Role of Preoperative Biomarkers in Predicting Myocardial Injury and Improving Postoperative Outcomes in Cardiac Surgery
DOI:
https://doi.org/10.70749/ijbr.v3i4.1085Keywords:
Myocardial Injury, Preoperative Biomarkers, CK-MB, Troponin I, NT-proBNP, Risk StratificationAbstract
Background: Preoperative biomarkers serve as crucial indicators of myocardial injury risk in patients undergoing cardiac surgery. Identifying reliable biomarkers can enhance risk stratification, optimize surgical planning, and improve postoperative outcomes. This study evaluates the predictive role of preoperative biomarkers in myocardial injury and their influence on post-surgical recovery. Methodology: A retrospective case-control study was conducted at Mayo Hospital Lahore from February 03, 2023 to August 19, 2023, including 220 patients undergoing cardiac surgery. Patients were classified into cases (with myocardial injury) and controls (without myocardial injury) based on postoperative cardiac enzyme levels. Preoperative biomarkers assessed included Troponin I, CK-MB, NT-proBNP, CRP, and D-dimer. Intraoperative factors (bypass time, cross-clamp duration, blood loss, inotropic support) and postoperative outcomes (ICU stay, hospital stay, complications, mortality) were analyzed as secondary determinants. Statistical tests included independent t-tests and chi-square tests, with a significance threshold of p < 0.05. Results: Preoperative CK-MB levels were significantly higher in the myocardial injury group (15.92 ± 6.84 vs. 11.48 ± 5.23 ng/mL, p < 0.001), along with Troponin I (0.78 ± 0.34 vs. 0.42 ± 0.21 ng/mL, p < 0.001) and NT-proBNP (2651.42 ± 875.32 vs. 1987.64 ± 720.18 pg/mL, p = 0.002). CRP and D-dimer levels were also elevated in cases compared to controls (p = 0.008 and p = 0.014, respectively), confirming their role in predicting myocardial injury. While intraoperative factors were not independent predictors, longer bypass time (p = 0.027), cross-clamp duration (p = 0.015), and inotropic support requirement (p = 0.012) were significantly associated with myocardial injury when adjusted for preoperative biomarker levels. Postoperatively, the myocardial injury group experienced a longer ICU stay (8.4 ± 3.7 vs. 6.1 ± 2.8 days, p = 0.011), extended hospital stay (17.9 ± 6.5 vs. 14.2 ± 5.3 days, p = 0.019), and higher mortality (14.5% vs. 5.2%, p = 0.004). Conclusion: Elevated preoperative levels of CK-MB, Troponin I, NT-proBNP, CRP, and D-dimer were significant predictors of myocardial injury following cardiac surgery. Secondary intraoperative and postoperative factors were influenced by preoperative biomarker levels, underscoring their vital role in risk stratification. Routine biomarker assessment should be integrated into preoperative screening protocols to enhance patient outcomes. Further prospective studies are recommended to validate these findings.
Downloads
References
Karthikeyan, G., Moncur, R. A., Levine, O., Heels-Ansdell, D., Chan, M. T., Alonso-Coello, P., Yusuf, S., Sessler, D., Villar, J. C., Berwanger, O., McQueen, M., Mathew, A., Hill, S., Gibson, S., Berry, C., Yeh, H., & Devereaux, P. (2009). Is a pre-operative brain Natriuretic peptide or N-terminal pro–b-type Natriuretic peptide measurement an independent predictor of adverse cardiovascular outcomes within 30 days of Noncardiac surgery? Journal of the American College of Cardiology, 54(17), 1599-1606. https://doi.org/10.1016/j.jacc.2009.06.028
Devereaux, P., Goldman, L., Cook, D. J., Gilbert, K., Leslie, K., & Guyatt, G. H. (2005). Perioperative cardiac events in patients undergoing noncardiac surgery: A review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. Canadian Medical Association Journal, 173(6), 627-634. https://doi.org/10.1503/cmaj.050011
Puelacher, C., Lurati Buse, G., Seeberger, D., Sazgary, L., Marbot, S., Lampart, A., Espinola, J., Kindler, C., Hammerer, A., Seeberger, E., Strebel, I., Wildi, K., Twerenbold, R., Du Fay de Lavallaz, J., Steiner, L., Gurke, L., Breidthardt, T., Rentsch, K., Buser, A., … Buser, A. (2018). Perioperative myocardial injury after Noncardiac surgery. Circulation, 137(12), 1221-1232. https://doi.org/10.1161/circulationaha.117.030114
Devereaux, P. J., Chan, M. T., Alonso-Coello, P., Walsh, M., Berwanger, O., Villar, J. C., ... & Undok, A. (2012). Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery (Journal of the American Medical Association (2012) 307, 21 (2295-2304)). Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery (Journal of the American Medical Association (2012) 307, 21 (2295-2304)), 307(24), 2590. https://doi.org/10.1001/JAMA.2012.6832
Lurati Buse G, Koller MT, Steiner LA, Puelacher C, Grapow M, Korte W, et al. Perioperative troponin T and mortality after elective noncardiac surgery: a cohort study. Anesthesiology. 2011;114(3):574-82.
