCK-MB: 1.0 ng/mLMyoglobin: 5 ng/mLBNP: 5 pg/mL

    Measurable Ranges

    D-dimer: 100 - 5,000 ng/mLTroponin I: 0.05 - 30 ng/mLCK-MB: 1.0 - 80 ng/mLMyoglobin: 5 - 500 ng/mLBNP: 5 - 5,000 pg/mL

    Interfering SubstancesHemoglobin (up to 500 mg/dL), lipids (triolein up to 3,000 mg/dL),bilirubin (up to 15 mg/dL), fibrinogen (up to 1 mg/mL), fragment D (upto 20 g/mL) or fragment E (up to 20 g/mL) added to EDTA-anticoagulated plasma containing the five analytes did not interfere with therecovery of the analytes. These substances failed to produce a positiveresponse in a sample that did not contain any of the analytes of interest.However, severely hemolysed specimens should be avoided wheneverpossible. When a sample appears to be severely hemolyzed, anotherspecimen should be obtained and tested.

    The hematocrit was varied between 30% and 55% and with no significanteffect on the recovery of D-dimer, CK-MB, myoglobin, troponin I, or BNP.RA factor has not been tested.

    Performance Characteristics

  • page 10 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    PharmaceuticalsThe following drugs were evaluated for potential cross-reactivity andinterference in the Triage Profiler S.O.B. Panel. All drugs were tested atconcentrations that represent the blood concentrations that would resultfrom a maximal therapeutic dose and at least twice the maximal therapeuticdose. None of the drugs interfered with the recovery of D-dimer, CK-MB,myoglobin, troponin I, or BNP. Additionally, these drugs did not produce asignificant response when tested in a specimen containing none of theanalytes of interest. There was no significant interference with the analyte,nor was there any assay cross-reactivity.

    AcebutololAcetominophenAcetazolamideAcetylsalicylic acidAlbuterolAllopurinolAmilorideAmiodaroneAmoxicillinAmpicillinAscorbic acidAtenololAtorvastatinBepridilCaffeineCaptoprilCerivastatinChloramphenicolChlorothiazideClofibrateClopidrogrelCocaineCyclosporineDiclofenacDigoxinDiltiazem

    DipyridamoleDopamineEnalapril maleateErythromycinFluoxetineFosinoprilFurosemideHeparinHydrochlorothiazideHydrocodoneHydroflumethazideIbuprofenIndapamideIndomethacinIsosorbide dinitrateLisinoprilLoratidineLovastatinL-thyroxineMethyldopaMetolazoneMetoprololMilrinoneMorphineNadololNicotine

    Nicotinic acidNiphedipineNitrofurantoinNitroglycerinNoraminpyrineOmeprazoleOxazepamOxytetracyclinePCPPhenobarbitalPhenytoinPlasminogenProbenecidProcainamidePropanololQuinidineSimvastatinSotalolSulfamethoxazoleTheophyllineTimololTocainideTriamtereneTrimethoprimVerapamilWarfarin

  • page 11 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    ProteinsThe CK-MB, myoglobin, and troponin I assays were evaluated for cross-reactivity with the following related proteins:

    Reactivity with Related ProteinCK-MB Troponin I Myoglobin

    Protein ng/mL % Cross-reactivity % Cross-reactivity % Cross-reactivityControlActin 500 0.0% 0.0% 0.0%Actin 1000 0.0% 0.0% 0.0%CK-BB 15.6 0.3% 0.0% 0.0%CK-BB 31.2 0.8% 0.0% 0.0%CK-BB 62.5 0.9% 0.0% 0.0%CK-BB 125 1.5% 0.0% 0.0%CK-BB 250 2.4% 0.0% 0.0%CK-BB 500 3.3% 0.0% 0.0%CK-MM 250 0.2% 0.0% 0.0%CK-MM 500 0.0% 0.0% 0.0%CK-MM 5000 0.0% 0.0% 0.0%cTnC 2000 0.0% 0.0% 0.0%cTnT 2000 0.0% 0.0% 0.0%Myosin 2000 0.0% 0.0% 0.0%sTnI 500 0.0% 0.0% 0.0%sTnI 1000 0.0% 0.0% 0.0%sTnT 500 0.0% 0.0% 0.0%sTnT 1000 0.0% 0.0% 0.0%Tropomyosin 2000 0.0% 0.0% 0.0%

    In addition to the proteins tested above, the Triage Profiler S.O.B. Panelwas tested with regard to the ability of the troponin I test to detect variouscomplexes of cardiac troponin I. The results below demonstrate that theTriage Profiler S.O.B. Panel recognizes 5 forms of cardiac troponin I on anequimolar basis.

    Reactivity with Various Forms of Cardiac Troponin ITroponin Form Troponin Recovery (ng/mL) Troponin Recovery (%)Troponin I, Oxidized 1.21 100Troponin I, Reduced 1.12 93Troponin I-C Complex 1.52 125Troponin I-T Complex 1.39 115Troponin C-T-I Complex 1.19 99

  • Recent reports show that cardiac troponin I is released as binary and ternarycomplexes, in addition to free troponin I from patients suffering from AMI.

    In light of these reports it would seem that assays for cardiac troponin Ishould be able to detect the analyte in each of its forms on an equimolarbasis (free and complex).

    Additionally, the BNP assay was evaluated for cross-reactivity with thefollowing related proteins and peptides:

    Reactivity with Related Proteins and PeptidesSubstance Concentration of Substance % RecoveryRenin 50 ng/ml 104%Aldosterone 1 ug/ml 104%Angiotensin I 600 pg/ml 108%Angiotensin II 600 pg/ml 108%Endothelin I 20 pg/ml 101%Adrenomedullin (ADM) 1000 pg/ml 97%Alpha-Atrial Natriuretic polypeptide 1-28 1000 pg/ml 104%Prepro BNP 22-46 1000 pg/ml 104%Prepro BNP 1-21 1000 pg/ml 106%Arg Vasopressin 1000 pg/ml 96%C-type natriuetic Peptide 53 1000 pg/ml 106%Prepro-ANF 56-92 1000 pg/ml 104%Prepro-ANF 104-123 1000 pg/ml 97%Urodilatin(CCD/ANP) 95-126 1000 pg/ml 100%Angiotensin III 1000 pg/ml 108%Prepro-ANF 26-55 1000 pg/ml 107%

    ImprecisionWithin-day and total imprecision were determined using the ANOVAmodel by testing control materials and human plasma pools that had therespective analytes added at concentrations near the decision points of theassay and throughout the range of the standard curve. The study wasconducted over 10 days, testing each control 10 times per day.

    page 12 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

  • page 13 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    D-DIMER

    Average Within Day Imprecision

    Mean (ng/mL) SD (ng/mL) CV

    128 18 14.4%

    451 44 9.7%

    2,990 180 6.0%

    CK-MB

    Average Within Day Imprecision

    Mean (ng/mL) SD (ng/mL) CV

    4.47 0.50 11.2%

    18.66 2.46 13.2%

    49.08 6.17 12.6%

    TROPONIN I

    Average Within Day Imprecision

    Mean (ng/mL) SD (ng/mL) CV

    0.35 0.04 11.7%

    1.22 0.14 11.7%

    11.60 1.17 10.1%

    MYOGLOBIN

    Average Within Day Imprecision

    Mean (ng/mL) SD (ng/mL) CV

    78.93 10.16 12.9%

    122.32 16.55 13.5%

    241.88 36.88 15.2%

    BNP

    Average Within Day Imprecision

    Mean (pg/mL) SD (pg/mL) CV

    109.01 8.86 8.1%

    608.32 59.60 9.8%

    3432.74 422.20 12.3%

    D-DIMER

    Average Total Imprecision

    Mean (ng/mL) SD (ng/mL) CV

    128 20 15.4%

    451 48 10.7%

    2,990 183 6.1%

    CK-MB

    Average Total Imprecision

    Mean (ng/mL) SD (ng/mL) CV

    4.47 0.55 12.2%

    18.66 2.66 14.3%

    49.08 6.15 12.5%

    TROPONIN I

    Average Total Imprecision

    Mean (ng/mL) SD (ng/mL) CV

    0.35 0.04 12.3%

    1.22 0.15 12.3%

    11.60 1.17 10.1%

    MYOGLOBIN

    Average Total Imprecision

    Mean (ng/mL) SD (ng/mL) CV

    78.93 10.24 13.0%

    122.32 17.75 14.5%

    241.88 38.84 16.1%

    BNP

    Average Total Imprecision

    Mean (pg/mL) SD (pg/mL) CV

    109.01 8.87 8.1%

    608.32 60.89 10.0%

    3432.74 421.23 12.3%

  • page 14 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    The method comparison was performed using samples from apparentlyhealthy individuals (N = 111, range < 100 ng/mL to 1,850 ng/mL), patientswith confirmed pulmonary embolism (N = 17, range 560 ng/mL to > 5,000ng/mL), patients with myocardial infarction (N = 32, range < 100 ng/mLto 2,630 ng/mL), patients with unstable angina (N = 11, range < 100ng/mL to 2,910 ng/mL), patients with CHF (N = 4, range 380 ng/mL to530 ng/mL, and patients with non-cardiac chest pain (N = 5, range < 100ng/mL to 690 ng/mL). Patients with deep venous thrombosis were notincluded in the study.

