Verification of candidate biomarkers requires specific assays to selectively detect and quantify target proteins in accessible biofluids. The primary objective of verification is to screen potential biomarkers to ensure that only the highest quality candidates from the discovery phase are taken forward into preclinical validation. Because antibody reagents for a clinical grade immunoassay often exist for a small number of candidates, alternative methodologies are required to credential new and unproven candidates in a statistically viable number of serum or plasma samples. Using multiple reaction monitoring coupled with stable isotope dilution MS, we developed quantitative, multiplexed assays in plasma for six proteins of clinical relevance to cardiac injury. The process described does not require antibodies for immunoaffinity enrichment of either proteins or peptides. Limits of detection and quantitation for each signature peptide used as surrogates for the target proteins were determined by the method of standard addition using synthetic peptides and plasma from a healthy donor. Limits of quantitation ranged from 2 to 15 ng/ml for most of the target proteins. Quantitative measurements were obtained for one to two signature peptides derived from each target protein, including low abundance protein markers of cardiac injury in the nanogram/milliliter range such as the cardiac troponins. Intra- and interassay coefficients of variation were predominantly <10 and 25%, respectively. The configured multiplex assay was then used to measure levels of these proteins across three time points in six patients undergoing alcohol septal ablation for hypertrophic obstructive cardiomyopathy. These results are the first demonstration of a multiplexed, MS-based assay for detection and quantification of changes in concentration of proteins associated with cardiac injury in the low nanogram/milliliter range. Our results also demonstrate that these assays retain the necessary precision, reproducibility, and sensitivity to be applied to novel and uncharacterized candidate biomarkers for verification of proteins in blood. Verification of candidate biomarkers requires specific assays to selectively detect and quantify target proteins in accessible biofluids. The primary objective of verification is to screen potential biomarkers to ensure that only the highest quality candidates from the discovery phase are taken forward into preclinical validation. Because antibody reagents for a clinical grade immunoassay often exist for a small number of candidates, alternative methodologies are required to credential new and unproven candidates in a statistically viable number of serum or plasma samples. Using multiple reaction monitoring coupled with stable isotope dilution MS, we developed quantitative, multiplexed assays in plasma for six proteins of clinical relevance to cardiac injury. The process described does not require antibodies for immunoaffinity enrichment of either proteins or peptides. Limits of detection and quantitation for each signature peptide used as surrogates for the target proteins were determined by the method of standard addition using synthetic peptides and plasma from a healthy donor. Limits of quantitation ranged from 2 to 15 ng/ml for most of the target proteins. Quantitative measurements were obtained for one to two signature peptides derived from each target protein, including low abundance protein markers of cardiac injury in the nanogram/milliliter range such as the cardiac troponins. Intra- and interassay coefficients of variation were predominantly <10 and 25%, respectively. The configured multiplex assay was then used to measure levels of these proteins across three time points in six patients undergoing alcohol septal ablation for hypertrophic obstructive cardiomyopathy. These results are the first demonstration of a multiplexed, MS-based assay for detection and quantification of changes in concentration of proteins associated with cardiac injury in the low nanogram/milliliter range. Our results also demonstrate that these assays retain the necessary precision, reproducibility, and sensitivity to be applied to novel and uncharacterized candidate biomarkers for verification of proteins in blood. Discovery of disease-specific biomarkers with diagnostic and prognostic utility has become an important challenge in clinical proteomics. In general, unbiased discovery experiments often result in the confident identification of thousands of proteins, hundreds of which may vary significantly between case and control samples in small discovery studies. However, because of the stochastic sampling of proteomes in discovery "omics" experiments, a large fraction of the protein biomarkers "discovered" in these experiments are false positives arising from biological or technical variability. Clearly discovery omics experiments do not lead to biomarkers of immediate clinical utility but rather produce candidates that must be qualified and verified in larger sample sets than were used for discovery (1Rifai N. Gillette M.A. Carr S.A. Protein biomarker discovery and validation: the long and uncertain path to clinical utility.Nat. Biotechnol. 