Fleisher, L. A., Fleischmann, K. E., Auerbach, A. D., Barnason, S. A., Beckman, J. A., Bozkurt, B., Davila-Roman, V. G., Gerhard-Herman, M. D., Holly, T. A., Kane, G. C., Marine, J. E., Nelson, M. T., Spencer, C. C., Thompson, A., Ting, H. H., Uretsky, B. F., & Wijeysundera, D. N. (2014). 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing Noncardiac surgery. Circulation, 130(24). https://doi.org/10.1161/cir.0000000000000106
Wijeysundera DN, Beattie WS, Austin PC, Hux JE, Laupacis A. Non-cardiac surgery in patients with ischemic heart disease: risk prediction and therapeutic implications. Anesthesiology. 2002;97(4):842-52.
Botto, F., Alonso-Coello, P., Chan, M. T., Villar, J. C., Xavier, D., Srinathan, S., ... & Dhanpal, R. (2014). Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology, 120(3), 564-578. https://air.unimi.it/handle/2434/662644
Lindenauer, P. K., Pekow, P., Wang, K., Mamidi, D. K., Gutierrez, B., & Benjamin, E. M. (2005). Perioperative beta-blocker therapy and mortality after major Noncardiac surgery. New England Journal of Medicine, 353(4), 349-361. https://doi.org/10.1056/nejmoa041895
Feringa, H. H., van Waning, V. H., Bax, J. J., Elhendy, A., Boersma, E., Schouten, O., ... & Poldermans, D. (2006). Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease. Journal of the American College of Cardiology, 47(6), 1182-1187. https://www.jacc.org/doi/abs/10.1016/j.jacc.2005.09.074
Mangano, D. T., Layug, E. L., Wallace, A., & Tateo, I. (1996). Effect of Atenolol on mortality and cardiovascular morbidity after Noncardiac surgery. New England Journal of Medicine, 335(23), 1713-1721. https://doi.org/10.1056/nejm199612053352301
Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, et al. (2008). Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): A randomised controlled trial. (2008). The Lancet, 371(9627), 1839-1847. https://doi.org/10.1016/s0140-6736(08)60601-7
Fleischmann, K. E., Beckman, J. A., Buller, C. E., Calkins, H., Fleisher, L. A., Freeman, W. K., Froehlich, J. B., Kasper, E. K., Kersten, J. R., Robb, J. F., & Valentine, R. J. (2009). 2009 ACCF/AHA focused update on perioperative beta blockade. Circulation, 120(21), 2123-2151. https://doi.org/10.1161/circulationaha.109.192689
Lindenauer, P. K. (2004). Lipid-lowering therapy and in-hospital mortality following major Noncardiac surgery. JAMA, 291(17), 2092. https://doi.org/10.1001/jama.291.17.2092
Poldermans D, Schouten O, Kertai MD, Bax JJ, Thomson IR, Hoeks S, et al. Perioperative statin therapy protects against myocardial infarction in patients undergoing major vascular surgery. Circulation. 2003;108(15):1779-84.
