Flightless anchors IQGAP1 and R-ras to mediate cell extension formation and matrix remodeling.

Tractional remodeling of collagen fibrils by fibroblasts requires long cell extensions that mediate fibril alignment. The formation of these cell extensions involves flightless I (FliI), an actin-binding protein that contains a leucine-rich-repeat (LRR), which binds R-ras and may regulate cdc42. We considered that FliI interacts with small GTPases and their regulators to mediate assembly of cell extensions. Mass spectrometry analyses of FliI immunoprecipitates showed abundant Ras GTPase-activating-like protein (IQGAP1), which in immunostained samples colocalized with FliI at cell adhesions. Knockdown of IQGAP1 reduced the numbers of cell extensions and the alignment of collagen fibrils. In experiments using dominant negative mutants, cdc42 activity was required for the formation of short extensions while R-ras was required for the formation of long extensions. Immunoprecipitation of wild-type and mutant constructs showed that IQGAP1 associated with cdc42 and R-ras; this association required the GAP-related domain (1004-1237 aa) of IQGAP1. In cells transfected with FliI mutants, the LRR of FliI, but not its gelsolin-like domains, mediated association with cdc42, R-ras, and IQGAP1. We conclude that FliI interacts with IQGAP1 and co-ordinates with cdc42 and R-ras to control the formation of cell extensions that enable collagen tractional remodeling.

Haemoglobin A1c analysis in the management of patients with diabetes: from chaos to harmony.

Effective management of patients with diabetes mellitus requires accurate assessments of blood glucose control. The best characterised marker of long term glycaemic control is whole blood haemoglobin A(1c) (HbA(1c)). Published clinical trials have identified quantitative and direct relationships between the HbA(1c) concentration and risks of diabetic microvascular complications. However, in order to practice evidence-based medicine, assays used to measure patient samples should ideally produce values comparable to the assays used in these trials. Numerous assays using chromatographic and immunological detection methods are used around the world. This paper briefly reviews the scientific evolution of HbA(1c) and its analysis, discusses the reasons why HbA(1c) assay standardisation is a challenge, describes the approaches that have been adopted to harmonise HbA(1c) assays, and addresses the current initiatives to standardise HbA(1c) globally. These efforts have established HbA(1c) as an essential component in the management of patients with diabetes mellitus and are likely to lead to the use of HbA(1c) in the screening/diagnosis of diabetes.

Compartmentalised MAPK pathways.

The mitogen-activated protein kinase (MAPK) pathway provides cells with the means to interpret external signal cues or conditions, and respond accordingly. This cascade regulates many cell functions such as differentiation, proliferation and migration. Through modulation of both the amplitude and duration of MAPK signalling, cells can control their responses to the multiple activators of the pathway. In addition, recent work has highlighted the importance of the cellular compartment from which the signalling occurs. Cells have developed intricate systems that enable them to localise MAPK components to specific subcellular domains in response to a particular stimulus. Consequently, different factors can activate the same kinase in separate locations. Crucial to this ability are molecular scaffolds, which act as signalling modules for MAPKs, confining them to the desired compartment. The participation of the MAPK network in fundamental physiological processes, such as cell proliferation and inflammation, and the derangement of the homeostasis that occurs in disease processes, renders MAPK a highly desirable target for therapeutic intervention. As we enhance our comprehension of scaffolds and other regulatory molecules, novel targets for drug design may be discovered that will afford selective and specific MAPK modulation.

The role of scaffold proteins in MEK/ERK signalling.

