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Published on: January 28, 2020
Cardiac Biomarker Kinetics in Patients after Coronary Artery Bypass Grafting with an Uncomplicated Course
Ellen J S Denessen1,2, Brian Swinnen2,3,4, Sacha K Lamers1,2
1Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, the Netherlands.
Insights
Biomarker levels after coronary artery bypass grafting (CABG) often exceed current thresholds for periprocedural myocardial infarction (PMI). These findings suggest current diagnostic cutoffs for PMI may need reevaluation in CABG patients.
Area of Science:
- Cardiology
- Biomarker Research
- Cardiac Surgery
Background:
- The definition and diagnostic criteria for periprocedural myocardial infarction (PMI) following coronary artery bypass grafting (CABG) are not standardized.
- Current biomarker thresholds, often based on multiples of upper reference limits (URL), may be outdated for assessing PMI after CABG.
- High-sensitivity cardiac troponin T (hs-cTnT), high-sensitivity cardiac troponin I (hs-cTnI), and creatine kinase MB isoform (CK-MB) are key biomarkers in this context.
Purpose of the Study:
- To investigate the postoperative kinetics of hs-cTnT, hs-cTnI, and CK-MB in patients undergoing CABG.
- To evaluate whether current diagnostic cutoffs for PMI are exceeded in patients with an uncomplicated CABG course.
- To explore variations in biomarker levels based on surgical approach and cardioplegia regimens.
Main Methods:
- Prospective inclusion of patients undergoing isolated on-pump CABG and minimally invasive direct CABG (MIDCAB).
- Serial blood collection preoperatively and postoperatively at intensive care unit (ICU) arrival, 5 and 8 hours subsequently, and on postoperative days 1 and 3.
- Measurement of hs-cTnT, hs-cTnI, and CK-MB, with normalization to upper reference limits (URL) based on package inserts or the Universal Sample Bank.
Main Results:
- On-pump CABG patients exhibited peak hs-cTnT levels of 44× URL, hs-cTnI of 150× URL, and CK-MB of 4.5× URL, 5 hours after ICU arrival.
- These peak biomarker levels, particularly hs-cTnT and hs-cTnI, significantly surpassed commonly used diagnostic thresholds for PMI.
- Minimally invasive direct CABG (MIDCAB) patients showed lower biomarker concentrations compared to on-pump CABG, with significant differences observed between cardioplegia regimens.
Conclusions:
- Postoperative biomarker kinetics in uncomplicated CABG cases indicate that hs-cTnT, hs-cTnI, and CK-MB levels frequently exceed current diagnostic cutoffs for PMI.
- The observed biomarker elevations suggest a need to re-evaluate and potentially update the diagnostic criteria for PMI after CABG.
- Variations in biomarker levels are influenced by the specific high-sensitivity troponin assay used, surgical technique (on-pump vs. MIDCAB), and cardioplegia strategies.
Background:
The definition of periprocedural myocardial infarction (PMI) after coronary artery bypass grafting (CABG) remains debated, particularly regarding the use of cardiac troponins vs creatine kinase MB isoform (CK-MB), and biomarker thresholds seem outdated [10×, 35×, or 70× multiples of upper reference limits (URL)]. We studied high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), and CK-MB, following CABG patients with an emphasis on those with an uncomplicated course.
Methods:
Patients undergoing isolated on-pump CABG and minimally invasive direct CABG (MIDCAB) were prospectively included. Blood was collected preoperatively and then postoperatively at intensive care unit (ICU) arrival, 5 h and 8 h subsequently, and postoperative days 1 and 3. hs-cTnT (Roche), hs-cTnI (Abbott), and CK-MB (Roche) were measured and normalized using URLs according to package inserts or the Universal Sample Bank.
Results:
Sixty-one on-pump CABG and 22 MIDCAB patients were included. On-pump CABG patients showed a median (interquartile range) hs-cTnT peak of 610 (466-879) ng/L, hs-cTnI 3918 (2154-6713) ng/L, and CK-MB 22.0 (14.9-34.8) µg/L 5 h after ICU arrival. When normalized according to package inserts, this corresponds to 44× (33×-63×) URL, 150× (82×-256×) URL, 4.5 × (3.0×-7.1×) URL, respectively. These values slightly differ when sex-specific or other URL definitions are used (P > 0.05). In subgroup analyses, MIDCAB patients had reduced biomarker concentrations, and significant differences were observed between cardioplegia regimens (P < 0.001).
Conclusion:
The postoperative kinetics of hs-cTnT, hs-cTnI, and CK-MB in CABG patients with an uncomplicated course illustrate that hs-cTn, in particular, surpasses current diagnostic cutoffs for PMI. This varies in time, across hs-cTn assays, surgical approaches, and cardioplegia regimens.
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