Berwanger, O., Le Manach, Y., Suzumura, E. A., Biccard, B., Srinathan, S. K., Szczeklik, W., ... & Devereaux, P. J. (2016). Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. European heart journal, 37(2), 177-185. https://doi.org/10.1093/eurheartj/ehv456
Devereaux, P. J., Mrkobrada, M., Sessler, D. I., Leslie, K., Alonso-Coello, P., Kurz, A., ... & Yusuf, S. (2014). Aspirin in patients undergoing noncardiac surgery. New England Journal of Medicine, 370(16), 1494-1503. https://www.nejm.org/doi/full/10.1056/NEJMoa1401105
Graham, M. M., Sessler, D. I., Parlow, J. L., Biccard, B. M., Guyatt, G., Leslie, K., ... & Devereaux, P. J. (2018). Aspirin in patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Annals of internal medicine, 168(4), 237-244. https://doi.org/10.7326/M17-2341
Oscarsson, A., Gupta, A., Fredrikson, M., Järhult, J., Nyström, M., Pettersson, E., Darvish, B., Krook, H., Swahn, E., & Eintrei, C. (2010). To continue or discontinue aspirin in the perioperative period: A randomized, controlled clinical trial. British Journal of Anaesthesia, 104(3), 305-312. https://doi.org/10.1093/bja/aeq003
Devereaux, P. J., Sessler, D. I., Leslie, K., Kurz, A., Mrkobrada, M., Alonso-Coello, P., ... & Yusuf, S. (2014). Clonidine in patients undergoing noncardiac surgery. New England Journal of Medicine, 370(16), 1504-1513. https://www.nejm.org/doi/full/10.1056/NEJMoa1401106
Devereaux, P. J., Sessler, D. I., Leslie, K., Kurz, A., Mrkobrada, M., Alonso-Coello, P., ... & Yusuf, S. (2014). Clonidine in patients undergoing noncardiac surgery. New England Journal of Medicine, 370(16), 1504-1513. https://www.nejm.org/doi/full/10.1056/NEJMoa1401106
Wijeysundera, D., Austin, P., Beattie, W., Hux, J., & Laupacis, A. (2012). Variation in the practice of preoperative medical consultation for major elective Noncardiac surgery. Anesthesiology, 116(1), 25-34. https://doi.org/10.1097/aln.0b013e31823cfc03
Biccard, B. M., & Rodseth, R. N. (2009). A meta‐analysis of the prospective randomised trials of coronary revascularisation before noncardiac vascular surgery with attention to the type of coronary revascularisation performed. Anaesthesia, 64(10), 1105-1113. https://doi.org/10.1111/j.1365-2044.2009.06010.x
Poldermans, D., Boersma, E., Bax, J. J., Thomson, I. R., Van de Ven, L. L., Blankensteijn, J. D., Baars, H. F., Yo, T., Trocino, G., Vigna, C., Roelandt, J. R., Fioretti, P. M., Paelinck, B., & Van Urk, H. (1999). The effect of Bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. New England Journal of Medicine, 341(24), 1789-1794. https://doi.org/10.1056/nejm199912093412402
Ladapo, J. A., Jaffer, F. A., Hoffmann, U., Thomson, C. C., Bamberg, F., Dec, W., Cutler, D. M., Weinstein, M. C., & Gazelle, G. S. (2009). Clinical outcomes and cost-effectiveness of coronary computed tomography angiography in the evaluation of patients with chest pain. Journal of the American College of Cardiology, 54(25), 2409-2422. https://doi.org/10.1016/j.jacc.2009.10.012
Landesberg, G., & Mosseri, M. (2008). PRO: Preoperative coronary Revascularization in high-risk patients undergoing vascular surgery. Anesthesia & Analgesia, 106(3), 759-763. https://doi.org/10.1213/ane.0b013e3181685054
Badner, N., Knill, R., Brown, J., Novick, T., & Gelb, A. (1998). Myocardial infarction after Noncardiac surgery. Anesthesiology, 88(3), 572-578. https://doi.org/10.1097/00000542-199803000-00005
Kristensen, S. D., & Knuuti, J. (2014). New ESC/ESA guidelines on non-cardiac surgery: Cardiovascular assessment and management. European Heart Journal, 35(35), 2344-2345. https://doi.org/10.1093/eurheartj/ehu285
Landesberg, G., Beattie, W. S., Mosseri, M., Jaffe, A. S., & Alpert, J. S. (2009). Perioperative myocardial infarction. Circulation, 119(22), 2936-2944. https://doi.org/10.1161/circulationaha.108.828228
Botto, F., Alonso-Coello, P., Chan, M. T., Villar, J. C., Xavier, D., Srinathan, S., ... & Dhanpal, R. (2014). Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology, 120(3), 564-578. https://dx.doi.org/10.1097/ALN.0000000000000113
Fleisher, L. A. (2016). Preoperative assessment of the patient with cardiac disease undergoing noncardiac surgery. Anesthesiology clinics, 34(1), 59-70. https://www.anesthesiology.theclinics.com/article/S1932-2275(15)00110-X/abstract
Garcia S, Canoniero M, Young L, Curtis AB. (2012). Predictors of perioperative complications and mortality in patients with heart failure undergoing surgery: a systematic review. Congest Heart Fail, 18(3):103-8.
