Markers of perioperative myocardial injury in patients undergoing coronary artery bypass grafting depending on the prehabilitation program

Aim. To evaluate the morphological and functional cardiac parameters and to measure markers of myocardial injury in the perioperative period of patients undergoing coronary artery bypass grafting (CABG), depending on the prehabilitation program.

Methods. 60 male patients with stable coronary artery disease (CAD) underwent screening in the preoperative period and were randomized into two groups. Group 1 (n = 30) underwent supervised treadmill exercises at intensity corresponding to 80% of VO2 peak during the preoperative management. Group 2 (n = 30) patients did not undergo any additional trainings. Patients underwent a standard echocardiographic (ECHO-CG) study in the preoperative period and at days 5-7 after CABG. Serum markers of myocardial injury (troponin I, NT-proBNP) were measured in both groups of patients in the preoperative period before training (measurement 1), at the end of exercise training sessions (measurement 2) and at days 5-7 (measurement 3) after CABG.

Results. ECHO-CG findings reported that left ventricular end-systolic dimension (p = 0.039) and left ventricular end-systolic volume (p = 0.039) increased by 8.5% and 18% in patients who underwent supervised exercise trainings as compared to the baseline values. An increase in these parameters was more pronounced in the control group (17% (p = 0.00029) and 41% (p = 0.00028), respectively). NT-proBNP levels showed a downward trend in patients with prehabilitation at the end of the training sessions, while in the control group NT-proBNP levels increased. An increase in NT-proBNP levels was reliable in patients without exercise trainings (p = 0.003) after CABG compared to the preoperative values, while NT-proBNP levels did not differ significantly in patients who underwent prehabilitation (p>0.05).

Conclusion. The safety of high-intensity exercise trainings in the prehabilitation program for CABG had been confirmed by laboratory markers of myocardial damage. The obtained data proved the efficiency of active prehabilitation for optimizing echocardiographic parameters and inducing cardioprotection.

1. Scheede-Bergdahl C, Minnella EM, Carli F. Multi-modal prehabilitation: addressing the why, when, what, how, who and where next? Anaesthesia. 2019; 74 (S 1): 20-26. doi: 10.1m/anae.14505.

2. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD; ESC Scientific Document Group. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019; 40(3): 237-269. doi: 10.1093/eurheartj/ehy462.

3. Ben-Yehuda O, Chen S, Redfors B, McAndrew T, Crowley A, Kosmidou I, Kandzari DE, Puskas JD, Morice MC, Taggart DP, Leon MB, Lembo NJ, Brown WM, Simonton CA, Dressler O, Kappetein AP, Sabik JF, Serruys PW, Stone GW. Impact of large periprocedural myocardial infarction on mortality after percutaneous coronary intervention and coronary artery bypass grafting for left main disease: an analysis from the EXCEL trial. Eur Heart J. 2019; 40(24) :1930-1941. doi: 10.1093/eurheartj/ehz113.

4. Dhingra R, Vasan RS. Biomarkers in cardiovascular disease: Statistical assessment and section on key novel heart failure biomarkers. Trends Cardiovasc Med. 2017; 27(2): 123-133. doi: 10.1016/j.tcm.2016.07.005.

5. Argunova YA, Korotkevich AA, Pomeshkina SA, Kokov AN, Inozemtseva AA, Barbarash OL. Efficacy of physical trainings as cardioprotection method for coronary bypass surgery. Russian Journal of Cardiology. 2018; (6): 159-165. (In Russ.) doi: 10.15829/1560-4071-2018-6-159-165.

6. Argunova YA, Pomeshkina SA, Inozemtseva AA, Moskin EG, Barbarash OL. Clinical efficiency of prehabilitation program in patients undergoing coronary artery bypass grafting. Complex Issues of Cardiovascular Diseases. 2018; 7(4S): 15-23. (In Russian.) doi: 10.17802/2306-1278-2018-7-4S-15-23.

7. Poltavskaja MG, Mkrtumjan JeA, Svet AV, Doletskiyi AA, Novikova NA, Gilyarov MU.Nagruzochnye proby s gazovym analizom: posobie dlja vrachej obshhej praktiki. M: Moskovskaja medicinskaja akademija imeni I.M. Sechenova, 2009. 40 p. (In Russian).

8. Ferguson B. ACSM’s Guidelines for Exercise Testing and Prescription 9th Ed. 2014.The Journal of the Canadian Chiropractic Association 2014; 58(3): 328.

9. Devereaux PJ, Biccard BM, Sigamani A, Xavier D, Chan MTV, et al. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2017; 317(16): 1642-1651. doi: 10.1001/jama.2017.4360.

