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J Thorac Cardiovasc Surg 2003;126:807-813
© 2003 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Prognostic significance of elevated creatine kinase MB after coronary bypass surgery and after an acute coronary syndrome: results from the GUARDIAN trial

Jeffrey A. Gavard, PhDa, Bernard R. Chaitman, MD, FACCa,*, Shunta Sakai, MDa, Karen Stocke, MBAa, Nicolas Danchin, MD, FACCb, Leif Erhardt, MDc, Richard Gallo, MD, FACCd, Eric Chi, PhDe, Andreas Jessel, MDe, Pierre Théroux, MD, FACCd GUARd During Ischemia Against Necrosis (GUARDIAN) Investigators*

a St Louis University School of Medicine, St Louis, Mo, USA
b Hôpital Européen Georges Pompidou, Paris, France
c Malmoc University Hospital, Malmö, Sweden
d Montreal Heart Institute, Montreal, Quebec, Canada
e Aventis Pharmaceuticals, Inc, Bridgewater, NJ, USA.

Received for publication January 7, 2003; revisions received February 11, 2003; revisions received March 5, 2003; accepted for publication April 24, 2003.

* Address for reprints: Bernard R. Chaitman, MD, St Louis University School of Medicine, Division of Cardiology (15th Floor), 3635 Vista Avenue at Grand Blvd, PO Box 15250, St Louis, MO 63110-0250, USA
chaitman{at}slu.edu

OBJECTIVE: To determine if the correlation between magnitude of creatine kinase-myocardial band release after coronary artery bypass surgery and 6-month mortality is comparable to that of patients admitted with an acute coronary syndrome.

METHODS: The GUARDIAN trial tested the efficacy of cariporide, an Na+/H+ exchange inhibitor, on reduction of myocardial ischemia or death in high-risk patients. We compared 6-month survival in a cohort of 2332 GUARDIAN patients scheduled for coronary artery bypass surgery at entry with 4233 acute coronary syndrome patients stratified by level of creatine kinase-myocardial band release. Cumulative 6-month survival by creatine kinase-myocardial band categories was performed using life table analysis, adjusting for variables known to impact prognosis using Cox regression.

RESULTS: The 6-month mortality rates for coronary artery bypass surgery patients with peak creatine kinase-myocardial band ratios of <1, >=1 and <5, >=5 and <10, and >=10 upper limits of normal (ULN) were 5.8, 2.8, 5.9, and 12.0%, respectively (P < .0001). The 6-month mortality rates for acute coronary syndrome patients with peak creatine kinase-myocardial band ratios of <1, >=1 and <5, >=5 and <10, and >=10 ULN were 6.3, 9.8, 10.0, and 12.3%, respectively (P < .0001). Patients with coronary artery bypass surgery or acute coronary syndrome had similar adjusted 6-month survival estimates at normal creatine kinase-myocardial band levels and when the creatine kinase-myocardial band level was >=10 ULN. Patients with coronary artery bypass surgery had significantly better survival at intermediate enzyme levels (>=1 and <10 ULN; P < .001).

CONCLUSIONS: Modest elevations of creatine kinase-myocardial band release (>=1 and <10 ULN) after coronary artery bypass surgery are not associated with adverse 6-month survival, in contrast to that seen in acute coronary syndrome patients. Routine creatine kinase-myocardial band sampling should be considered in all higher-risk patients undergoing coronary artery bypass surgery procedures to identify the sizable cohort of patients with creatine kinase-myocardial band release >=10 ULN; these patients may benefit from postoperative angiotensin-converting enzyme inhibitor and beta-blocker therapy. Newer cardioprotective agents that reduce the number of patients with marked creatine kinase-myocardial band release are currently being tested in large randomized controlled clinical trials.




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