Lee, T. H., Marcantonio, E. R., Mangione, C. M., Thomas, E. J., Polanczyk, C. A., Cook, E. F., Sugarbaker, D. J., Donaldson, M. C., Poss, R., Ho, K. K., Ludwig, L. E., Pedan, A., & Goldman, L. (1999). Derivation and prospective validation of a simple index for prediction of cardiac risk of major Noncardiac surgery. Circulation, 100(10), 1043-1049. https://doi.org/10.1161/01.cir.100.10.1043
Puelacher, C., Lurati Buse, G., Seeberger, D., Sazgary, L., Marbot, S., Lampart, A., Espinola, J., Kindler, C., Hammerer, A., Seeberger, E., Strebel, I., Wildi, K., Twerenbold, R., Du Fay de Lavallaz, J., Steiner, L., Gurke, L., Breidthardt, T., Rentsch, K., Buser, A., … Buser, A. (2018). Perioperative myocardial injury after Noncardiac surgery. Circulation, 137(12), 1221-1232. https://doi.org/10.1161/circulationaha.117.030114
Levy, M., Heels-Ansdell, D., Hiralal, R., Bhandari, M., Guyatt, G., Yusuf, S., Cook, D., Villar, J. C., McQueen, M., McFalls, E., Filipovic, M., Schünemann, H., Sear, J., Foex, P., Lim, W., Landesberg, G., Godet, G., Poldermans, D., Bursi, F., … Devereaux, P. J. (2011). Prognostic value of troponin and creatine kinase muscle and brain Isoenzyme measurement after Noncardiac surgery. Anesthesiology, 114(4), 796-806. https://doi.org/10.1097/aln.0b013e31820ad503
Jaffer FA, O'Donnell TF, Larson MG, Aranson E, Creager MA, Thiele GM, et al. (2013). High-sensitivity troponin T and B-type natriuretic peptide are associated with perioperative myocardial infarction and mortality in vascular surgery. J Am Coll Cardiol, 61(17), 1855-64.
Ashton, C. M., Petersen, N. J., Wray, N. P., Kiefe, C. I., Dunn, J. K., Wu, L., & Thomas, J. M. (1993). The incidence of perioperative myocardial infarction in men undergoing Noncardiac surgery. Annals of Internal Medicine, 118(7), 504-510. https://doi.org/10.7326/0003-4819-118-7-199304010-00004
Noordzij, P. G., Poldermans, D., Schouten, O., Bax, J. J., Schreiner, F. A., & Boersma, E. (2010). Postoperative mortality in The Netherlands. Anesthesiology, 112(5), 1105-1115. https://doi.org/10.1097/aln.0b013e3181d5f95c
Spence J, Belley-Côté EP, Moodley P, Devereaux PJ. (2019). Cardiovascular disease in perioperative medicine. J Am Coll Cardiol, 73(3), 293-310.
Landesberg, G., Luria, M., Cotev, S., Eidelman, L., Anner, H., Mosseri, M., Schechter, D., Assaf, J., Erel, J., & Berlatzky, Y. (1993). Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery. The Lancet, 341(8847), 715-719. https://doi.org/10.1016/0140-6736(93)90486-z
Biccard BM, Scott DJ, Chan MT. (2018). Myocardial injury after noncardiac surgery: evidence-based clinical implications and perspectives. Anesth Analg. 127(6), 1400-13.
Hess PE, Boersma E, Poldermans D. Cardiac risk index and postoperative cardiac complications: a systematic review. J Am Coll Cardiol. 2006;48(7):1527-32.
van Waes JA, Nathoe HM, de Graaff JC, Kemperman H, de Borst GJ, Peelen LM, et al. Myocardial injury after noncardiac surgery and the association with short-term and long-term mortality. Anesthesiology. 2013;118(4):890-902.Howard-Alpe GM, de Bono J, Hudsmith L, Orr WP, Foëx P, Sear JW. Coronary artery disease and coronary artery bypass grafting surgery. Br J Anaesth. 2006;97(1):1-9.
Chassot, P. G., Marcucci, C., & Spahn, D. R. (2007). Urgent or Semiurgent Surgery in Patients with Severe Coronary Artery Disease. In Heart Disease and the Surgical Patient (pp. 317-346). CRC Press. https://www.taylorfrancis.com/chapters/edit/10.3109/9781420014099-18/urgent-semiurgent-surgery-patients-severe-coronary-artery-disease-pierre-guy-chassot-carlo-marcucci-donat-spahn
Devereaux, P. J., Chan, M. T., Alonso-Coello, P., Walsh, M., Berwanger, O., Villar, J. C., ... & Undok, A. (2012). Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery (Journal of the American Medical Association (2012) 307, 21 (2295-2304)). Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery (Journal of the American Medical Association (2012) 307, 21 (2295-2304)), 307(24), 2590. https://doi.org/10.1001/JAMA.2012.6832
Sear, J. W., Giles, J. W., Howard-Alpe, G., & Foex, P. (2008). Perioperative beta-blockade, 2008: what does POISE tell us, and was our earlier caution justified?. British journal of anaesthesia, 101(2), 135-138. https://doi.org/10.1093/bja/aen194
Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, De Hert S, et al. Perioperative cardiovascular risk assessment and management in non-cardiac surgery: 2014 ESC/ESA guidelines. Eur Heart J. 2014;35(35):2383-431. https://doi.org/10.1093/eurheartj/ehu282
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Indus Journal of Bioscience Research
This work is licensed under a Creative Commons Attribution 4.0 International License.