Signal transduction networks allow cells to recognize and respond to changes in the extracellular environment. All eukaryotic cells have MAPK (mitogen-activated protein kinase) pathways that participate in diverse cellular functions, including differentiation, survival, transformation and movement. Five distinct groups of MAPKs have been characterized in mammals, the most extensively studied of which is the Ras/Raf/MEK [MAPK/ERK (extracellular-signal-regulated kinase) kinase]/ERK cascade. Numerous stimuli, including growth factors and phorbol esters, activate MEK/ERK signalling. How disparate extracellular signals are translated by MEK/ERK into different cellular functions remains obscure. Originally identified in yeast, scaffold proteins are now recognized to contribute to the specificity of MEK/ERK pathways in mammalian cells. These scaffolds include KSR (kinase suppressor of Ras), beta-arrestin, MEK partner-1, Sef and IQGAP1. Scaffolds organize multiprotein signalling complexes. This targets MEK/ERK to specific substrates and facilitates communication with other pathways, thereby mediating diverse functions. The adaptor proteins regulate the kinetics, amplitude and localization of MEK/ERK signalling, providing an efficient mechanism that enables an individual extracellular stimulus to promote a specific biological response.

The national glycohemoglobin standardization program: a five-year progress report.

BACKGROUND: The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated conclusively that risks for complications in patients with diabetes are directly related to glycemic control, as measured by glycohemoglobin (GHB). In 1994, one year after the DCCT results were reported, the American Diabetes Association (ADA) set specific diabetes treatment goals. However, 1993 College of American Pathologists (CAP) Survey results indicated a lack of comparability of GHB test results among methods and laboratories that represented a major obstacle to meaningful implementation of the ADA guidelines. Thus, an AACC subcommittee was formed in 1993 to develop a standardization program that would enable laboratories to report DCCT-traceable GHB results. This program was implemented in 1996 by the National Glycohemoglobin Standardization Program (NGSP) Steering Committee. APPROACH: We review the NGSP process and summarize progress in standardization through analysis of CAP data. CONTENT: Since 1996, the number of methods and laboratories certified by the NGSP as traceable to the DCCT has steadily increased. CAP GH2-B survey results reported in December 2000 show marked improvement over 1993 data in the comparability of GHB results. In 2000, 90% of surveyed laboratories reported GHB results as hemoglobin A(1c) (HbA(1c)) or equivalent, compared with 50% in 1993. Of laboratories reporting HbA(1c) in 2000, 78% used a NGSP-certified method. For most certified methods in 2000, between-laboratory CVs were <5%. For all certified methods in 2000, the mean percent HbA(1c) was within 0.8% HbA(1c) of the NGSP target at all HbA(1c) concentrations.

The effect of IQGAP1 on Xenopus embryonic ectoderm requires Cdc42.

IQGAP1 contains a number of protein recognition motifs through which it binds to targets. Several in vitro studies have documented that IQGAP1 interacts directly with calmodulin, actin, E-cadherin, beta-catenin, and the small GTPases Cdc42 and Rac. Nevertheless, direct demonstration of in vivo function of mammalian IQGAP1 is limited. Using a novel assay to evaluate in vivo function of IQGAP1, we document here that microinjection of IQGAP1 into early Xenopus embryos generates superficial ectoderm lesions at late blastula stages. This activity was retained by the mutated variants of IQGAP1 in which the calponin homology domain or the WW domain was deleted. By contrast, deletion of the IQ (IQGAP1-DeltaIQ), Ras-GAP-related (IQGAP1-DeltaGRD), or C-terminal (IQGAP1-DeltaC) domains abrogated the effect of IQGAP1 on the embryos. None of the latter mutants bound Cdc42, suggesting that the binding of Cdc42 by IQGAP1 is critical for its function. Moreover, overexpression of IQGAP1, but not IQGAP1-DeltaGRD, significantly increased the amount of active Cdc42 in embryonic cells. Co-injection of wild type IQGAP1 with dominant negative Cdc42, but not the dominant negative forms of Rac or Rho, blocked the effect of IQGAP1 on embryonic ectoderm. Together these data indicate that the activity of IQGAP1 in embryonic ectoderm requires Cdc42 function.

Calmodulin enhances the stability of the estrogen receptor.