    A comparison of 180 D-dimer measurements on the Triage Profiler S.O.B.Panel to measurements obtained using another commercially availablemethod yielded the following statistics (Passing-Bablok regression):

    Slope Intercept Correlation coefficient0.999 -85.89 0.92

    Triage Profiler S.O.B. D-dimer vs. Predicate Method

    Altman-Bland Bias Plot

    Method Comparison D-dimer

  • page 15 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    The expected values were calculated non-parametrically and represent the95th percentile of the population tested. The expected values from 208apparently healthy individuals (77 females age 19-79, 131 males age 19-73)are less than 600 ng/mL. The 90th percentile of measurements is less than400 ng/mL.

    Healthy VolunteersCK-MB and myoglobin concentrations were determined using specimensobtained from 452 apparently healthy individuals (264 women and 188 men).The 95th percentiles of concentrations for each analyte are shown below.

    Analyte 95th PercentileCK-MB < 4.3 ng/mLMyoglobin < 107 ng/mL

    Troponin I concentrations were determined using specimens obtained from133 apparently healthy individuals. The 95th, 97.5th and 99th percentilesare shown below.

    Analyte 95th Percentile 97.5th Percentile 99th PercentileTroponin I 0.05 ng/mL 0.05 ng/mL 0.05 ng/mL

    Patients with Skeletal Muscle Injury andRenal DiseaseTwo additional groups of patients were evaluated for the presence of thevarious analytes. Both myoglobin and CK-MB are known to be potentiallyelevated in these conditions and diseases. Most of the patients' analyteconcentrations were evaluated at a single time. Those patients who weresuffering from renal insufficiency were evaluated at the time they receivedtheir dialysis. Cardiac involvement was not considered during the initialscreening of the patients in the study. Some patients were determined tohave cardiac injury or contusions after the initial diagnosis. Twelve of thetwenty-one specimens having elevated troponin I concentrations obtainedfrom patients having a primary diagnosis of skeletal muscle trauma wereelevated as a result of cardiac involvement.

    Expected Values - Diagnosis ofMyocardial Infarction (Injury)

    Expected Values - D-dimer

  • page 16 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Skeletal Muscle Injury

    Renal Patients

    Those conditions that result in myocardial cell damage potentially can causeincreased blood concentrations of any of these analytes. For example,troponin I concentrations have been reported to be elevated as a result ofunstable angina, congestive heart failure, myocarditis, and cardiac surgery,including invasive cardiac testing and cardiac contusions. Additionally, bothCK-MB and myoglobin have been reported to be elevated in both skeletalmuscle injury and renal disease.

    Number ofpatientsCut-OffNo. SamplesAbove Cut-OffNo. Samples fromPatients withCardiacInvolvementClinical Specificity

    CK-MB(ng/mL)

    804.3

    22

    563/80 x 100

    79%

    Troponin-I(ng/mL)

    800.4

    5

    580/80 x 100

    100%

    Myoglobin(ng/mL)

    80107

    74

    511/80 x 100

    16%

    Number ofpatients/SamplesCut-OffNo. SamplesAbove Cut-OffNo. Samples fromPatients withCardiacInvolvementClinical Specificity

    CK-MB(ng/mL)

    117/1894.3

    121

    1583/189 x 100

    44%

    Troponin-I(ng/mL)

    117/1890.4

    21

    12180/189 x 100

    95%

    Myoglobin(ng/mL)

    117/189107

    165

    1539/189 x 100

    21%

  • page 17 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Interpretation of ResultsTemporal elevations of CK-MB, myoglobin and troponin I are observed inpatients diagnosed with myocardial infarction. However, CK-MB andmyoglobin, but not cardiac troponin I, may be elevated in renal disease andskeletal muscle injury. Cardiac troponin I appears to be elevated only inthose diseases that directly involve the heart. Collectively, the diagnosis ofmyocardial infarction should include measurement of these cardiac relatedproteins and other clinical information including patient history andelectrocardiographic data. Other conditions that may result in elevatedcardiac proteins are: cardiac contusions, myocarditis, invasive examinationof the heart, coronary artery bypass surgery, congestive heart failure andunstable angina. Therefore, these data must be considered when interpretingthe results.

    These values are representative. Each laboratory should establish a referencerange that is representative of the patient population to be evaluated.Additionally, each laboratory should consider the current practice in theevaluation of patients experiencing chest pain and AMI at their respectiveinstitution.

    Clinical Performance in the Evaluation ofChest PainCK-MB, myoglobin, and troponin I concentrations were evaluated inpatients at 4 clinical sites. In addition to the ranges of expectedconcentrations in apparently healthy individuals, patients with renal diseaseand patients suffering from acute muscle injury, the clinical sites evaluatedpatients for whom a diagnosis of myocardial infarction was indicated.Clinical diagnosis of myocardial infarction was based on satisfying at leasttwo of the three criteria outlined below:

    Chest pain (discomfort) for a duration of at least 20 minutes Electrocardiographic changes that are consistent with myocardial

    infarction Temporal changes in cardiac enzymes (markers)Those patients who did not satisfy 2 of the 3 criteria listed above wereclassified in the rule-out group.

    The diagnostic sensitivity and specificity were evaluated by comparing themarker concentration to the discharge diagnosis for each patient. Inasmuch asthe WHO criteria used in the diagnosis of myocardial infarction does notencompass the diagnosis of minor myocardial injury, the diagnostic specificityof troponin I may appear to be less than CKMB when using these criteria.

  • page 18 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Clinical Sensitivity and Specificity by TimeIntervalTemporal elevations of all three cardiac markers (troponin I, CK-MB, andmyoglobin) are useful in the management of patients with chest pain, to aidin the diagnosis myocardial infarction and assessment of patients exhibitingchest pain. Serial sampling of the patient's blood following myocardialinfarction is recommended, as changes in the marker concentrations mayalso be diagnostic. In particular, it has been demonstrated that temporalchanges in myoglobin concentration provide additional diagnosticinformation that would otherwise not be identified if using a single timepoint. It is recommended that each hospital establish a suitable samplingprotocol in addition to establishing an appropriate reference range. The cut-off concentrations for troponin I (0.4 ng/mL), CK-MB (4.3 ng/mL) andmyoglobin (107 ng/mL) were used to calculate the clinical sensitivity andspecificity.

    225 patients experiencing symptoms of acute myocardial infarction wereevaluated. 207 specimens were obtained and evaluated from 72 patientsdiagnosed with myocardial infarction. An additional 316 samples from 153patients were obtained and evaluated from patients for whom a diagnosis ofAMI was excluded. Included were patients with unstable angina, coronaryartery disease and other causes of chest pain but where AMI was ruled out.

    Clinical Sensitivity

    # of samplesCardiacTroponin ISensitivity95%ConfidenceIntervalCK-MBSensitivity95%ConfidenceIntervalMyoglobinSensitivity95%ConfidenceInterval

    0-6 hrs.40

    65%

    50.2%-79.8%

    78%

    64.6%-90.4%

    75%

    61.%-88.4%

    Time6-12 hrs.

    32

    72%

    56.3%-87.5%

    78%

    63.8%-92.4%

    75%

    60.0%-90.0%

    12-24 hrs.44

    93%

    85.7%-100%

    80%

    67.6%-91.5%

    73%

    59.6%-85.9%

    > 24 hrs.91

    96%

    91.4%-99.8%

    85%

    77.2%-92.0%

    74%

    64.6%-82.7%

  • Clinical Specificity

    ROC Analysis of Troponin I, CK-MB andMyoglobinThe graph below depicts the clinical sensitivity and specificity of cardiactroponin I, CK-MB and myoglobin when using various cut-offconcentrations. The upper end of normal values were used as the cut-off forCK-MB (4.3 ng/mL), myoglobin (107 ng/mL), and troponin I (0.4ng/mL). Additionally these values were used as the cut-off concentrationsfor the statistics provided above. Each laboratory should establish their owndiagnostic cut-off concentrations based on the clinical practice at theirrespective institutions.

    page 19 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    # of samplesCardiacTroponin ISpecificity95%ConfidenceIntervalCK-MBSpecificity95%ConfidenceIntervalMyoglobinSpecificity95%ConfidenceInterval

    0-6 hrs.89

    100%

    100%-100%

    91.00%

    85.1%-97.0%

    74.20%

    65.1%-83.3%

    Time6-12 hrs.