10. Alam SR, Stirrat C, Spath N, Zamvar V, Pessotto R, Dweck MR, Moore C, Semple S, El-Medany A, Manoharan D, Mills NL, Shah A, Mirsadraee S, Newby DE, Henriksen PA. Myocardial inflammation, injury and infarction during on-pump coronary artery bypass graft surgery. J Cardiothorac Surg. 2017; 12(1): 115. doi: 10.1186/s13019-017-0681-6.

11. Momeni M, De Hert S. New advances in perioperative cardioprotection. F1000Res. 2019; 8. pii: F1000 Faculty Rev-538. doi:10.12688/f1000research.17184.1.

12. Davidson SM, Ferdinandy P, Andreadou I. Multitarget strategies to reduce myocardial ischemia/reperfusion injury: JACC review topic of the week. J Am Coll Cardiol. 2019; 73(1): 89-99. doi:10.1016/jjacc.2018.09.086.

13. Punjabi PP, Valuckiene Z, Nihoyannopoulos P. Essentials of Operative Cardiac Surgery. Springer International Publishing; 2015. p. 1-53.

14. Sadeghi M, Garakyaraghi M, Khosravi M, Taghavi M, Sarrafzadegan N, Roohafza H. The impacts of cardiac rehabilitation program on echocardiographic parameters in coronary artery disease patients with left ventricular dysfunction. Cardiol Res Pract. 2013; 2013:201713. doi: 10.1155/2013/201713.

15. Saiiari A, Kashef M, Adel M H, Rajabie H. The Effect of Various Cardiac Rehabilitation Programs on Cardiac Dimensions of Post-CABG Patients, Jentashapir J Health Res. 2017; 8(2): e59997. doi: 10.5812/jjhr.59997.

16. Ghardashi-Afousi A, Holisaz MT, Shirvani H, Pishgoo B. The effects of low-volume high-intensity interval versus moderate intensity continuous training on heart rate variability, and hemodynamic and echocardiography indices in men after coronary artery bypass grafting: A randomized clinical trial study. ARYA Atheroscler. 2018; 14(6): 260-271. doi: 10.22122/arya.v14i6.1781.

17. Hassanpour Dehkordi A, Khaledi Far A. Effect of exercise training on the quality of life and echocardiography parameter of systolic function in patients with chronic heart failure: a randomized trial. Asian J Sports Med. 2015; 6(1): e22643. doi:10.5812/asjsm.22643.

18. Koreckaja AJu. Dinamicheskie i statiko-dinamicheskie fizicheskie nagruzki u pacientov s HSN i sohrannoj frakciej vybrosa. Kuban Scientific Medical Bulletin. 2009; 4: 98-103. (In Russian).

19. Kruger S, Graf J, Kunz D, Stickel T, Hanrath P, Janssens U. Brain natriuretic peptide levels predict functional capacity in patients with chronic heart failure. J Am Coll Cardiol. 2002; 40: 718-722.

20. Ohba H, Takada H, Musha H, Nagashima J, Mori N, Awaya T, Omiya K, Murayama M Effects of prolonged strenuous exercise on plasma levels of atrial natriuretic peptide in healthy men. Am Heart J. 2001; 141(5): 751-758. doi: 10.1067/mhj.2001.114371

21. Sabatine MS, Morrow DA, de Lemos JA, Omland T, Desai MY, Tanasijevic M, et al. Acute changes in circulating natriuretic peptide levels in relation to myocardial ischemia. J Am Coll Cardiol. 2004; 44(10): 1988-1995. doi: 10.1016/j.jacc.2004.07.057

22. Ramos LW, Murad N, Goto E, Antonio EL, Silva Jr. JA, Tucci PF, et al. Ischemia/reperfusion is an independent trigger for increasing myocardial content of mRNA B-type natriuretic peptide. Heart Vessels. 2009; 24(6): 454-459. doi: 10.1007/s00380-009-1148-z.

23. Wu B, Jiang H, Lin R, Cui B, Wen H, Lu Z. Pretreatment with B-type natriuretic peptide protects the heart from ischemia-reperfusion injury by inhibiting myocardial apoptosis. Тохоку J Exp Med. 2009; 219(2): 107-114. doi: 10.1620/tjem.219.107

24. Breivik L, Jensen A, Guvag S, Aarnes EK, Aspevik A, Helgeland E, Hovland S, Brattelid T, Jonassen AK. B-type natriuretic peptide expression and cardioprotection is regulated by Akt-dependent signaling at early reperfusion. Peptides. 2015; 66: 43-50. doi: 10.1016/j.peptides.2015.01.011.

25. Usol'ceva EN. Rol' N-terminal'nogo fragmenta mozgovogo natrijureticheskogo peptida v ocenke prognoza razvitija serdechno-sosudistyh sobytij pri infarkte miokarda. [dissertation] Kemerovo; 2011. (In Russian).