The estrogen receptor mediates breast cell proliferation and is the principal target for chemotherapy of breast carcinoma. Previous studies have demonstrated that the estrogen receptor binds to calmodulin-Sepharose in vitro. However, the association of endogenous calmodulin with endogenous estrogen receptors in intact cells has not been reported, and the function of the interaction is obscure. Here we demonstrate by co-immunoprecipitation from MCF-7 human breast epithelial cells that endogenous estrogen receptors bind to endogenous calmodulin. Estradiol treatment of the cells had no significant effect on the interaction. However, incubation of the cells with tamoxifen enhanced by 5-10-fold the association of calmodulin with the estrogen receptor and increased the total cellular content of estrogen receptors by 1.5-2-fold. In contrast, the structurally distinct calmodulin antagonists trifluoperazine and CGS9343B attenuated the interaction between calmodulin and the estrogen receptor and dramatically reduced the number of estrogen receptors in the cell. Neither of these agents altered the amount of estrogen receptor mRNA, suggesting that calmodulin stabilizes the protein. This hypothesis is supported by the observation that, in the presence of Ca2+, calmodulin protected estrogen receptors from in vitro proteolysis by trypsin. Furthermore, overexpression of wild type calmodulin, but not a mutant calmodulin incapable of binding Ca2+, increased the concentration of estrogen receptors in MCF-7 cells, whereas transient expression of a calmodulin inhibitor peptide reduced the estrogen receptor concentration. These data demonstrate that calmodulin binds to the estrogen receptor in intact cells in a Ca2+-dependent, but estradiol-independent, manner, thereby modulating the stability and the steady state level of estrogen receptors.

Effects of hemoglobin variants and chemically modified derivatives on assays for glycohemoglobin.

BACKGROUND: Glycohemoglobin (gHb), measured as hemoglobin (Hb) A(1c) or as total gHb, provides a common means for assessing long-term glycemic control in individuals with diabetes mellitus. Genetic variants and chemically modified derivatives of Hb can profoundly affect the accuracy of these measurements, although effects vary considerably among commercially available methods. The prevalence of genetic variants such as HbS, HbC, and HbE, and chemically modified derivatives such as carbamyl-Hb among patient populations undergoing testing is not insignificant. Clinical laboratories and sites responsible for point-of-care testing of gHb need to be aware of the interferences produced in assays by these Hbs. APPROACH: We conducted a review of the literature describing the effects of variant Hbs on gHb assay methods commonly used in clinical laboratories. CONTENT: This review summarizes the documented effects of both common and uncommon Hb variants and derivatives on the measurement of gHb. Where known, we discuss mechanisms of interference on specific assays and methodologies. We specifically address effects of commonly encountered Hbs, such as carbamyl-Hb, HbS, HbC, HbE, and HbF, on assays that use cation-exchange chromatography, immunoassays, or boronate affinity methods for measuring gHb. SUMMARY: A variety of patient- and laboratory-related factors can adversely affect the measurement of gHb in patients harboring Hb variants or derivatives. Identification of the variant or derivative Hb before or during testing may allow accurate measurement of gHb by the selection of a method unaffected by the given variant or derivative. However, laboratories should make available alternative, non-Hb-based methods for assessing long-term glycemic control in individuals with HbCC, HbSS, or HbSC disease, or with other underlying disorders where the concentration of gHb does not accurately reflect long-term glycemic control.

E-cadherin-mediated cell-cell attachment activates Cdc42.