    66

    97.00%

    92.8%-100%

    86.40%

    78.1%-94.6%

    81.80%

    72.5%-91.1%

    12-24 hrs.90

    94.40%

    89.7%-99.2%

    82.20%

    74.3%-90.1%

    67.80%

    58.1%-77.4%

    > 24 hrs.71

    90.10%

    83.2%-97.1%

    88.70%

    81.4%-96.1%

    71.80%

    61.4%-82.3%

  • page 20 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    30

    20

    15

    10 75 4.3

    0.0%

    10.0%

    20.0%

    30.0%

    40.0%

    50.0%

    60.0%

    70.0%

    80.0%

    90.0%

    100.0%

    1- Specificity

    Pe

    rce

    nt

    Se

    nsitiv

    ity

    ROC CK-MB

    0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

    2 1

    10

    20

    5

    1

    0.40.18

    0.0%

    10.0%

    20.0%

    30.0%

    40.0%

    50.0%

    60.0%

    70.0%

    80.0%

    90.0%

    100.0%

    1- Specificity

    Perc

    entS

    ensitiv

    ity

    ROC Troponin I

    0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

    2

    0.80.6

  • Individuals Without CHFThe circulating BNP concentration was determined from 1286 individualswithout CHF (676 women and 610 men). This population includedindividuals with hypertension, diabetes, renal insufficiency, and chronicobstructive pulmonary disease. There are no statistically significant changesin BNP concentration associated with hypertension, diabetes, renalinsufficiency, and chronic obstructive pulmonary disease. The descriptivestatistics for BNP concentrations in individuals without CHF are shown inthe table below. The values are representative of the values obtained fromclinical studies. The decision threshold was determined by the 95%confidence limit of BNP concentration in the non-CHF population age 55and older. The most appropriate decision threshold apparent from thesedistributions is 100 pg/ml. This value translates into a general specificity ofthe test of 98%, i.e. less than 2% expected false positives in individualswithout CHF. Each laboratory should establish a reference range thatrepresents the patient population that is to be evaluated.

    Expected Values - Diagnosis andAssessment of Severity of CHF

    page 21 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    300

    200150

    100

    90

    80

    0.0%

    10.0%

    20.0%

    30.0%

    40.0%

    50.0%

    60.0%

    70.0%

    80.0%

    90.0%

    100.0%

    1- Specificity

    Perc

    entS

    ensi

    tivity

    ROC MYOGLOBIN

    0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

    40

    70.0% 80.0% 90.0% 100.0%

    10

  • page 22 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Descriptive Statistics - BNP Concentration(pg/ml)

    Non-CHF PopulationAll

    Males

    Females

    Individuals With CHFBlood samples were obtained from 804 patients diagnosed with CHF (246women and 558 men). The descriptive statistics for BNP concentrations inpatients with CHF are presented in the table below. These values arerepresentative of the values obtained from clinical studies. Each laboratoryshould establish a reference range that represents the patient population thatis to be evaluated. In addition, laboratories should be aware of theirrespective institutions' current practice for the evaluation of patientswith CHF.

    Median

    95thPercentile

    Percent < 100pg/ml

    Minimum

    Maximum

    N

    All

    7.1

    56.9

    98.9%

    5.0

    252.0

    610

    Age < 45

    5.0

    23.8

    98.9%

    5.0

    251.3

    183

    Age 45-54

    7.2

    39.0

    99.5%

    5.0

    252.0

    196

    Age 55-64

    9.0

    72.4

    98.3%

    5.0

    207.7

    118

    Age 65-74

    15.7

    62.7

    98.9%

    5.0

    127.3

    89

    Age 75+

    39.0

    77.9

    95.8%

    5.0

    218.5

    24

    Median

    95thPercentile

    Percent < 100pg/ml

    Minimum

    Maximum

    N

    All

    18.5

    84.2

    97.2%

    5.0

    197.9

    676

    Age < 45

    11.6

    47.4

    100.0%

    5.0

    92.6

    240

    Age 45-54

    17.7

    71.7

    98.9%

    5.0

    142.8

    189

    Age 55-64

    28.2

    80.5

    96.4%

    5.0

    143.2

    111

    Age 65-74

    27.6

    95.4

    95.1%

    5.0

    197.9

    103

    Age 75+

    67.1

    179.5

    75.8%

    5.0

    194.1

    33

    Median

    95thPercentile

    Percent < 100pg/ml

    Minimum

    Maximum

    N

    All

    12.3

    73.5

    98.0%

    5.0

    252.0

    1286

    Age < 45

    7.7

    39.6

    99.5%

    5.0

    251.3

    423

    Age 45-54

    11.1

    64.5

    99.2%

    5.0

    252.0

    385

    Age 55-64

    17.9

    76.1

    97.4%

    5.0

    207.7

    229

    Age 65-74

    19.8

    84.7

    96.9%

    5.0

    197.9

    192

    Age 75+

    53.9

    179.4

    84.2%

    5.0

    218.5

    57

  • CHF Population - All

    NYHA Functional Class

    CHF Population - Males

    NYHA Functional Class

    CHF Population - Females

    NYHA Functional Class

    * 2 CHF with unknown NYHA class (male)

    The New York Heart Association (NYHA) developed a four-stagefunctional classification system for CHF that is based on a subjectiveinterpretation of the severity of a patient's clinical signs and symptoms. ClassI patients have no limitations of physical activity and have no symptomswith ordinary physical activity. Class II patients have a slight limitation ofphysical activity and have symptoms with ordinary physical activity. ClassIII patients have a marked limitation of physical activity and have symptoms

    page 23 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Median

    5th Percentile

    Percent> 100pg/ml

    Minimum

    Maximum

    N

    All CHF*

    359.5

    22.3

    80.6%

    5.0

    >5000

    804

    I

    95.4

    14.8

    48.3%

    5.0

    904.6

    118

    II

    221.5

    9.9

    76.6%

    5.0

    4435.8

    197

    III

    459.1

    37.6

    86.0%

    5.2

    >5000

    300

    IV

    1006.3

    147.2

    96.3%

    5.0

    >5000

    187

    Median

    5th Percentile

    Percent> 100pg/ml

    Minimum

    Maximum

    N

    All CHF*

    317.8

    21.9

    78.9%

    5.0

    >5000

    558

    I

    87.8

    16.8

    46.5%

    5.0

    904.6

    101

    II

    232.6

    10.7

    78.8%

    5.0

    2710.6

    146

    III

    458.9

    25.0

    85.2%

    5.2

    >5000

    203

    IV

    1060.3

    196.5

    97.2%

    5.0

    >5000

    106

    Median

    5th Percentile

    Percent> 100pg/ml

    Minimum

    Maximum

    N

    All CHF*

    499.7

    30.7

    84.6%

    5.0

    >5000

    246

    I

    114.7

    6.8

    58.8%

    5.0

    519.6

    17

    II

    191.2

    9.7

    70.6%

    5.0

    4435.8

    51

    III

    469.2

    45.6

    87.6%

    11.7

    4582.0

    97

    IV

    966.5

    121.0

    95.1%

    15.5

    4706.5

    81

  • page 24 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    with less than ordinary physical activity, but not at rest. Class IV patients areunable to perform any physical activity without discomfort. Reports in thescientific literature have indicated that there is a relationship between BNPand the severity of CHF. An analysis of NYHA classification and BNPconcentrations from the clinical study data indicate that there is arelationship between the severity of the clinical signs and symptoms of CHFand BNP concentration. These data are consistent with the previous reportsin the literature, and further demonstrate that BNP measurements, alongwith NYHA classification, can provide additional objective information tothe physician about the patient's CHF severity.

    Various studies have demonstrated that circulating BNP concentrationsincrease with the severity of CHF based on the NYHA classification. BNPconcentrations are much lower than ANP concentrations normally, but asthe severity of CHF advances according to the NYHA classification, plasmaBNP increases progressively more than respective ANP values. Therefore,BNP is a more useful marker than ANP to distinguish between normalsubjects and patients in the earlier stages of CHF. BNP is more sensitive andspecific than ANP for detecting decreases in LVEF. Additionally, there is apositive correlation between blood BNP concentrations and left ventricularend diastolic pressure and inverse correlation to left ventricular functionfollowing acute myocardial infarction. Blood BNP concentrations representan independent assessment of ventricular function without the use of otherinvasive or expensive diagnostic tests. There is an association with elevatedBNP concentrations and alterations in hemodynamic parameters includingraised atrial and pulmonary wedge pressures, reduced ventricular systolic

    BNP vs. NYHA Classification

    Med

    ian

    BN

    P C

    once

    ntra

    tion

    (pg/

    mL

    )

    1200

    1000

    800

    600

    400

    200

    0Non-CHF

    NYHAClass I

    NYHA Class II

    NYHA Class III

    NYHA Class IV

  • and diastolic function, left ventricular hypertrophy, and myocardialinfarction. Numerous reports in the scientific literature have described theutility of BNP as a diagnostic marker for CHF and left ventriculardysfunction. These observations are supported by an analysis of the clinicalstudy data. The Receiver Operating Characteristic (ROC) Curve of BNPcut-offs versus clinical sensitivity and specificity from the clinical study datais provided below. The area under the curve is 0.955 0.005. The clinicalutility of BNP also has been confirmed and described in detail in thescientific literature.

    page 25 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    0 0%

    10 0%

    20 0%

    30 0%

    40 0%

    50 0%

    60 0%

    70 0%

    80 0%

    90 0%

    100 0%

    0 0% 20 0% 40 0% 60 0% 80 0% 100 0%

    1000

    500

    200180150125

    100 80 6040

    205

    Sens

    itivi

    ty

    ROC Curve

    1-Specificity

  • page 26 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    The clinical sensitivity and specificity of BNP using a cutoff of 100 pg/mlfor various age groups within each gender is described in the table below.