2006; 24: 971-983Crossref PubMed Scopus (1383) Google Scholar). Traditional, clinical validation of biomarkers has relied primarily on immunoassays because of their specificity and sensitivity for the target analyte and high throughput capability. However, antibody reagents for a clinical grade immunoassay often only exist for a short list of candidates. The development of a reliable sandwich immunoassay for one target protein is expensive, has a long development time, and is dependent upon the generation of high quality protein antibodies. For the large majority of new, unproven candidate biomarkers, an intermediate verification technology is required that has shorter assay development time lines, lower assay cost, and effective multiplexing of dozens of candidates in low sample volumes. Ideally the approach should be capable of analyzing hundreds of samples of serum or plasma with good precision. The desired outcome of verification is a small number of highly credentialed candidates suitable for traditional preclinical and clinical validation studies. Multiple reaction monitoring (MRM) 1The abbreviations used are:MRMmultiple reaction monitoringSIDstable isotope dilutionCVcoefficient of variationPMIplanned myocardial infarctionCRPC-reactive proteinMRP14myeloid related protein 14MPOmyeloperoxidasecTnIcardiac troponin IcTnTcardiac troponin TBNPB-type natriuretic peptideNT-proBNPN-terminal prohormone B-type natriuretic peptideIL-33interleukin 33sCD40Lsoluble CD40 ligandSCXstrong cation exchange chromatographyLOQlimit of quantitationLODlimit of detectionSISCAPAStable Isotope Standards and Capture by Anti-Peptide Antibodies. coupled with stable isotope dilution (SID) MS has recently been shown to be well suited for direct quantification of proteins in plasma (2Kuhn E. Wu J. Karl J. Liao H. Zolg W. Guild B. Quantification of C-reactive protein in the serum of patients with rheumatoid arthritis using multiple reaction monitoring mass spectrometry and 13C-labeled peptide standards.Proteomics. 2004; 4: 1175-1186Crossref PubMed Scopus (369) Google Scholar, 3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar, 4Bondar O.P. Barnidge D.R. Klee E.W. Davis B.J. Klee G.G. LC-MS/MS quantification of Zn-alpha 2 glycoprotein: A potential serum biomarker for prostate cancer.Clin. Chem. 2007; 53: 673-678Crossref PubMed Scopus (106) Google Scholar) and has emerged as the core technology for candidate biomarker verification. MRM assays can be highly multiplexed such that a moderate number of candidate proteins (in the range of 10–50) can be simultaneously targeted and measured in the statistically viable number of patient samples required for verification (hundreds of serum samples). However, sensitivity for unambiguous detection and quantification of proteins by MS-based assays is often constrained by sample complexity, particularly when the measurements are being made in complex fluids such as plasma. multiple reaction monitoring stable isotope dilution coefficient of variation planned myocardial infarction C-reactive protein myeloid related protein 14 myeloperoxidase cardiac troponin I cardiac troponin T B-type natriuretic peptide N-terminal prohormone B-type natriuretic peptide interleukin 33 soluble CD40 ligand strong cation exchange chromatography limit of quantitation limit of detection Stable Isotope Standards and Capture by Anti-Peptide Antibodies. Many biomarkers of current clinical importance, such as prostate-specific antigen and the cardiac troponins, reside in the low nanogram/milliliter range in plasma and, until recently, have been inaccessible by non-antibody approaches. Our laboratory has recently shown for the first time that a combination of abundant protein depletion with limited fractionation at the peptide level prior to SID-MRM-MS provides robust limits of quantitation (LOQs) in the 1–20 ng/ml range with coefficient of variation (CV) of 10–20% at the LOQ for proteins in plasma (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar). Here we demonstrate that this work flow can be extended