E-cadherin is a transmembrane protein that mediates Ca(2+)-dependent cell-cell adhesion. Cdc42, a member of the Rho family of small GTPases, participates in cytoskeletal rearrangement and cell cycle progression. Recent evidence reveals that members of the Rho family modulate E-cadherin function. To further examine the role of Cdc42 in E-cadherin-mediated cell-cell adhesion, we developed an assay for active Cdc42 using the GTPase-binding domain of the Wiskott-Aldrich syndrome protein. Initiation of E-cadherin-mediated cell-cell attachment significantly increased in a time-dependent manner the amount of active Cdc42 in MCF-7 epithelial cell lysates. By contrast, Cdc42 activity was not increased under identical conditions in MCF-7 cells incubated with anti-E-cadherin antibodies nor in MDA-MB-231 (E-cadherin negative) epithelial cells. By fusing the Wiskott-Aldrich syndrome protein/GTPase-binding domain to a green fluorescent protein, activation of endogenous Cdc42 by E-cadherin was demonstrated in live cells. These data indicate that E-cadherin activates Cdc42, demonstrating bi-directional interactions between the Rho- and E-cadherin signaling pathways.

Binding of IRS proteins to calmodulin is enhanced in insulin resistance.

The IRS proteins, major endogenous targets of the insulin receptor, bind to calmodulin in a Ca(2+)-dependent manner. Here, we have examined the interaction between these proteins in animal and cultured cell models of insulin resistance. Both IRS-1 and IRS-2 co-immunoprecipitate with calmodulin from insulin target tissues in rats. The interaction between calmodulin and IRS proteins in rat soleus muscle was enhanced when insulin resistance was induced in rats by treatment with dexamethasone for 5 days. Moreover, injection of angiotensin II into the inferior vena cava enhanced the binding in rat cardiac muscle. Similarly, increased binding between calmodulin and IRS-1 was observed in isolated cells incubated with tumor necrosis factor-alpha. Overexpression of calmodulin in Chinese hamster ovary cells reduced the tyrosine phosphorylation of IRS-1 induced by insulin, with a concomitant decrease in insulin-stimulated association of IRS-1 with the 85-kDa regulatory subunit of phosphatidylinositol 3-kinase. Insulin-stimulated phosphatidylinositol 3-kinase activity associated with IRS-1 was also reduced in cells overexpressing calmodulin, while this activity was increased in cells incubated with the cell-permeable calmodulin antagonist trifluoperazine. These data demonstrate an enhanced interaction between calmodulin and IRS proteins in models of insulin resistance and suggest a possible mechanism by which increased intracellular Ca(2+) concentrations may contribute to impaired insulin sensitivity.

Calmodulin antagonists inhibit insulin-stimulated GLUT4 (glucose transporter 4) translocation by preventing the formation of phosphatidylinositol 3,4,5-trisphosphate in 3T3L1 adipocytes.

It has been previously reported that calmodulin plays a regulatory role in the insulin stimulation of glucose transport. To examine the basis for this observation, we examined the effect of a panel of calmodulin antagonists that demonstrated a specific inhibition of insulin-stimulated glucose transporter 4 (GLUT4) but not insulin- or platelet-derived growth factor (PDGF)-stimulated GLUT1 translocation in 3T3L1 adipocytes. These treatments had no effect on insulin receptor autophosphorylation or tyrosine phosphorylation of insulin receptor substrate 1 (IRS1). Furthermore, IRS1 or phosphotyrosine antibody immunoprecipitation of phosphatidylinositol (PI) 3-kinase activity was not affected. Despite the marked insulin and PDGF stimulation of PI 3-kinase activity, there was a near complete inhibition of protein kinase B activation. Using a fusion protein of the Grp1 pleckstrin homology (PH) domain with the enhanced green fluorescent protein, we found that the calmodulin antagonists prevented the insulin stimulation of phosphatidylinositol 3,4,5-trisphosphate [PI(3,4,5)P3] formation in vivo. Similarly, although PDGF stimulation increased PI 3-kinase activity in in vitro immunoprecipitation assays, there was also no significant formation of PI(3,4,5)P3 in vivo. These data demonstrate that calmodulin antagonists prevent insulin-stimulated GLUT4 translocation by inhibiting the in vivo production of PI(3,4,5)P3 without directly affecting IRS1- or phosphotyrosine-associated PI 3-kinase activity. This phenomenon is similar to that observed for the PDGF stimulation of 3T3L1 adipocytes.