    MalesAge < 45 Age 45-54 Age 55-64 Age 65-74 Age 75+

    Sensitivity 81.6% 76.0% 75.6% 79.3% 82.4%95% Confidence Interval 70.8-92.5% 67.5-84.6% 68.2-82.9% 72.6-86% 76.1-88.7%

    Specificity 98.9% 99.5% 98.3% 98.9% 95.8%95% Confidence Interval 97.4-100.0% 98.5-100.0% 97.7-98.9% 98.4-99.4% 94.7-96.9%

    FemalesAge < 45 Age 45-54 Age 55-64 Age 65-74 Age 75+

    Sensitivity 82.1% 69.0% 82.4% 97.9% 91.9%95% Confidence Interval 68.0-96.3% 57.1-80.9% 71.9-92.8% 93.7-100.0% 85.2-98.7%

    Specificity 100.0% 98.9% 96.4% 95.0% 75.7%95% Confidence Interval 100.0-100.0% 97.5-100.0% 95.5-97.4% 93.4-96.7% 72.2-79.2%

    It has been reported that BNP has excellent utility as an aid in the diagnosisof patients with CHF and preserved systolic function (CHF-PSF), generallyreferred to as diastolic dysfunction. The diagnostic utility of BNP in CHF-PSF patients was determined from the clinical study data by determiningthe area under the ROC curve for individuals without CHF versus 155individuals with CHF that had ejection fractions 50%. The area under thecurve is 0.934 0.012, which indicates that the test is effective as an aid inthe diagnosis of CHF in patients with preserved systolic function.

    An age-matched analysis of the clinical data was performed with thefollowing common age distribution in the groups of individuals with andwithout CHF: individuals less than 35 years old comprise 3% of the totalnumber of observations, individuals age 35-44 comprise 6% of the total,individuals age 45-54 comprise 11% of the total, individuals 55-64 years oldcomprise 22% of the total, individuals 65-74 years old comprise 26% of thetotal, and individuals 75 years and older comprise 32% of the total. This agedistribution reflects the prevalence of CHF within the age groups andgenders, according to data published by the American Heart Association inthe 2000 Heart and Stroke Statistical Update, and also reflects the agestructure of the United States population, according to data published bythe National Center for Health Statistics in Health, United States, 2000.The resulting area under the ROC curve is 0.930 with a 95% confidenceinterval of 0.902-0.958.

  • BNP concentrations measured in patients with acute coronary syndromes(ACS) or cardiovascular disease provide prognostic information about thepatient's risk for death and the development of CHF. Statistically significantincreases in death, future myocardial infarction, and CHF have beenassociated with higher BNP concentrations measured within the first 72hours after the onset of ACS symptoms. In a recent clinical study, BNPconcentrations were evaluated in an observational, retrospective manner inpatients with ACS (consisting of unstable angina, myocardial infarctionwith ST-segment elevation, or myocardial infarction without ST-segmentelevation). BNP measurements were performed on specimens obtainedwithin 72 hours after the onset of ischemic discomfort from a population of2525 high-risk ACS patients that met standard diagnostic criteria for ACS.Patients whose BNP concentration was at least 80 pg/mL had higher ratesof death, myocardial infarction, and CHF both at 30 days and at 10 monthsafter presentation than patients whose BNP concentration was below 80pg/mL. In this population of patients with ACS, BNP measurements withinthe first 72 hours after the onset of symptoms provide useful predictiveinformation to aid in the risk stratification of patients with ACS.

    Troponin I concentrations also have been described in the scientificliterature to provide prognostic information related to the risk of futurecardiac events and mortality in patients with acute coronary syndromes.More recently, it has been demonstrated that a multimarker analysisincluding troponin I, CK-MB, and myoglobin provides better riskstratification than a single-marker approach.

    Expected values - Risk Stratificationof Patients With ACS

    page 27 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

  • page 28 of 35 Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    AHA Medical/Scientific Statement, ACC/AHA Guidelines for the EarlyManagement of Patients with Acute Myocardial Infarction. Circulation 82:664-707, 1990.

    Bodor, G.S., Porter S., Landt, Y. and Ladenson, J.H. Development ofMonoclonal Antibodies Specific for Troponin I and Preliminary Results inSuspected Cases of Myocardial Infarction. Clin. Chem. 38: 2203-2214,1992.

    Puleo, P.R., Guadagno P.A., Roberts, R., Scheel, M.V., Marian, A.J.,Churchill, D., and Perryman, M.B. Early Diagnosis of MyocardialInfarction for Subforms of Creatine Kinase-MB. Circulation 82: 759-764,1990.

    Marin, M.M., and Teichman, S.L. Use of Rapid Serial Sampling of CreatineKinase MB for Very Early Detection of Myocardial Infarction in Patientswith Acute Chest Pain. Am. Heart J. 123: 354-361, 1992.

    Gerhardt, W., Waldenstrom, J., Horder, M., Hofvendahl, S., Billstrom, R.,Ljungdahl, R., Berning, H., and Bagger, P. Creatine Kinase and CreatineKinase B-Subunit Activity in Serum in Cases of Suspected MyocardialInfarction. Clin. Chem. 26: 277-283, 1982.

    Lee, T.H. and Goldman, L. Serum Enzyme Assays in the Diagnosis ofAcute Myocardial Infarction: Recommendations Based on QuantitativeAnalysis. Ann. Int. Med. 105: 221-233, 1986.

    Vaidya, H.C., Maynard, Y., Dietzler, D.N., and Ladenson, J.H. DirectMeasurement of Creatine Kinase-MB Activity in Serum after Extractionwith a Monoclonal Antibody Specific to the MB isoenzyme. Clin. Chem.32: 657-663, 1986.

    Hedges, J.R., Rouan, G.W., Tolzis, R., Goldstein-Wayne, B., and Stein, E.A.Use of Cardiac Enzymes Identifies Patients with Acute MyocardialInfarction Otherwise Unrecognized in the Emergency Department. Ann.Emerg. Med. 16: 248-252, 1987.

    Apple, F.S. Diagnostic Use of CK-MM and CK-MB Isoforms for DetectingMyocardial Infarction. Clin. Lab. Med. 9: 643-655, 1989.

    Bibliography of Suggested Reading

  • page 29 of 35 Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Hedges, J.R., Swanson, J.R., and Heeter, C. Prospective Assessment ofPresenting Serum Markers for Cardiac Risk Stratification. Ac. Emerg. Med.3: 27-33, 1996.

    Willerson, J.T., Clinical Diagnosis of Acute Myocardial Infarction. Hosp.Prac. 24: 65-77, 1989.

    Cummins, B., Auckland, M.S. and Cummins, P. Cardiac-Specific TroponinI Radioimmunoassay in the Diagnosis of Acute Myocardial Infarction. Am.Heart J. 113: 1333-1344, 1987.

    Brogan, G.X., Friedman, S., McCluskey, C., Cooling, D.S., Berrutti, L.,Thode, H.C., and Bock, J.L. Evaluation of a New QuantitativeImmunoassay for Serum Myoglobin Versus CK-MB for Ruling Out AcuteMyocardial Infarction in the Emergency Department. Ann. Emerg. Med. 24:665-671, 1994.

    Juronen, E.I., Viikmaa, M.H. and Mikelsaar, A-V. N. Rapid, Simple andSensitive Antigen Capture ELISA for the Quantitation of Myoglobin UsingMonoclonal Antibodies. J. Immuno. Met. 111: 109 - 115, 1988.

    Apple, F.S. Acute Myocardial Infarction and Coronary Reprofusion: SerumCardiac Markers for the 1990s. Am. J. Clin. Path. 97: 217-226, 1992.

    Mainard, F., Massoubre, B., LeMarec, H. and Madec, Y. Study of aMyoglobin Test in Patients Hospitalized for Suspected MyocardialInfarction. Clin. Chim. Act. 153: 1-8, 1985.

    Laure, C., Calzolari, C., Bertinchant, J-P., Leclercq, F., Grolleau, R., andPau, B. Cardiac Specific Immunoenzymometric Assay for Troponin I in theEarly Phase of Acute Myocardial Infarction. Clin. Chem. 39: 972-979,1993.

    Adams, J.E., Schechtman, K.D., Landt, Y., Ladenson, J.H., and Jaffe, A.S.Comparable Detection of Acute Myocardial Infarction by Creatine KinaseMB Isoenzyme and Cardiac Troponin I. Clin. Chem. 40: 1291-1295, 1994.

