• Jaganathan Sickan Abbott Diagnostics, Singapore
  • Tar Choon Aw Department of Laboratory Medicine, Changi General Hospital, Singapore.
  • Shaoqing X Du Abbott Diagnostics, Singapore
  • Jian Li Abbott Diagnostics, Singapore
  • Janel Huang Abbott Diagnostics, Singapore
  • Agim Beshiri Abbott Diagnostics, Singapore



biomarkers, BNP, B-type natriuretic peptide, cardiovascular disease, homocysteine, troponin, Malaysia, risk classification, screening


Although cardiovascular disease (CVD) is a major health challenge in Malaysia, many Malaysians are unaware of their CVD risk. The measurement of biomarkers in the general population may help to identify at-risk individuals before the onset of symptomatic CVD. The aim of this community health screening project was to determine the distribution of high-sensitivity troponin I (hsTnI) and other biomarkers of CVD risk in the general population of Johor, Malaysia. A sampling of self-declared healthy volunteers was conducted during the 2016 Kembara Mahkota community event in Johor. Levels of hsTnI, B-type natriuretic peptide (BNP) and homocysteine (HCY) were analyzed using the ARCHITECT immunoassay and clinical chemistry platforms utilizing fresh venous blood samples. Based on previous data, biomarker levels indicative of high risk were >10 and >12 ng/mL for hsTnI in women and men, respectively, BNP >50 pg/mL in the overall population, and HCY >13.6 µmol/L in women and >16.2 µmol/L in men. A total of 2744 volunteers participated in biomarker testing.  Biomarker measurements showed that up to 10% of participants had moderate or high CVD risk based on hsTnI, approximately 2% were above the BNP threshold and >50% of subjects were above the HCY threshold. General population biomarker testing shows distribution of biomarker levels that may be indicative of CVD risk or the presence of disease and suggests that biomarker-guided risk strategies should be more widely implemented to determine the impact they would have on early detection and prevention of disease.



Institute for Public Health. National Health and Morbidity Survey 2015 (NHMS 2015). Volume II: Non-communicable diseases, risk factors and other health problems. Kuala Lumpur, Malaysia: Ministry of Health Malaysia; 2015.

Low WY, Lee YK, Samy AL. Non-communicable diseases in the Asia-Pacific region: Prevalence, risk factors and community-based prevention. Int J Occup Med Environ Health 2015; 28(1): 20-26.

Wan Ahmad WA, Kui-Hian S, editors. Annual Report of the Percutaneous Coronary Intervention (PCI) Registry. 2010 - 2012. . Kuala Lumpur: National Heart Association of Malaysia (NHAM) and the Ministry of Health Malaysia; 2013.

World Health Organization. Noncommunicable diseases country profiles. Geneva: World Health Organization; 2014.

Cheong AT, Khoo EM, Tong SF, Liew SM. To Check or Not to Check? A Qualitative Study on How the Public Decides on Health Checks for Cardiovascular Disease Prevention. PLoS One 2016; 11(7): e0159438.

Yen ST, Tan AK, Mustapha FI. Awareness of diabetes, hypertension, and hypercholesterolemia in Malaysia. J Diabetes 2017; 9(9): 874-883.

Shemisa K, Bhatt A, Cheeran D, Neeland IJ. Novel Biomarkers of Subclinical Cardiac Dysfunction in the General Population. Curr Heart Fail Rep 2017; 14(4): 301-310.

McKie PM, AbouEzzeddine OF, Scott CG, Mehta R, Rodeheffer RJ, Redfield MM et al. High-sensitivity troponin I and amino-terminal pro--B-type natriuretic peptide predict heart failure and mortality in the general population. Clin Chem 2014; 60(9): 1225-1233.

Bostom AG, Silbershatz H, Rosenberg IH, Selhub J, D’Agostino RB, Wolf PA et al. Nonfasting plasma total homocysteine levels and all-cause and cardiovascular disease mortality in elderly Framingham men and women. Arch Intern Med 1999; 159(10): 1077-1080.10.

Doust JA, Glasziou PP, Pietrzak E, Dobson AJ. A systematic review of the diagnostic accuracy of natriuretic peptides for heart failure. Arch Intern Med 2004; 164(18): 1978-1984.

Eggers KM, Johnson N, Lind L, Venge P, Lindahl B. Cardiac troponin I levels in an elderly population from the community — the implications of sex. Clin Biochem 2015; 48(12): 751-756.

Iribarren C, Chandra M, Rana JS, Hlatky MA, Fortmann SP, Quertermous T et al. High-sensitivity cardiac troponin I and incident coronary heart disease among asymptomatic older adults. Heart 2016; 102(15): 1177-1182.

Kim HJ, Kim MK, Kim JU, Ha HY, Choi BY. Major determinants of serum homocysteine concentrations in a Korean population. J Korean Med Sci 2010; 25(4): 509-516.

Ledwidge M, Gallagher J, Conlon C, Tallon E, O’Connell E, Dawkins I et al. Natriuretic peptide-based screening and collaborative care for heart failure: the STOP-HF randomized trial. JAMA 2013; 310(1): 66-74.

Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002; 347(3): 161-167.