Thrombin-induced phosphorylation of MARCKS does not alter its interactions with calmodulin or actin.

Myristoylated alanine-rich C kinase substrate (MARCKS) is a calmodulin (CaM)- and actin-binding protein and prominent protein kinase C (PKC) substrate. In vitro phosphorylation of MARCKS by PKC has been shown to induce the release of both CaM and actin, leading to the suggestion that MARCKS may regulate CaM availability during agonist-induced signalling. In support of this hypothesis we previously demonstrated that thrombin-induced MARCKS phosphorylation in endothelial cells (EC) parallels activation of myosin light chain kinase, a CaM-dependent enzyme. To test this theory further, we transfected CHO cells, which normally do not express significant levels of MARCKS, with a MARCKS cDNA. The thrombin-stimulated phosphorylation of myosin light chains and the sensitivity to CaM antagonists in the MARCKS overexpressing cells was the same as that in control CHO cells. MARCKS associated with the actin cytoskeleton in EC was markedly increased upon treatment with the PKC activator, PMA, but only modestly enhanced by thrombin treatment. Similarly, colocalisation of MARCKS with actin was enhanced when the EC were challenged with PMA but not thrombin. These data may be partially explained by PKC-independent phosphorylation of MARCKS in response to thrombin stimulation.

Both calmodulin and the unconventional myosin Myr4 regulate membrane trafficking along the recycling pathway of MDCK cells.

In epithelial cells, endocytosed transferrin and its receptor, which cycle basolaterally, have been shown to transit through recycling endosomes which can also be accessed by markers internalized from the apical surface. In this work, we have used an in vitro assay to follow transfer of an endocytosed marker from apical or basolateral early endosomes to recycling endosomes labeled with transferrin. We show that calmodulin (CaM) function is necessary for transfer and identified myr4, a member of the unconventional myosin superfamily known to use CaM as a light chain, as a possible target protein for CaM. Since myr4 is believed to act as an actin-based mechanoenzyme, we tested the role of polymerized actin in the assay. Our data show that conditions which either prevent actin polymerization or induce the breakdown of existing filaments strongly inhibit interactions between recycling endosomes and either set of early endosomes. Altogether, our data indicate that trafficking at early steps of the endocytic pathway in Madin-Darby Canine Kidney cells depends on the actin-based mechanoenzyme myr4, its light chain CaM, and polymerized actin.

Emergency department triage strategies for acute chest pain using creatine kinase-MB and troponin I assays: a cost-effectiveness analysis.

BACKGROUND: Evaluation of acute chest pain is highly variable. OBJECTIVE: To evaluate the cost-effectiveness of strategies using cardiac markers and noninvasive tests for myocardial ischemia. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Prospective data from 1066 patients with chest pain and from the published literature. TARGET POPULATION: Patients admitted with acute chest pain. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTIONS: Creatine kinase (CK)-MB mass assay alone; CK-MB mass assay followed by cardiac troponin I assay if the CK-MB value is normal; CK-MB mass assay followed by troponin I assay if the CK-MB value is normal and electrocardiography shows ischemic changes; both CK-MB mass and troponin I assays; and troponin I assay alone. These strategies were evaluated alone or in combination with early exercise testing. OUTCOME MEASURES: Lifetime cost, life expectancy (in years), and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: For patients 55 to 64 years of age, measurement of CK-MB mass followed by exercise testing in appropriate patients was the most competitive strategy ($43000 per year of life saved). Measurement of CK-MB mass followed by troponin I measurement had an incremental cost-effectiveness ratio of $47400 per year of life saved for patients 65 to 74 years of age; it was also the most cost-effective strategy when early exercise testing could not be performed, CK-MB values were normal, and ischemic changes were seen on electrocardiography. RESULTS OF SENSITIVITY ANALYSIS: Results were influenced by age, probability of myocardial infarction, and medical costs. CONCLUSIONS: Measurement of CK-MB mass plus early exercise testing is a cost-effective initial strategy for younger patients and those with a low to moderate probability of myocardial infarction. Troponin I measurement can be a cost-effective second test in higher-risk subsets of patients if the CK-MB level is normal and early exercise testing is not an option.