    Adams, J.E., Sicard, G.A., Allen, B.T., Bridwell, K.H., Lenke, L.G., Davila-Roman, V.G., Bodor, G.S., Ladenson, L.H., and Jaffe, A.S. Diagnosis ofPerioperative Myocardial Infarction with Measurement of Cardiac TroponinI. N. Eng. J. Med. 330: 670-674, 1994.

    Brogan, G.X., Hollander, J.E., McCuskey, C.F., Thode, Jr., H.C., Sama, A.,Bock, J.L., and the Biochemical Markers for Acute Myocardial IschemiaStudy Group. Evaluation of a New Assay for Cardiac Troponin I vs CreatineKinase-MB for the Diagnosis of Acute Myocardial Infarction. Acad. Emerg.Med. 4: 6-12, 1997.

  • page 30 of 35 Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Davis, C.P., Barnett, K., Torre P., and Wacasey, K. Serial Myoglobin Levelsfor Patients with Possible Myocardial Infarction. Acad. Emerg. Med. 3: 590-597, 1996.

    Gibler, W.B., Gibler, C.D., Weinshenker, E., Abbotsmith, C., Hedges, J.R.,Barsan, W.G., Sperling, M., Chen, I-W., Embry, S., and Kereiakes, D.Myoglobin as an Indicator of Acute Myocardial Infarction. Ann. Emerg.Med. 16: 851-856, 1987.

    Tucker, J.F., Collins, R.A., Anderson, A.J., Hess, M., Farley, I.M.,Hegemann, D.A., Harkins H.J., and Zwicke, D. Value of Serial MyoglobinLevels in the Early Diagnosis of Patients Admitted for Acute MyocardialInfarction. Ann. Emerg. Med. 24: 704-708, 1994.

    Adams, J.E., Bodor, G., D-Roman, V.G., Delmez, J.A., Apple, F.S.,Ladenson J.H., and Jaffe, A.S. Cardiac Troponin I: A Marker with HighSpecificity for Cardiac Injury. Circulation 88: 101-106, 1993.

    Buechler, K.F., and McPherson, P.H. Novel Methods for the Assay ofTroponin I and T and Complexes of Troponin I and T and Selections ofAntibodies for Use in Immunoassays. International Patent WO 96/33415,18 April, 1995.

    Katrukha, A.G., Bereznikova, A.V., Esakova, T.V., Pettersson, K., Lvgren,T., Severina, M.E., Pulkki, K., Vuopio-Pulkki, L.-M., and Gusev, N.B.Troponin I is released in bloodstream of patients with acute myocardialinfaction not in free form but as complex. Clin. Chem. 43: 1379-1385,1997.

    Wu, A., B-Type natriuretic peptide and its clinical utility in patients withheart failure. Med. Lab. Ob. 10: 10-14, 2001.

    Wu, A., Analytical and clinical evaluation of new diagnostic tests formyocardial damage. Clin. Chim. Acta 272: 11-21, 1998

    Bonow, R. O., New insights into the cardiac natriuretic peptides.Circulation, 93: 1946-1950, 1996.

    McDowell, G., Shaw, C., Buchanan, K., and Nicholls, D., The natriureticpeptide family. Eur. J. Clin. Invest. 25: 291-298, 1995.

    Yandle, T., Biochemistry of natriuretic peptides. J. Internal Med. 235:561-576, 1994.

  • page 31 of 35 Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Mukoyama, M., Nakao, K., Hosoda, K., Hosoda, K., Suga, S., Saito, Y.,Ogawa, Y., Shirakami, G., Jougaski, M., Obata, K., Yasue, H., Kambayashi,Y., Inouye, K., and Imura, H., Brain natriuretic peptide as a novel cardiachormone in humans: Evidence for an exquisite dual natriuretic peptidesystem, atrial natriuretic peptide and brain natriuretic peptide. J. Clin Invest.87: 1402-1412, 1991.

    Clerico, A., Iervasi, G., Del Chicca, M.G., Emdin, M., Maffei, S.,Nannipieri, M., Sabatino, L.,Forini, F., Manfredi, C., and Donato, L.,Circulating levels of cardiac natriuretic peptides (ANP and BNP) measuredby highly sensitive and specific immunoradiometric assays in normalsubjects and in patients with different degrees of heart failure. J. Endocrinol.Invest. 21: 170-179, 1998.

    deLemos, J.A., Morrow, D.A., Bentley, J.H., Omland, T., Sabatine, M.S.,McCabe, C.H., Hall, C., Cannon, C.P., and Braunwald, E., The prognosticvalue of B-type natriuretic peptide in patients with acute coronarysyndromes. N. Eng. J. Med. 345: 1014-1021, 2001.

    Maeda, K., Tsutamoto, T., Wada, A., Hisanaga, T. and Kinoshita, M.,Plasma brain natriuretic peptide as a biochemical marker of high leftventricular end-diastolic pressure in patients with symptomatic leftventricular dysfunction. Am. Heart J. 135: 825-832, 1998.

    Dao, Q., Krishnaswamy, P., Kazanegra, R., Harrison, A., Amirnovin, R.,Lenert, L., Clopton, P., Alberto, J., Hlavin, P., and Maisel, A., Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in anurgent-care setting. J. Am. Coll. Cardiol. 37: 379-385, 2001.

    Mukoyama, M., Nakao, K., Saito, Y., Ogawa, Y., Hosoda, K., Suga, S.,Shirakami, G., Jougasaki, M., and Imura, H., Increased human brainnatriuretic peptide in congestive heart failure. N. Engl. J. Med. 323: 757-758, 1990.

    Sagnella, G.A., Measurement and significance of circulating natriureticpeptides in cardiovascular disease. Clin. Science 95: 519-529, 1998.

    McDonagh, T.A., Robb, S.D., Murdoch, D.R., Morton, J.J., Ford, I.,Morrison, C.E., Tunstall-Pedoe, H., McMurray, J.J.V., and Dargie, H.J.,Biochemical detection of left-ventricular systolic dysfunction. Lancet 351: 9-13, 1998.

  • page 32 of 35 Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Mair, J., Friedl, W., Thomas, S., and Puschendorf, B., Natriuretic Peptidesin assessment of left-ventricular dysfunction. Scand. J. Clin. Lab. Invest. 59:132-142, 1999.

    Muders, F., Kromer, E.P., Griese, D.P., Pfeifer, M., Hense, H.-W., Riegger,G.A.J., and Elsner, D., Evaluation of plasma natriuretic peptides as markersfor left ventricular dysfunction. Am. Heart J. 134: 442-449, 1997.

    Cowie, M.R., Struthers, A.D., Wood, D.A., Coats, A.J.S., Thompson, S.G.,Poole-Wilson, P.A., and Sutton, G.C., Value of natriuretic peptides inassessment of patients with possible new heart failure in primary care. Lancet350: 1347-1351, 1997.

    Maisel, A.S., Krishnaswamy, P, Nowak, R.M., McCord, J., Hollander, J.E.,Duc, P., Omland, T., Storrow, A.B., Abraham, W.T., Wu, A.H., Clopton, P.,Steg, P.G., Westheim, A., Knudsen, C.W., Perez, A., Kazanegra, R.,Herrmann, H.C., McCullough, P.A; Breathing Not Properly MultinationalStudy Investigators. Rapid measurement of B-type natriuretic peptide in theemergency diagnosis of heart failure. N. Engl. J. Med. 347: 161-167, 2002.

    McCullough, P.A., Nowak, R.M., McCord, J., Hollander, J.E., Herrmann,H.C., Steg, P.G., Duc, P., Westheim, A., Omland, T., Knudsen, C.W.,Storrow, A.B., Abraham, W.T., Lamba, S., Wu, A.H., Perez, A., Clopton, P.,Krishnaswamy, P., Kazanegra, R., and Maisel, A.S. B-type natriureticpeptide and clinical judgment in emergency diagnosis of heart failure:analysis from Breathing Not Properly (BNP) Multinational Study.Circulation 106: 416-422, 2002.

    Maisel, A.S., Koon, J., Krishnaswamy, P., Kazanegra, R., Clopton, P.,Gardetto, N., Morrisey, R., Garcia, A., Chiu, A., and De Maria, A., Utilityof B-natriuretic peptide as a rapid, point-of-care test for screening patientsundergoing echocardiography to determine left ventricular dysfunction.Am. Heart J. 141: 367-374, 2001.

    Lubien, E., DeMaria, A., Krishnaswamy, P., Clopton, P., Koon, J.,Kazanegra, R., Gardetto, N., Wanner, E., and Maisel, A.S., Utility of B-natriuretic peptide in detecting diastolic dysfunction. Circulation 105: 595-601, 2002.

    Krishnaswamy, P., Lubien, E., Clopton, P., Koon, J., Kazanegra, R., Wanner,E., Gardetto, N., Garcia, A., DeMaria, A., and Maisel, A.S., Utility of B-natriuretic peptide in identifying patients with left ventricular systolic ordiastolic dysfunction. Am. J. Med. 111: 274-279, 2001.

