Future of Biomarkers in Acute Coronary Syndromes Moving Toward a Multimarker Strategy

Clinicians have become increasingly sophisticated in their application of cardiac biomarkers in the management of acute coronary syndromes (ACS). In the 1950s, clinical investigators first reported that proteins released from necrotic cardiac myocytes could be detected in the serum and could aid in the diagnosis of acute myocardial infarction.1 The ensuing 40 years witnessed progressive improvement in the cardiac tissue-specificity of biomarkers of myocardial necrosis and a corresponding enhancement in the clinical sensitivity and specificity of their use for establishing the diagnosis of acute myocardial infarction. Over the past decade, the emergence of convincing evidence for the value of cardiac troponin in guiding therapy has dramatically accelerated the integration of cardiac biomarkers into clinical decision-making for patients with ACS.2 Concurrently, advances in our understanding of the pathogenesis and consequences of acute coronary atherothrombosis have stimulated the development of new biomarkers and created the opportunity for an expanded role of multiple biomarkers, some old and others new, in the classification and individualization of treatment for ACS.3,4 The report by James et al5 in the present issue of Circulation adds substantially to the accumulating evidence that a multimarker strategy, employing a pathobiologically diverse set of biomarkers,3 is likely to add importantly to cardiac-specific troponin alone in the risk assessment of patients with ACS. See p 275 ACS is a complex syndrome with multiple causes, analogous to anemia or hypertension.6 As such, treatment is likely to be most effective when directed at the underlying cause of the disease. Five principal causes of ACS have been described; these include (1) plaque rupture with acute thrombosis, (2) progressive mechanical obstruction, (3) inflammation, (4) secondary unstable angina, and (5) dynamic obstruction (coronary vasoconstriction).7 It is rare that any of these contributors exists in isolation. However, patients with ACS may …