to configure assays for a number of known markers of cardiovascular disease and, more importantly, can be deployed to measure their concentrations in clinical samples. We modeled a verification study comprising six patients undergoing alcohol septal ablation treatment for hypertrophic obstructive cardiomyopathy, a human model of "planned" myocardial infarction (PMI), and obtained targeted, quantitative measurements for moderate to low concentrations of cardiac biomarkers in plasma. This work provides additional evidence that MS-based assays can be configured and applied to verification of new protein targets for which high quality antibody reagents are not available. A total of six patients undergoing PMI using alcohol septal ablation for the treatment of symptomatic hypertrophic obstructive cardiomyopathy were included in this study. The protocol for obtaining blood from patients was approved by the Massachusetts General Hospital Institutional Review Board, and all subjects gave written informed consent. Inclusion criteria for patients to receive alcohol ablation treatment were as described previously (5Lewis G.D. Wei R. Liu E. Yang E. Shi X. Martinovic M. Farrell L. Asnani A. Cyrille M. Ramanathan A. Shaham O. Berriz G. Lowry P.A. Palacios I.F. Ta°an M. Roth F.P. Min J. Baumgartner C. Keshishian H. Addona T. Mootha V.K. Rosenzweig A. Carr S.A. Fifer M.A. Sabatine M.S. Gerszten R.E. Metabolite profiling of blood from individuals undergoing planned myocardial infarction reveals early markers of myocardial injury.J. Clin. Investig. 2008; 118: 3503-3512Crossref PubMed Scopus (233) Google Scholar). The most proximal accessible septal branch was instrumented using standard angioplasty guiding catheters and guide wires and 1.5 or 2.0-mm × 9-mm MaverickTM balloon catheters. Radiographic and echocardiographic contrast injections confirmed proper selection of the septal branch and balloon catheter position. Ethanol was infused through the balloon catheter at 1 ml/min. Additional injections in the same or other septal branches were administered as needed, causing cessation of blood flow to the isolated myocardium, and to reduce the gradient in the left ventricular outflow tract caused by the excessive heart muscle to <20 mm Hg (6Baggish A.L. Smith R.N. Palacios I. Vlahakes G.J. Yoerger D.M. Picard M.H. Lowry P.A. Jang I.K. Fifer M.A. Pathological effects of alcohol septal ablation for hypertrophic obstructive cardiomyopathy.Heart. 2006; 92: 1773-1778Crossref PubMed Scopus (43) Google Scholar). Blood was drawn from femoral venous catheters at base line (just prior to the onset of the ablation) and at 10 min, 1 h, 2 h, 4 h, and 24 h following the onset of injury. Samples were collected in K2EDTA-treated tubes (BD Biosciences). All blood samples were centrifuged at 2000 × g for 10 min to pellet cellular elements within 10 min of sample collection. The supernatant plasma was then aliquoted and immediately frozen at −80 °C to minimize freeze-thaw degradation. Additional blood samples were sent to the clinical chemistry laboratory for evaluation of the standard cardiac markers creatine kinase, creatine kinase MB, and troponin T (Roche Diagnostics). For this study, only plasma sampled at base line and 4 and 24 h postinjury was analyzed by the targeted LC-MS/MS-based approach. Supplemental Table 1 lists the protein targets and their "signature peptides" for which final MRM assays were configured. Signature peptides have both high responses in electrospray LC-MS/MS and are sequence-unique when searched against a non-redundant human protein database (NCBInr). Signature peptides were identified for each protein by tryptic digest of the protein standards and analysis of the resulting peptides on a LTQ ion trap mass spectrometer as described previously (Fig. 1A) (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar). C-reactive protein, sCD40L, myeloperoxidase, cardiac troponin T, and cardiac troponin I were purchased from EMD Chemicals Inc. (San Diego, CA); BNP and NT-proBNP were purchased from United States Biological (Swampscott, MA); and IL-33 was a kind gift from Dr. Richard Lee (Brigham and Women's Hospital, Boston, MA). Peptides for MRP14 were chosen based on previous knowledge. The detailed criteria for selection of peptides for synthesis and ultimately for assay configuration were described previously (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar). Stable isotope-labeled amino acids, [13C6]leucine (98.4 atom % isotopic enrichment), [13C6]isoleucine, and [13C5]valine (98 atom % isotopic enrichment) were purchased from Cambridge Isotope Laboratories (Andover, MA). Twenty-seven peptides derived from the target proteins were synthesized with a single, uniformly labeled [13C6]leucine, [13C6]isoleucine, or [13C5]valine using standard Fmoc (N-(9-fluorenyl)methoxycarbonyl) chemistry (Massachusetts Institute of Technology, Cambridge, MA). Unlabeled 12C forms of each peptide were synthesized by GL Biochem. For methionine-containing peptides derived from cardiac troponin T, NT-proBNP, and BNP-32, the sulfoxide forms of the same sequence were synthesized to account for this modification during sample processing. Synthetic peptides were purified to >90% purity and analyzed by amino acid analysis (Dana-Farber Cancer Institute, Boston, MA). Calculations of concentration were based upon the amino acid analysis. Plasma from all patients and time points was processed as described previously (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar) (Fig. 1C). Briefly volumes of 0.8–1.2 ml of plasma per time point per patient were depleted of 12 high abundance proteins using an IgY-12 high capacity LC10 column (12.7 × 79 mm; GenWay Biotech, San Diego, CA) according to the manufacturer's instructions. Depleted plasma was concentrated to the original starting volume via Vivaspin 15R concentrators (5000 molecular weight cutoff; Vivascience, Hannover, Germany). Protein concentration of depleted, concentrated plasma was determined by Coomassie Plus Bradford assay (Pierce) and was 4.5 ± 1.1 mg/ml. 100 µl of depleted patient plasma was denatured with 6 m urea, 10 mm Tris, pH 8.0; reduced with 20 mm dithiothreitol at 37 °C for 30 min; and alkylated with 50 mm iodoacetamide at room temperature in the dark for 30 min. Urea concentration was diluted 10-fold with water prior to overnight digestion at 37 °C with porcine trypsin (sequencing grade modified; Promega, Madison, WI) using a 1:50 (w/w) enzyme to substrate ratio. Digests were terminated with formic acid to a final concentration of 1% and desalted using Oasis HLB 1cc (30 mg) reversed phase cartridges (Waters) as described previously (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar). Eluates were frozen, dried to dryness via vacuum centrifugation, and stored at −80 °C. Digested plasma samples from each patient and time point were normalized to total protein amount such that ∼350 µg of total protein was injected per patient per time point. Each sample was processed in duplicate. Detailed methods for SCX fractionation can be found in Keshishian et al. (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar). Briefly the fractionation was done on an Agilent 1100 capillary LC system (Agilent Technologies, Palo Alto, CA) using a BioBasic 1 × 250-mm column (ThermoFisher, San Jose, CA) at a flow rate of 50 µl/min and mobile phases that consisted of 5 mm potassium phosphate in 25% acetonitrile, pH 3.0 (A) and 500 mm potassium chloride in 5 mm potassium phosphate, 25% acetonitrile, pH 3.0 (B). After loading the sample onto the column, the mobile phase was held at 1% B for 15 min. Peptides were then separated with a linear gradient of 1–20% B in 20 min, 20–40% B in 10 min, and 40–100% B in 10 min. Fractions were collected every minute, and acetonitrile was removed from collected fractions by vacuum centrifugation. The elution profile of the peptide internal standards was predefined and used to generate seven pools of SCX fractions for MRM analysis per patient per time point (Fig. 1B). Each pool was desalted using Oasis HLB 1cc (10 mg) reversed phase cartridges as described previously (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar) and stored at −80 °C until LC-MRM/MS analysis. To ensure detection of peptides that eluted in or near the void volume of the SCX column (e.g. fractions 1–2), the flow-through was desalted and analyzed by LC-MRM/MS. Pooled SCX fractions were reconstituted in 25 µl of 5% formic acid, 3% acetonitrile and spiked with a mixture of 13C-labeled peptides for a final concentration of 5 fmol/µl. Nano-LC-MRM/MS/MS was performed on a 4000 Q Trap hybrid triple quadrupole/linear ion trap mass spectrometer coupled to a Tempo LC system (Applied Biosystems, Foster City, CA). Chromatography was performed with Solvent A (0.1% formic acid) and Solvent B (90% acetonitrile in 0.1% formic acid). Full loop injection of 1 µl of each sample was done in triplicate on PicoFrit columns (75-µm inner diameter, 10-µm tip opening; New Objective, Woburn, MA) packed in house with 11–12 cm of ReproSil-Pur C18-AQ 3-µm reversed phase resin (Dr. Maisch, GmbH). Sample was eluted at 300 nl/min with a gradient of 3–20% Solvent B for 3 min, 20–55% solvent B for 35 min, and 55–80% solvent B for 3 min. Data were acquired with an ion spray voltage of 2200 V, curtain gas of 20 p.s.i., nebulizer gas of 3 p.s.i., and an interface heater temperature of 150 °C. Collision energy (7Lakkis N.M. Nagueh S.F. Kleiman N.S. Killip D. He Z.X. Verani M.S. Roberts R. Spencer 3rd, W.H. Echocardiography-guided ethanol septal reduction for hypertrophic obstructive cardiomyopathy.Circulation. 