CLINICAL STUDY
Increased mortality after coronary artery bypass graft surgery is associated with increased levels of postoperative creatine kinase-myocardial band isoenzyme release
Results from the GUARDIAN trial
Karen Klatte, MD*,
Bernard R. Chaitman, MD, FACC*,2,
Pierre Theroux, MD, FACC ,2,
Jeffrey A. Gavard, PhD*,
Karen Stocke, MBA*,
Steven Boyce, MD, FACC ,2,
Claus Bartels, MD ,2,
Birgit Keller, MS||,2,
Andreas Jessel, MD||,2 for the GUARDIAN Investigators1
* St. Louis University Health Sciences Center, St. Louis, Missouri, USA
Montreal Heart Institute, Montreal, Quebec, Canada
Washington Heart Center, Washington, DC, USA
Med. Universitatsklinik, Herzchirurgische Klinik, Luebeck, Germany
|| Aventis Pharmaceuticals, Inc., Bridgewater, New Jersey, USA
Manuscript received February 9, 2001;
revised manuscript received May 29, 2001,
accepted June 15, 2001.
Reprint requests and correspondence: Dr. Bernard R. Chaitman, St. Louis University Health Sciences Center, Division of Cardiology (15th Floor), 3635 Vista Avenue at Grand Boulevard, P.O. Box 15250, St. Louis, Missouri 63110-0250
chaitman{at}slu.edu
OBJECTIVES
We sought to determine if elevated cardiac serum biomarkers after coronary artery bypass graft surgery (CABG) are associated with increased medium-term mortality and to identify patients that may benefit from better postoperative myocardial protection.
BACKGROUND
The relationship between the magnitude of cardiac serum protein elevation and subsequent mortality after CABG is not well defined, partly because of the lack of large, prospectively studied patient cohorts in whom postoperative elevations of cardiac serum markers have been correlated to medium- and long-term mortality.
METHODS
The GUARD during Ischemia Against Necrosis (GUARDIAN) study enrolled 2,918 patients assigned to the entry category of CABG and considered as high risk for myocardial necrosis. Creatine kinase-myocardial band (CK-MB) isoenzyme measurements were obtained at baseline and at 8, 12, 16 and 24 h after CABG.
RESULTS
The unadjusted six-month mortality rates were 3.4%, 5.8%, 7.8% and 20.2% for patients with a postoperative peak CK-MB ratio (peak CK-MB value/upper limits of normal [ULN] for laboratory test) of <5,  5 to <10, 10 to <20 and 20 ULN, respectively (p < 0.0001). The relationship remained statistically significant after adjustment for ejection fraction, congestive heart failure, cerebrovascular disease, peripheral vascular disease, cardiac arrhythmias and the method of cardioplegia delivery. Receiver operating characteristic curve analysis revealed an area under the curve of 0.648 (p < 0.001); the optimal cut-point to predict six-month mortality ranged from 5 to 10 ULN.
CONCLUSIONS
Progressive elevation of the CK-MB ratio in clinically high-risk patients is associated with significant elevations of medium-term mortality after CABG. Strategies to afford myocardial protection both during CABG and in the postoperative phase may serve to improve the clinical outcome.
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Abbreviations and Acronyms
| | AUC | = area under the curve | | CABG | = coronary artery bypass graft surgery | | CK-MB | = creatine kinase-myocardial band | | ECG | = electrocardiogram or electrocardiographic | | GUARDIAN | = GUARD during Ischemia Against Necrosis | | MI | = myocardial infarction | | PTCA | = percutaneous transluminal coronary angioplasty | | ROC | = receiver operating characteristic | | ULN | = upper limits of normal |
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