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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

^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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