1998; 98: 1750-1755Crossref PubMed Scopus (213) Google Scholar), declustering potential and collision cell exit potential were optimized for maximum transmission and sensitivity of each MRM transition with infusion of each peptide standard and the Quantification Optimization function provided in Analyst (Fig. 1B). Identical declustering potential, collision energy, and collision cell exit potential values were used for each 12C/13C pair. A dwell time of 10–75 ms was used for different SCX fraction pools based upon the number of peptides and transitions monitored in that pool. In all experiments cycle times did not exceed 1 s, and a minimum of five to six data points were collected per peak. Three MRM transitions per peptide (supplemental Table 1) were monitored and acquired at unit resolution both in the first and third quadrupoles (Q1 and Q3) to maximize specificity. In general, transitions were chosen based upon relative abundance and m/z greater than the precursor m/z in the full-scan MS/MS spectrum recorded on the 4000 Q Trap mass spectrometer. The final MRM method included 162 optimized MRMs for nine target proteins. These MRMs were distributed among seven SCX fractions in accordance with the elution profile of the synthetic peptides. Data analysis was performed using MultiQuantTM software (AB/MDS Sciex, Foster City, CA). The relative ratios of the three transitions selected and optimized for the final MRM assay were predefined in the absence of plasma (i.e. in buffer) for each peptide using the 13C internal standards (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar). The most abundant transition for each pair was used for quantification unless interference from the matrix was observed. In these cases, another transition free of interference was chosen for quantification. 12C/13C peak area ratios were used to calculate concentrations of target proteins in plasma by the following equation: Measured concentration = (Peak area ratio)(5 fmol/µl internal standard)(Protein molecular weight)(Analysis volume)/(Process volume)/1000 (see above). Intra-assay imprecision (CV) for each peptide was based on the calculated average protein concentration for a set of triplicate injections. Interassay CV was calculated for each peptide from two process replicates per time point per patient. All data are summarized in supplemental Table 2. The limit of detection (LOD) and LOQ for each signature peptide derived from the target proteins were determined in SCX matrix by the method of standard addition. Female plasma from a healthy donor was immunoaffinity-depleted, digested, and SCX-fractionated to generate SCX-fractionated plasma pools. Response curves ranging from 0.1 to 10 fmol/µl were generated for each 12C-peptide by spiking them into corresponding SCX pools. Labeled internal standard peptides were spiked in at a constant concentration of 5 fmol/µl prior to LC-MRM/MS. This concentration range is equivalent to 5–800 ng/ml of corresponding target proteins. For this study a modification of the Linnet and Kondratovich (8Linnet K. Kondratovich M. Partly nonparametric approach for determining the limit of detection.Clin. Chem. 2004; 50: 732-740Crossref PubMed Scopus (73) Google Scholar) method was used for calculating LOD. The LOD was based on the variance of the blank sample and the variance of the lowest level spike-in sample. Assuming a type I error rate α = 0.05 for deciding that the analyte is present when it is not and a type II error rate β = 0.05 for not detecting the analyte when it is present, the LOD was derived as follows.LOD=LOB+cβ×S.D.s(Eq. 1) The limit of blank (LOB) was defined as the 95th percentile of the blank samples. This was estimated as meanb + t1 − α × S.D.b where meanb and S.D.b are the mean and standard deviation of the blank sample, and S.D.s is the standard deviation of the low level spike. For a relatively small number of repeated measurements for the blank, cβ was approximated as t1 − β. t1 − α and t1 − β are the (1 − α) and (1 − β) percentile, respectively, of the standard t distribution on (n − 1) degrees of freedom where the blank and low level spike samples have n = 3 replicate measurements. In this study, the LOD for the sample is obtained from the three