  • page 33 of 35 Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Omland, T., Aakvaag, A., Bonarjee, V.V.S., Caidahl, K., Lie, R.T., Nilsen,D.W.T., Sundsfjord, J.A., and Dickstein, K., Plasma brain natriureticpeptide as an indicator of left ventricular systolic function and long-termsurvival after acute myocardial infarction. Circulation 93: 1963-1969, 1996.

    Richards, A.M., Nicholls, M.G., Yandle, T.G., Ikram, H., Espiner, E.A.,Turner, J.G., Buttimore, R.C., Lainchbury, J.G., Elliott, J.M., Frampton,C., Crozier, I.G., and Smyth, D.W., Neuroendocrine prediction of leftventricular function and heart failure after acute myocardial infarction.Heart 81: 114-120, 1999.

    Stein, B.C. and Levin, R.I., Natriuretic peptides: physiology, therapeuticpotential, and risk stratification in ischemic heart disease. Am. Heart J. 135:914-923, 1998.

    Wallen, T., Landahl, S., Hedner, T., Nakao, K., and Saito, Y., Brainnatriuretic peptide predicts mortality in the elderly. Heart 77: 264-267,1997.

    Darbar, D., Davidson, N.C., Gillespie, N., Choy, A.M.J., Lang, C.C., Shyr,Y., McNeill, G.P., Pringle, T.H., and Struthers, A.D., Diagnostic value of B-type natriuretic peptide concentrations in patients with acute myocardialinfarction. Am. J. Cardiol. 78: 284-287, 1996.

    Galvani, M., Ferrini, D., Ghezzi, F., and Ottani, F., Cardiac markers and riskstratification: an integrated approach. Clin Chim Acta 311: 9-17, 2001

    Meyer, T., Binder, L., Graeber, T., Luthe, H., Kreuzer, H., Oellerich, M.,Buchwald, A.B., Superiority of combined CK-MB and troponin Imeasurements for the early risk stratification of unselected patientspresenting with acute chest pain. Cardiology 90: 286-294, 1998

    de Winter, R.J., Risk stratification with cardiac troponin I in acute coronarysyndromes. J. Am. Coll. Cardiol. 36: 1824-1826, 2000

    Newby, L.K., Storrow, A.B., Gibler, W.B., Garvey, J.L., Tucker, J.F., Kaplan,A.L., Schreiber, D.H., Tuttle, R.H., McNulty, S.E., and Ohman, E.M.,Bedside multimarker testing for risk stratification in chest pain units: thechest pain evaluation by creatine kinase-MB, myoglobin, and troponin I(CHECKMATE) study. Circulation 103: 1832-1837, 2001.

  • page 34 of 35

    EN

    GLI

    SH

    Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    Biosite's express and implied warranties (including implied warranties ofmerchantability and fitness) are conditioned upon observance of Biosite'spublished directions with respect to the use of Biosite's products.

    UNDER NO CIRCUMSTANCES WHATSOEVER SHALL BIOSITEINCORPORATED BE LIABLE FOR ANY INDIRECT ORCONSEQUENTIAL DAMAGES.

    For Technical Assistance in the U.S. and Canada callBiosite Technical Services at 1-888-BIOSITE (246-7483).

    In France contact Biosite France SAS (toll free number: 0800 246 800).

    In Germany contact Biosite GmbH (Tel: 0800 244 4000).

    In all other countries, for Technical Assistance contact your nationaldistributor of this product.

    Manufacturer:Biosite Incorporated

    11030 Roselle St.San Diego, California 92121

    +1 (858) 455-4808www.biosite.com

    Made in USA

    This product is protected by one or more of the following patents:

    United States: pat. 5,458,852; pat. 5,763,189; pat. 5,885,527; pat. 6,019,944; pat. 6,074,616; pat. 6,143,576; pat. 6,194,222; pat. 6,238,931; pat. 6,251,687; pat. 6,391,265; pat. 6,392,894; pat. 6,544,797.

    Japan: pat. 3,451,088.

    Europe: pat. 0596104; pat. 0670041. Additional patents pending.

    TRIAGE and BIOSITE are registered trademarks of Biosite Incorporated inthe United States, Canada, member countries of the European EconomicCommunity, Switzerland and Japan. NEW DIMENSIONS IN DIAGNOSIS isa registered trademark of Biosite Incorporated in the United States, Canada andmember countries of the European Economic Community.PROFILER S.O.B. is a trademark of Biosite Incorporated.

    2004, Biosite Incorporated

    Part No. 22483(en) Rev. DDate of last revision: 2004/07/19

    Biosite EuropeBiosite Incorporated Liaison Office1232, Rue Louis Blriot78530.BUC. FRANCE33 (0) 1 39 20 21 10

  • page 35 of 35 Triage Profiler S.O.B. 22483(en)D 2004 Biosite Incorporated

    YYYY/MM/DD

    Glossary of Symbols

    Use by

    Batch code

    Catalog number

    Caution, consult accompanying documents

    Manufacturer

    Authorized representative in the European Community

    In vitro diagnostic medical device

    Upper limit of temperature

    Lower limit of temperature

    Temperature limitation

    Biological risks

    Control

    Contents

    Mean

    Standard deviation

    Symbol Used For

  • Le panel Triage Profiler S.O.B. (Shortness of Breath) (Dyspne) est undosage immunologique par fluorescence destin tre utilis avec le Triage

    MeterPlus pour la dtermination quantitative de la cratine kinase MB, dela myoglobine, de la troponine I, du peptide natriurtique de type B et desproduits de dgradation de la fibrine rticule contenant du D-dimre dansdes chantillons de sang total et de plasma recueillis sur EDTA. Le testpermet de diagnostiquer linfarctus du myocarde (lsion), de diagnostiqueret dvaluer la svrit de linsuffisance cardiaque, dexaminer et dvaluer lespatients souponns dtre atteints de coagulation intravasculaire dissmineou dvnements thromboemboliques dont une embolie pulmonaire, et destratifier le risque des patients prsentant des syndromes coronaires aigus.

    Le diagnostic de linfarctus du myocarde (IDM) chez un patient prsentant desdouleurs thoraciques est souvent difficile tablir. Les trois principaux critresretenus par lOrganisation Mondiale de la Sant pour diffrencier les douleursthoraciques associes lIDM des douleurs thoraciques dues dautres causessont : 1) les antcdents du patient associs lexamen clinique, 2) lesmodifications de llectrocardiogramme (ECG) et 3) laugmentation desconcentrations des marqueurs cardiaques circulants. Au moins 2 de ces 3critres doivent tre confirms pour poser le diagnostic de lIDM.

    Il nest pas rare que lexamen clinique ne permette pas de diffrencier lIDMdautres troubles cardiaques. LECG, bien que fondamental pour lediagnostic de lIDM, nest cependant contributif que pour environ 50 % despatients dveloppant un IDM. Gnralement, lapparition dondes Q et lesmodifications du segment S-T, quil sagisse dune augmentation ou dunediminution, sont des indicateurs de lIDM. Il convient cependant, pouravoir un tableau clinique complet, de prendre en compte, en plus desrsultats de lECG, lexamen clinique et les antcdents du patient. LECGpeut tre initialement normal pour un patient dveloppant un IDM.

    Les marqueurs protiques sanguins jouent un rle fondamental dans lediagnostic diffrentiel de lIDM, en particulier lorsque les autres indicateurssont non contributifs ou difficilement interprtables. Les marqueursgnralement utiliss pour le diagnostic de linfarctus du myocarde sont : lacratine kinase (CK), lisoenzyme MB de la cratine kinase (CK-MB), la

    Rsum et principe du test

    UtilisationFR

    AN

    A

    IS

    page 1 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

  • FRA

    N

    AIS

    page 2 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    lactate dshydrognase, plus prcisment LDH-1 et LDH-2, la myoglobine,les isoformes des isoenzymes MM et MB de la CK et les protinesstructurales du complexe troponine : troponine T et troponine I.

    Aprs un IDM, la libration des marqueurs protiques dans le sang rsultedune ncrose cellulaire initie par un vnement ischmique. Les protinesprsentes aux concentrations les plus leves, ainsi que les plus solubles,comme la myoglobine, apparaissent dabord dans le sang. Les protinesstructurales et mitochondriales des myocytes, comme la CK-MB et lesprotines du complexe troponine, dont la troponine I, apparaissent un peuplus tard.