IQGAP1 and calmodulin modulate E-cadherin function.

Ca(2+)-dependent cell-cell adhesion is mediated by the cadherin family of transmembrane proteins. Adhesion is achieved by homophilic interaction of the extracellular domains of cadherins on adjacent cells, with the cytoplasmic regions serving to couple the complex to the cytoskeleton. IQGAP1, a novel RasGAP-related protein that interacts with the cytoskeleton, binds to actin, members of the Rho family, and E-cadherin. Calmodulin binds to IQGAP1 and regulates its association with Cdc42 and actin. Here we demonstrate competition between calmodulin and E-cadherin for binding to IQGAP1 both in vitro and in a normal cellular milieu. Immunocytochemical analysis in MCF-7 (E-cadherin positive) and MDA-MB-231 (E-cadherin negative) epithelial cells revealed that E-cadherin is required for accumulation of IQGAP1 at cell-cell junctions. The cell-permeable calmodulin antagonist CGS9343B significantly increased IQGAP1 at areas of MCF-7 cell-cell contact, with a concomitant decrease in the amount of E-cadherin at cell-cell junctions. Analysis of E-cadherin function revealed that CGS9343B significantly decreased homophilic E-cadherin adhesion. On the basis of these data, we propose that disruption of the binding of calmodulin to IQGAP1 enhances the association of IQGAP1 with components of the cadherin-catenin complex at cell-cell junctions, resulting in impaired E-cadherin function.

Acute coronary ischemia: troponin I and T.

Despite advances in diagnosis and management, ischemic heart disease remains the leading cause of death in the USA. Serum cardiac enzymes, one of the three fundamental criteria for establishing the diagnosis of myocardial infarction, are not specific for cardiac muscle and have a narrow time-window. The recent development of monoclonal antibodies to cardiac troponin I and troponin T has resulted in cardiac-specific assays. Several published studies have documented the utility of troponin proteins in the evaluation of myocardial necrosis. A brief overview of the characteristics and clinical utility of troponin T and I is presented here.

PKC-dependent regulation of transepithelial resistance: roles of MLC and MLC kinase.

The mechanisms by which protein kinase C (PKC) activation results in increased transepithelial resistance (TER) are unknown [G. Hecht, B. Robinson, and A. Koutsouris. Am. J. Physiol. 266 (Gastrointest. Liver Physiol. 29): G214-G221, 1994]. We have previously shown that phosphorylation of the regulatory light chain of myosin II (MLC) is associated with decreases in TER and have suggested that contraction of the perijunctional actomyosin ring (PAMR) increases tight junction (TJ) permeability [J. R. Turner, B. K. Rill, S. L. Carlson, D. Carnes, R. Kerner, R. J. Mrsny, and J. L. Madara. Am. J. Physiol. 273 (Cell Physiol. 42): C1378-C1385, 1997]. We therefore hypothesized that PKC activation alters TER via relaxation of the PAMR. Activation of PKC by the phorbol ester phorbol 12-myristate 13-acetate (PMA) resulted in a progressive dose-dependent increase in TER that was apparent within 15 min (111% of controls) and maximal within 2 h (142% of controls). Similar increases were induced by a diacylglycerol analog, and the effects of both PMA and the diacylglycerol analog were prevented by the PKC inhibitor bisindolylmaleimide I. PMA treatment caused progressive decreases in MLC phosphorylation, by 12% at 15 min and 41% at 2 h. Phosphorylation of MLC kinase (MLCK) increased by 64% within 15 min of PMA treatment and was stable over 2 h (51% greater than that of controls). Thus increases in MLCK phosphorylation preceded decreases in MLC phosphorylation. These data suggest that PKC regulates TER via decreased phosphorylation of MLC, possibly due to inhibitory phosphorylation of MLCK. The decreased phosphorylation of MLC likely reduces PAMR tension, leading to decreased TJ permeability.

