title: 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.
abstract: OBJECTIVE
  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, > or = 5 to <10, > or =10 to < 20 and > or =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.
authors.affiliation: St. Louis University Health Sciences Center, St. Louis, Missouri 63110-0250, USA.
authors.forename: K
authors.initials: K
authors.lastname: Klatte
authors.forename: B R
authors.initials: BR
authors.lastname: Chaitman
authors.forename: P
authors.initials: P
authors.lastname: Theroux
authors.forename: J A
authors.initials: JA
authors.lastname: Gavard
authors.forename: K
authors.initials: K
authors.lastname: Stocke
authors.forename: S
authors.initials: S
authors.lastname: Boyce
authors.forename: C
authors.initials: C
authors.lastname: Bartels
authors.forename: B
authors.initials: B
authors.lastname: Keller
authors.forename: A
authors.initials: A
authors.lastname: Jessel
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000401:mortality*; D003327:Coronary Disease / Q000201:enzymology* / Q000401:mortality*; D003402:Creatine Kinase / Q000378:metabolism*; D052279:Creatine Kinase, MB Form; D004562:Electrocardiography; D005260:Female; D006801:Humans; D007527:Isoenzymes / Q000378:metabolism*; D016015:Logistic Models; D008297:Male; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000201:enzymology; D011184:Postoperative Period; D012372:ROC Curve; D016032:Randomized Controlled Trials as Topic
chemical_list: D007527:Isoenzymes; D003402:Creatine Kinase; D052279:Creatine Kinase, MB Form