    La myoglobine est une protine cytoplasmique soluble possdant un groupehminique et prsente dans les cellules musculaires. Sa masse molculaire estdenviron 17.000 daltons. En raison de son poids relativement faible, de saconcentration cellulaire leve et de sa situation cytoplasmique, lamyoglobine est libre plus tt que les autres marqueurs cardiaques aprsune ncrose ou une lsion cellulaire. Les concentrations sanguines demyoglobine augmentent au-del des valeurs normales au cours des 2premires heures suivant lincident cardiaque et atteignent leurs valeursmaximales entre 6 et 8 heures aprs lapparition des symptmes. Lamyoglobine revient des concentrations normales ou initiales entre 20 et 36heures aprs les lsions tissulaires. La myoglobine est prsente dans tous lestypes de cellules musculaires. Par consquent, son apparition dans le sangnest pas ncessairement associe une lsion myocardique. Lesconcentrations sanguines de myoglobine peuvent tre leves la suite dediffrents types de lsions musculaires : traumatisme, ischmie, interventionchirurgicale, exercice et diffrentes affections musculaires dgnratives.Dans ce contexte, lutilit de la myoglobine est plus grande pour lediagnostic dexclusion de lIDM, au cours des toutes premires heuressuivant lapparition des douleurs thoraciques. En raison de laugmentationrapide des concentrations de myoglobine dans le sang et de sa clairance, lamyoglobine est contributive au diagnostic de lIDM dans les 2 30 heuressuivant la lsion cellulaire. Nanmoins, la myoglobine est particulirementutile lorsque les antcdents cliniques du patient sont connus.

    La cratine kinase MB (CK-MB) est une enzyme cytosolique de 82.000daltons prsente en concentrations leves dans le myocarde. Cetteisoenzyme de la cratine kinase est frquemment utilise pour tablir lediagnostic de lIDM. En gnral, la CK-MB augmente au-dessus de lanormale dans les 4 8 premires heures aprs lIDM, atteint desconcentrations maximales entre 12 et 24 heures et revient la normale en 3

  • FRA

    N

    AIS

    page 3 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    jours environ. La CK-MB, comme la myoglobine, nest pas spcifiquementlocalise dans le muscle cardiaque. Les concentrations sanguines en CK-MBpeuvent augmenter la suite dune lsion musculaire chronique ou aigu,dun exercice intense ou dun traumatisme. Les mesures des concentrationssanguines de CK-MB sont nanmoins largement utilises pour la prise encharge des patients prsentant un IDM.

    Les protines contractiles de la myofibrille, telles la troponine I et latroponine T sont de plus en plus utilises comme marqueurs cardiaquesspcifiques de lIDM et de la souffrance myocardique. Ces deux protinessont spcifiques au complexe de rgulation de la contraction musculaire. Latroponine I et la troponine T, isoles du muscle cardiaque, prsentent dessquences dacides amins uniques qui ont permis le dveloppementdanticorps spcifiques des protines cardiaques. Lextrmit N-terminale dela squence dacides amins de lisoforme cardiaque de la troponine I compte31 rsidus dacides amins que lon ne retrouve dans aucune des deux autresisoformes de la troponine I des muscles squelettiques. En consquence, lestests immunologiques spcifiques de la troponine I cardiaque sont utilissdans les cas de suspicions dIDM. Les concentrations sanguines detroponine I augmentent entre 4 8 heures aprs le dbut de lIDM. Lesconcentrations atteignent leur maximum entre 12 et 16 heures et demeurentleves pendant 5 9 jours aprs le dommage myocardique. LIDM est laprincipale cause daugmentation de la troponine I cardiaque. Cependant, latroponine I cardiaque peut galement tre leve la suite datteintesmyocardiques mineures comme langor instable. Des contusions cardiaques,une transplantation cardiaque, un pontage coronarien, un traumatismemcanique du cur, une insuffisance cardiaque congestive et toute autrepathologie susceptible dendommager le myocarde peuvent aussi engendrerune lvation de la troponine I cardiaque. Par ailleurs, la troponine Icardiaque ne semble pas augmenter la suite de lsion des musclessquelettiques. En raison de sa spcificit analytique et de sa duredaugmentation, la troponine I cardiaque est devenue un marqueurimportant pour le diagnostic et lvaluation de suspicions dIDM. Unequantification simultane de la myoglobine, de la CK-MB et de la troponine I cardiaque peut considrablement aider les mdecins prendreen charge les patients pour lesquels il y a suspicion dIDM.

    Il est estim quaux tats-Unis, 4,79 millions de personnes souffrentdinsuffisance cardiaque, et que 550.000 nouveaux cas se prsentent chaqueanne. Linsuffisance cardiaque congestive (ICC) apparat lorsque le cur estincapable dassurer le dbit sanguin ncessaire aux besoins de lorganisme.

  • FRA

    N

    AIS

    page 4 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    Cette pathologie peut se manifester nimporte quel ge mais sa prvalenceest plus leve chez les sujets gs. Les symptmes de lICC comprennentlessoufflement, la surcharge hydrique et la dtresse respiratoire. Cessymptmes sont souvent vagues et manquent de spcificit pour dtecter lesstades prcoces de lICC.

    Le peptide natriurtique de type B (BNP) appartient une classedhormones qui rgulent la pression sanguine. Chez lhomme, le coeur est lasource principale de BNP circulant. La molcule est libre dans lacirculation en rponse llvation de la pression sanguine. Plusieurs tudesont dmontr la prsence dune concentration leve de BNP circulant lorsdes phases prcoces de lICC. La concentration de BNP circulant slve aufur et mesure de la progression de lICC. De plus, lutilit des mesures deBNP a t dmontre en tant quindicateur pronostique chez les patientsatteints de syndromes coronariens aigus (SCA). Le panel Triage ProfilerS.O.B. permet une mesure objective, non invasive permettant lvaluationde patients risque dICC et la stratification de risque chez les patientsatteints dun SCA.

    Au cours du processus de coagulation, la thrombine transforme lefibrinogne en fibrine soluble par la dgradation protolytique desfibrinopeptides A et B. La fibrine soluble se polymrise spontanment et lesrgions D tablissent des liaisons covalentes croises par un processus qui estcatalys par le facteur XIIIa. La fibrine rticule est finalement dgrade parle processus de fibrinolyse. La plasmine dissocie les liaisons croises du rseaude fibrine et libre les produits de dgradation de la fibrine (PDF), y comprisune rticulation de deux molcules de fragment D (D-dimre) de 200 kDa.Il a t constat une lvation des taux de D-dimres circulants chez lespatients atteints de thromboembolie veineuse, y compris une emboliepulmonaire (EP) et une thrombose veineuse profonde (TVP) (voirGoldhaber, S.Z. (1998) New Engl. J. Med. 339; 93-104).

    Le panel Triage Profiler S.O.B. est un dosage immunologique parfluorescence destin la dtermination quantitative des protines D-dimre,CK-MB, myoglobine, troponine I et BNP dans des chantillons de sangtotal et de plasma humains recueillis sur EDTA (anticoagulant). Aprs ledpt de lchantillon dans lemplacement prvu cet effet, les lmentscellulaires sont spars du plasma via un filtre contenu dans le dispositif dutest. Une quantit prdtermine de plasma peut alors ragir avec desanticorps conjugus fluorescents lintrieur de la chambre de raction.Aprs une incubation suffisante, le mlange ractionnel migre le long de la

    Principes de la mthode

  • FRA

    N

    AIS

    page 5 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    ligne de dtection du systme. Les complexes analytes-conjugus fluorescentssont capturs par des anticorps primmobiliss sur des zones dterminespour chaque analyte. La concentration de lanalyte prsent et dos danslchantillon est directement proportionnelle la fluorescence dtecte.

    La cassette-test Triage Profiler S.O.B contient tous les ractifs ncessaires la quantification simultane des protines D-dimre, CK-MB, myoglobine,troponine I et BNP dans le plasma et le sang total.

    La cassette-test contient :

    Des anticorps monoclonaux et polyclonaux de souris anti-CK-MB, desanticorps monoclonaux et polyclonaux de souris anti-myoglobine, desanticorps monoclonaux de souris et polyclonaux de chvre anti-troponineI cardiaque, des anticorps monoclonaux de souris anti-D-dimre et desanticorps monoclonaux et polyclonaux de souris anti-BNP marqus parun agent fluorescent et immobiliss sur la phase solide (prsence dagentsde stabilisation).

    Pour usage diagnostique in vitro. Respecter rigoureusement les directives et les mthodes dcrites dans

    cette notice. Les chantillons sanguins, les cassettes-tests usages et les pipettes de

    transfert sont potentiellement infectieux. Observer les mthodes demanipulation et dlimination conformes aux rglementations locales etnationales en vigueur.

    La manipulation dchantillons sanguins potentiellement infectieuximplique un respect systmatique des techniques de laboratoire envigueur en matire de scurit.

    Le panel Triage Profiler S.O.B. ne doit pas tre utilis comme preuvedfinitive dune manifestation dIDM, dICC, dEP ou de TVP. Commepour tous les tests diagnostiques in vitro, les rsultats doivent treinterprts par le clinicien en fonction des donnes cliniques et des autrestests biologiques.

    Les concentrations sanguines de BNP peuvent tre leves chez lespatients ayant dvelopp une crise cardiaque, les patients en attente dedialyse rnale et les patients dj dialyss.