Omland T, de Lemos JA, Holmen OL, Dalen H, Benth JŠ, Nygård S et al. Impact of sex on the prognostic value of high-sensitivity cardiac troponin I in the general population: the HUNT study. Clin Chem 2015; 61(4): 646-656.

Thorsteinsdottir I, Aspelund T, Gudmundsson E, Eiriksdottir G, Harris TB, Launer LH, et al. High-sensitivity cardiac troponin I is a strong predictor of cardiovascular events and mortality in the AGES-Reykjavik community-based cohort of older individuals Clin Chem 2016; 62(4): 623-30.

Veeranna V, Zalawadiya SK, Niraj A, Pradhan J, Ference B, Burack RC et al. Homocysteine and reclassification of cardiovascular disease risk. J Am Coll Cardiol 2011; 58(10): 1025-1033.

Whinecup PJ, Refsum H, Perry IJ, Morris R, Walker M, Lennon L, et al. Serum total homocysteine and coronary heart disease: prospective study in middle aged men. Heart 1999; 82: 448-454.

Zeller T, Tunstall-Pedoe H, Saarela O, Ojeda F, Schnabel RB, Tuovinen T et al. High population prevalence of cardiac troponin I measured by a high-sensitivity assay and cardiovascular risk estimation: the MORGAM Biomarker Project Scottish Cohort. Eur Heart J 2014; 35(5): 271-281.

AbouEzzeddine OF, McKie PM, Scott CG, Rodeheffer RJ, Chen HH, Michael Felker G et al. Biomarker-based risk prediction in the community. Eur J Heart Fail 2016; 18(11): 1342-1350.

Daniels LB, Clopton P, deFilippi CR, Sanchez OA, Bahrami H, Lima JA et al. Serial measurement of N-terminal pro-B-type natriuretic peptide and cardiac troponin T for cardiovascular disease risk assessment in the Multi-Ethnic Study of Atherosclerosis (MESA). Am Heart J 2015; 170(6): 1170-1183.

Gilstrap LG, Wang TJ. Biomarkers and cardiovascular risk assessment for primary prevention: an update. Clin Chem 2012; 58(1): 72-82.

Huelsmann M, Neuhold S, Resl M, Strunk G, Brath H, Francesconi C et al. PONTIAC (NT-proBNP selected prevention of cardiac events in a population of diabetic patients without a history of cardiac disease): a prospective randomized controlled trial. J Am Coll Cardiol 2013; 62(15): 1365-1372.

Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, Omland T et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med 2004; 350(7): 655-663.

Blankenberg S, Salomaa V, Makarova N, Oieda F, Wild P, Lackner KJ et al. Troponin I and cardiovascular risk prediction in the general population: the BiomarCaRE consortium. Eur Heart J 2016; 37(30): 2428-2437.

Blankenberg S, Zeller T, Saarela O, Havulinna AS, Kee F, Tunstall-Pedoe H et al. Contribution of 30 biomarkers to 10-year cardiovascular risk estimation in 2 population cohorts: the MONICA, risk, genetics, archiving, and monograph (MORGAM) biomarker project. Circulation 2010; 121(22): 2388-2397.

Antoniades C, Antonopoulos AS, Tousoulis D, Marinou K, Stefanadis C. Homocysteine and coronary atherosclerosis: from folate fortification to the recent clinical trials. Eur Heart J 2009; 30(1): 6-15.

Mallikethi-Reddy S, Briasoulis A, Akintoye E, Afonso L. Novel biomarkers with potential for cardiovascular risk reclassification. Biomarkers 2017; 22(3-4): 189-199.

Apple FS, Collinson PO, IFCC Task Force on Clinical Applications of Cardiac Biomarkers. Analytical characteristics of high-sensitivity cardiac troponin assays. Clin Chem 2012; 58(1) :54-61.

Wierzbicki AS. Homocysteine and cardiovascular disease: a review of the evidence. Diab Vasc Dis Res 2007; 4(2): 143-150.

Leistner DM, Klotsche J, Pieper L, Stalla GK, Lehnert H, Silber S et al. Circulating troponin as measured by a sensitive assay for cardiovascular risk assessment in primary prevention. Clin Chem 2012; 58(1): 200-208.

Redfield MM, Rodeheffer RJ, Jacobsen SJ, Mahoney DW, Bailey KR et al. Plasma brain natriuretic peptide concetration: impact of age and gender. J Am Coll Cardiol 2002; 40(5):976-982.

Kuo HK, Sorond FA, Chen JH, Hashmi A, Milberg WP et al. The role of homocysteine in multisystem age-related problems: a systematic review. J Gerontol A Biol Sci Med Sci 2005; 60(9):1190-1201.

Eggers KM, Venge P, Lindahl B, Lind L. Cardiac Troponin I Levels Measured With a High-Sensitive Assay Increase Over Time and Are Strong Predictors of Mortality in an Elderly Population. J Am Coll Cardiol 2013; 61(18):1906-1913.

Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2017; 70(6):776-803.

Sigurdardottir FD, Lyngbakken MN, Holmen OL, Dalen H, Hveem K et al. Relative Prognostic Value of Cardiac Troponin I and C-Reactive Protein in the General Population (from the Nord-Trondelag Health [HUNT] Study). Am J Cardiol 2018; 121(8):949-955.




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