replications as measured by the best transition. When three values are averaged to obtain the final measurement, the LOD calculation requires the S.D. estimates to be divided by [rad]3[/rad] = 1.73. Because α = β = 0.05, the LOD equation becomes Equation 2.LOD=meanb+t0.95×(S.D.b+S.D.s)/n(Eq. 2) Once the LOD was determined separately for each transition of each peptide, the LOQ was calculated using the customary relation: LOQ = 3 × LOD (9Currie L.A. Limits for qualitative detection and quantitative determination.Anal. Chem. 1968; 40: 586-593Crossref Scopus (3626) Google Scholar). Depending on the LC-MS matrix in which the analyte is measured, an endogenous non-zero analyte level may exist even in the blank sample for some of the peptides under consideration. This endogenous level of an analyte was estimated by using the linear part of the concentration curve. A robust linear fit using least median squares regression (10Venables W.N. Ripley B.D. Venables W.N. Modern Applied Statistics with S. 4th Ed. Springer, New York2002Crossref Google Scholar) was performed. The 99% confidence interval of the regression line intercept was calculated using bootstrap estimation (11Davison A.C. Hinkley D.V. Bootstrap Methods and Their Application. Cambridge University Press, Cambridge, UK1997Crossref Google Scholar). If the lower limit of the confidence interval is positive, then the analyte is deemed to have an endogenous level equal to the regression intercept. If the lower 99% confidence interval is zero or negative, there is no expected endogenous level for that analyte. Plasma concentrations of CRP, MPO, MRP14, NT-proBNP, and cTnT for patients 1–3 before and after immunoaffinity depletion were determined by immunoassay at the Department of Laboratory Medicine at Children's Hospital (Boston, MA). Samples were analyzed by the following kits or systems: CRP, DiaSorin; MPO, Alpco; MRP14, Peninsula; NT-proBNP, Cobas, Roche Diagnostics; and cTnT, Elecsys TnT. Fig. 1 illustrates the strategy used for sample processing and assay configuration. Peptides derived from the target proteins (supplemental Table 1) were selected based upon experimental data obtained by tryptic digestion of standard protein and subsequent analysis by LC-MS/MS (Fig. 1A). Two to five peptides per protein were selected based upon criteria described previously (3Keshishian H. Addona T. Burgess M. Kuhn E. Carr S.A. Quantitative, multiplexed assays for low abundance proteins in plasma by targeted mass spectrometry and stable isotope dilution.Mol. Cell. Proteomics. 2007; 6: 2212-2229Abstract Full Text Full Text PDF PubMed Scopus (575) Google Scholar) and synthesized both in 12C and 13C forms. Assay configuration was conducted to optimize the SCX peptide separation and MS instrument parameters to maximize detection of the target peptides (Fig. 1B). For peptide fractionation via SCX, the elution profile of all signature peptides was evaluated to determine the pooling strategy for patient samples. For MRM acquisition, three transitions per peptide were selected and monitored to achieve maximum selectivity and sensitivity in the MRM assay. Peptides that were synthesized but that did not make the final MRM assay after optimization were dropped because of poor electrospray response or poor chromatographic behavior by reversed phase. The final MRM assay included two to four peptides per protein (supplemental Table 1). Fig. 1C shows the final limited fractionation/MRM assay in which patient plasma was depleted of high abundance plasma proteins before reduction, alkylation, and tryptic digestion. Peptides were minimally fractioned by SCX, pooled according to a predefined elution profile, and analyzed by LC-MRM/MS following addition of heavy labeled internal peptide standards. Three technical replicates were performed for each fraction, and two process replicates were performed across all patients and time points. 12C-Peptides derived from each of the target proteins were added to SCX-fractionated plasma from a healthy donor to determine the LOD and LOQ for each peptide as described under "Materials and Methods." Response curves for all peptides are shown in supplemental Fig. 1. For seven of nine proteins, at least one signature peptide derived from the target protein had an LOD in plasma that ranged from 0.052 (cTnT) to 0.287 fmol/µl (MPO) and an LOQ in plasma that ranged from 0.157 to 0.862 fmol/µl (Table I). These molar concentrations are equivalent to 0.9–24 and 5–72 ng/ml target protein for LOD and LOQ, respectively. Values for LOD and LOQ listed in Table I for CRP and MRP14 reflect endogenous levels of these prote