    Avertissements et prcautions

    Ractifs

  • FRA

    N

    AIS

    page 6 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    Utiliser une pipette de transfert par chantillon. La jeter aprs la premireutilisation.

    Conserver la cassette-test dans son enveloppe scelle jusquau moment deson utilisation. La jeter aprs la premire utilisation.

    La cassette-test Triage Profiler S.O.B. reste stable (dans son enveloppescelle) jusqu la date de premption indique, si elle est conserve aurfrigrateur entre 2 et 8 C. Une fois sortie du rfrigrateur, la cassette-testTriage Profiler S.O.B. peut tre conserve dans son enveloppe scellependant 14 jours temprature ambiante dans les limites de la date depremption indique sur son emballage. Si celle-ci nest pas utilise le jourde sa sortie du rfrigrateur, inscrire la date de son retrait et la date laquelleil convient de la jeter sur son emballage et/ou sur le coffret contenant lescassettes-tests (utiliser un feutre doux).

    Une fois sortie du rfrigrateur, laisser la cassette-test revenir tempratureambiante pendant au moins 30 minutes dans son enveloppe scelle.

    Ne retirer la cassette-test de son enveloppe quau moment de sonutilisation.

    Lutilisation de ce produit implique lutilisation de sang total ou de plasmarecueillis sur EDTA (anticoagulant). Les autres types dchantillons sanguinsnont pas t valus.

    Analyser les chantillons de sang laide de la cassette-test Triage ProfilerS.O.B. immdiatement ou dans les 6 heures suivant leur prlvement. Sile test ne peut pas tre effectu dans les 6 heures, sparer le plasma et leconserver -20 C jusqu ralisation du test.

    Transporter les chantillons temprature ambiante ou sur glace et viterles tempratures extrmes.

    Lchantillon doit tre homogne et temprature ambiante avant ledosage.

    Mlanger lchantillon sanguin en retournant doucement le tubeplusieurs fois avant de dposer lchantillon sur la cassette-test.

    Si possible, viter les chantillons trs hmolyss. Lorsquun chantillonapparat trs hmolys, il est prfrable dobtenir un autre prlvement etde raliser le test.

    Prlvement et prparation des chantillons

    Conditions de conservation et de manipulation

  • FRA

    N

    AIS

    page 7 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    Panel Triage Profiler S.O.B. Biosite, Rfrence 97300Contenu du coffret:Cassettes-tests 25Pipettes de transfert 25Puce code ractif (Code Chip) 1Papier imprimante 1 rouleau

    Triage MeterPlus tats-Unis Rfrence 55040ou

    International Rfrence 55041

    Contrles Triage Profiler S.O.B. Rfrence 97301

    Utilisation de la pipette de transfert1.Presser compltement la plus grosse poire de la pipette (partie suprieure

    bombe) et plonger son embout dans lchantillon sanguin.2.Relcher lentement la poire. Le capillaire de la pipette doit se remplir

    compltement. Un peu de liquide doit scouler dans la poire infrieure(plus petite) de la pipette.

    3.Positionner lembout de la pipette au-dessus de lemplacementchantillon de la cassette-test et presser compltement la plus grossepoire. Tout lchantillon contenu dans le capillaire de la pipette doit tredpos. Le volume dchantillon restant dans la petite poire (infrieure)ne doit tre pas expuls.

    4.Retirer lembout de lemplacement chantillon et relcher la poire.

    ProcdureTAPE 1. Dposer lchantillon dans la cassette-test Triage Profiler

    S.O.B.Ouvrir lenveloppe, inscrire le numro de lchantillon patientsur ltiquette de la cassette-test et dposer le sang total ou leplasma EDTA (anticoagulant) dans lemplacement chantillon laide de la pipette de transfert fournie (se confrer auxinstructions relatives la pipette).

    TAPE 2. Introduire la cassette-test dans le Triage MeterPlusAprs absorption de lchantillon dans lemplacementchantillon de la cassette, introduire la cassette-test Triage

    Procdure

    Matriel ncessaire mais non fourni

    Matriel fourni

  • FRA

    N

    AIS

    page 8 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    Profiler S.O.B. dans le Triage MeterPlus. Procder cette tapedans les 30 minutes qui suivent lexcution de ltape 1.

    TAPE 3. Lire les rsultats sur lcran daffichage du Triage MeterPlusLes rsultats du test saffichent lcran lorsque le test esttermin. Aprs analyse de la cassette, celle-ci est libre par leTriage MeterPlus.

    Les rsultats du panel Triage Profiler S.O.B. sont calculs automatiquementpar le Triage MeterPlus. Les concentrations des 5 analytes saffichent lcran. Loprateur peut alors imprimer les rsultats sil le souhaite. Pourobtenir plus dinformations, consulter le Manuel dutilisation du Triage

    MeterPlus.

    Le panel Triage Profiler S.O.B. a t talonn partir de prparationsprotiques purifies de D-dimre, de CK-MB, de myoglobine, de troponineI cardiaque et de BNP, en tenant compte de la masse (concentration) delanalyte prsent dans le plasma EDTA (anticoagulant).

    Lutilisation de contrles positifs et/ou ngatifs est recommande pour testerinitialement chaque livraison de produit, puis au moins tous les 30 jours, ouchaque fois que le laboratoire souhaite vrifier la qualit des contrles ou duractif. Biosite fournit cet effet 2 solutions de contrle externes. Lunedelles contient des concentrations danalytes proches de la valeur seuil dediagnostic. Lautre contient des concentrations danalytes observes dans deschantillons de patients dveloppant un IDM ou une ICC. Il est conseilldutiliser ces contrles pour tester chaque nouvelle livraison ou nouveau lotde produit, ainsi que pour vrifier lintgrit et la manipulation correcte dusystme danalyse.

    Chaque cassette-test Triage Profiler S.O.B. contient deux contrles internesconformes aux exigences des contrles qualit de routine. Ces contrlesindiquent que la cassette-test a reu une quantit suffisante dchantillon,que le marqueur fluorescent non li a t suffisamment limin de la zonede dtection, que la cassette-test a t correctement introduite dans le Meteret lue par celui-ci. Lorsque le rsultat de lun des contrles est insatisfaisant,un message davertissement saffiche sur le Triage MeterPlus et indique quele test doit tre recommenc.

    Contrle qualit et validation des rsultats

    talonnage

    Rsultats

  • FRA

    N

    AIS

    page 9 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    Pour obtenir davantage dinformations concernant le contrle qualit globaldu systme, consulter le Manuel dutilisation du Triage MeterPlus.

    Il est ncessaire de tester le QC Device (peut tre aussi appel le QCSimulator) fourni avec le Triage MeterPlus chaque jour o des tests patientsont lieu afin de vrifier le bon fonctionnement de linstrument. Il estgalement ncessaire de tester le QC Device lors de linstallation du Triage

    MeterPlus et lorsque les rglementations locales et nationales lexigent.Consulter le Manuel dutilisation pour obtenir la description du QC Device.

    Il convient dvaluer les rsultats du panel Triage Profiler S.O.B. lalumire de lensemble des donnes cliniques et biologiques disponibles.Lorsque les rsultats biologiques sont en dsaccord avec lvaluation clinique,des examens complmentaires sont alors requis.

    Ce test a t valu en utilisant du sang total et du plasma prlevs sur EDTA(anticoagulant). Les chantillons sriques, sanguins ou plasmatiquesrecueillis sur dautres anticoagulants nont pas t valus et ne doivent doncpas tre utiliss (par exemple hparine ou citrate).

    Il est possible que des facteurs, comme des erreurs techniques ou deprocdure, ainsi que lajout de substances non numres ci-aprs dans leschantillons sanguins, interfrent avec le test et faussent les rsultats.

    Sensibilit analytiqueLa sensibilit analytique dfinie comme tant la plus faible concentrationdtectable diffrente de zro, pour les 5 analytes, a t dtermine en testant20 fois un calibreur zro et en utilisant chaque fois 3 lots de ractifs et 5Meters sur une priode de 3 jours. Les sensibilits analytiques de chaquedosage ralis sur la cassette-test du Triage Profiler S.O.B. sont les suivantes :

    D-dimre : 100 ng/mlTroponine I : 0,05 ng/mlCK-MB : 1,0 ng/mlMyoglobine : 5 ng/mlBNP : 5 pg/ml

    Performances du test

    Limites de la mthode

  • FRA

    N

    AIS

    page 10 sur 36 Triage Profiler S.O.B. 22483(fr)A 2004 Biosite Incorporated

    Domaines de mesure

    D-dimre : 100 - 5 000 ng/mlTroponine I : 0,05 - 30 ng/mlCK-MB : 1,0 - 80 ng/mlMyoglobine : 5 - 500 ng/mlBNP : 5 - 5 000 pg/ml

    Substances interfrentesDe lhmoglobine (jusqu 500 mg/dl), des lipides (trioline jusqu3 000 mg/dl), de la bilirubine (jusqu 15 m