Calmodulin binds to p21(Cip1) and is involved in the regulation of its nuclear localization.

p21(Cip1), first described as an inhibitor of cyclin-dependent kinases, has recently been shown to have a function in the formation of cyclin D-Cdk4 complexes and in their nuclear translocation. The dual behavior of p21(Cip1) may be due to its association with other proteins. Different evidence presented here indicate an in vitro and in vivo interaction of p21(Cip1) with calmodulin: 1) purified p21(Cip1) is able to bind to calmodulin-Sepharose in a Ca(2+)-dependent manner, and this binding is inhibited by the calmodulin-binding domain of calmodulin-dependent kinase II; 2) both molecules coimmunoprecipitate when extracted from cellular lysates; and 3) colocalization of calmodulin and p21(Cip1) can be detected in vivo by electron microscopy immunogold analysis. The carboxyl-terminal domain of p21(Cip1) is responsible for the calmodulin interaction, since p21(145-164) peptide is also able to bind calmodulin and to compete with full-length p21(Cip1) for the calmodulin binding. Because treatment of cells with anti-calmodulin drugs decreases the nuclear accumulation of p21(Cip1), we hypothesize that calmodulin interaction with p21(Cip1) is important for p21(Cip1), and in consequence for cyclin D-Cdk4, translocation into the cell nucleus.

Cardiac troponin T as a marker for myocardial ischemia in patients seen at the emergency department for acute chest pain.

BACKGROUND: Identification of patients with acute chest pain at high risk for cardiovascular complications is a common and difficult challenge for clinicians and must be based initially on data from the history, physical examination, electrocardiogram, and chest radiograph. Some data suggest that elevations in cardiac troponin T (cTnT) may be useful for detection of less severe degrees of myocardial injury that may occur in some patients with unstable angina. Therefore we designed a prospective follow-up study to assess the diagnostic performance and prognostic value of cTnT in a population of patients presenting to the emergency department with acute chest pain. METHODS: The patient population included all 1477 admitted patients aged 30 years or more who presented to the emergency department of an urban teaching hospital from October 1992, through February 1994, with a chief symptom of acute chest pain not explained by trauma or chest radiograph abnormalities. The 1303 patients (88%) who had 2 or more measurements of cTnT during the first 24 hours after presentation comprised the final study population. Sensitivity, specificity, positive predictive value, negative predictive value, and receiver operator characteristics curve (ROC) were determined for cTnT and creatine kinase-MB (CK-MB) (measured using activity and mass assays) data from the first 24 hours after admission for the outcomes of acute myocardial infarction (AMI) and major cardiac events during the first 72 hours of hospitalization. RESULTS: The sensitivity and specificity of cTnT (threshold of 0.1 ng/mL) for detecting AMI during the first 24 hours after presentation were 99% and 86%, respectively. The CK-MB activity and mass assays had diagnostic performance for detecting AMI similar to cTnT. Among patients who did not meet study criteria for AMI, cTnT was elevated during the first 24 hours in 31% of patients who had major complications, compared with a 17% rate for the CK-MB activity assay and a 3% rate for the CK-MB mass assay. In these patients, the cTnT assay had superior diagnostic performance compared with the CK-MB mass assay as a marker for cardiac complications as assessed with ROC analysis (P <.0004). CONCLUSIONS: In a heterogeneous population of patients seen in the emergency department with acute chest pain, cTnT was similar to CK-MB (activity and mass assays) for detection of AMI and superior to the CK-MB mass assay as a marker for major cardiac events early in the hospital course among those who were ruled out for an AMI. Further study is required to determine how this assay can be used to provide more appropriate, cost-effective care.