METHOD FOR THE DIAGNOSIS OF MACCE IN PATIENTS WHO UNDERWENT GASTROINTESTINAL SURGERY

Abstract

The invention pertains to a method for the prognosis and/or risk assessment and/or diagnosis of a major adverse cardio- or cerebrovascular event (MACCE) in a patient who underwent gastrointestinal surgery, the method comprising the steps of: i) providing a sample of a bodily fluid from said patient, ii) determining in said sample the level of a biomarker selected from the group consisting of copeptin, troponin and brain natriuretic peptide (BNP), iii) determining at least one additional parameter of said patient, iv) combining the biomarker level determined in step ii) and the additional parameter determined in step iii) into a combined assessment, and v) correlating the combined assessment to said at least one of prognosis, risk assessment and diagnosis of a MACCE in said patient. The invention further pertains to a kit for carrying out the method, a computer and a computer program product comprising computer-executable code being configured to carry out steps iv) and/or v) of the method of the invention.

Claims

1. A method for at least one of prognosis, risk assessment and diagnosis of a major adverse cardio- or cerebrovascular event (MACCE) in a patient who underwent gastrointestinal surgery, the method comprising the steps of: i) providing a sample of a bodily fluid from said patient, ii) determining in said sample the level of a biomarker selected from the group consisting of copeptin, troponin and brain natriuretic peptide (BNP), iii) determining at least one additional parameter of said patient, iv) combining the biomarker level determined in step ii) and the additional parameter determined in step iii) into a combined assessment, and v) correlating the combined assessment to said at least one of prognosis, risk assessment and diagnosis of a MACCE in said patient.

2. The method according to claim 1, wherein the method is a method for at least one of prognosis, risk assessment and diagnosis of a major adverse cardio- or cerebrovascular event (MACCE) in combination with an infection in a patient who underwent gastrointestinal surgery, preferably a method for risk stratification of said patients, stratifying said patients into a group more likely to develop both MACCE and an infection and another group less likely to develop both MACCE and an infection.

3. The method according to claim 1, wherein the additional parameter is selected from the group consisting of the level of at least one additional biomarker and a clinical parameter of said patient.

4. The method according to claim 3, wherein the additional biomarker is selected from the group consisting of copeptin, troponin, BNP, proadrenomedullin (proADM), preferably its fragment midregional proadrenomedullin (MR-proADM), proendothelin-1 (proET-1), preferably its fragment C-terminal proendothelin-1 (CT-proET-1), procalci-tonin (PCT), MR-proANP (mid-regional pro atrial natriuretic peptide), creatinine kinase, creatine kinase-MB, myoglobin, lactate and CRP (C-reactive protein).

5. The method according to claim 4, wherein the levels of the biomarkers copeptin, troponin and brain natriuretic peptide (BNP) and, optionally, at least one of proADM, MR-proADM, proET-1, CTproET-1 and PCT are determined and combined into the combined assessment.

6. The method according to claim 3, wherein the clinical parameter is selected from the group consisting of age, abnormal ECG, especially pathological Q-waves, LBBB, ST-elevation, ST-depression, T-wave inversion, intraoperative hypotension, intraoperative tachycardia, intraoperative bradycardia, hyperlipidaemia, smoking status, anaemia, functional capacities (METs), red-blood cell transfusion, arrhythmias, rhythm other than sinus, duration of the gastrointestinal surgery and operation size, patient history and liver disease.

7. The method according to claim 1, wherein the level of at least one of the biomarkers is determined by determining the level of at least one of a precursor, a precursor fragment and a fragment of the biomarker.

8. The method according to claim 1, wherein determining the level of troponin comprises determining the level of the subunit cardiac tro-ponin T (cTnT), preferably isoform 6 of cTnT or a homologous peptide with at least 75% amino acid sequence identity with isoform 6 of cTnT.

9. The method according to claim 1, wherein determining the level of BNP comprises determining the level of precursor fragment NT-proBNP.

10. The method according to claim 1, wherein the patient is at least 50 years old.

11. The method according to claim 1, wherein the patient is treated with analgesics or pain treatment.

12. The method according to claim 1, wherein the patient spent at least one day in a hospital after undergoing the gastrointestinal surgery.

13. The method according to claim 1, wherein the gastrointestinal surgery is one of laparoscopic and open and is selected from the group consisting of stomach surgery, small intestine surgery, in particular duodenum surgery, large intestine surgery, in particular rectum surgery, reproductive system surgery, in particular hysterectomy or salpingoophorectomy, kidney surgery, in particular nephrectomy, urinary bladder surgery, in particular cystectomy, gallbladder surgery, in particular cholecystectomy, and surgery of gastrointestinal cysts.

14. The method according to claim 1, wherein the patient is free from cardiovascular comorbidities.

15. The method according to claim 1, wherein the patient is excluded if an exclusion condition is present in the patient, the exclusion condition being selected from the group consisting of organ transplantation, traumatic injury, endocrine disease, endocrine surgery, vascular disease, vascular surgery, endovascular disease, endovascular surgery, acute coronary syndrome (ACS), heart failure, decompensated congestive heart failure, aortic stenosis, reduced left ventricular ejection fraction (LVEF), and circulatory shock.

16. The method according to claim 1, wherein the sample has been taken from the patient no more than 24 hours before the gastrointestinal surgery, no more than 24 hours after the gastrointestinal surgery, on day one after the gastrointestinal surgery, on day two after the gastrointestinal surgery or on day three after the gastrointestinal surgery.

17. The method according to claim 1, wherein the method comprises providing of from two to five samples from the patient, wherein the samples are taken at different times before and/or after the gastrointestinal surgery, and wherein steps ii), iv) and v) are practiced on all said samples.

18. The method according to claim 17, wherein the different times said of from two to five samples are taken are selected from the group con-sisting of no more than 24 hours before the gastrointestinal surgery, no more than 24 hours after the gastrointestinal surgery, day one after the gastrointestinal surgery, day two after the gastrointestinal surgery and day three after the gastrointestinal surgery.

19. The method according to claim 17, wherein the levels of said biomarkers in the samples taken at different times are determined and then compared, and wherein the differences in the levels of the biomarkers at different times are combined into the combined assessment.

20. The method according to claim 1, wherein a biomarker level determined to be above a specific threshold value is indicative of a MACCE in the patient.

21. The method according to claim 20, wherein the specific threshold value is selected from the group consisting of 25 pmol/L, preferably 75 pmol/L, more preferably 125 pmol/L, even more preferably 175 pmol/L and most preferably 225 pmol/L for copeptin, 15 ng/L, preferably 20 ng/L, more preferably 25 ng/L, even more preferably 30 ng/L and most preferably 35 ng/L, 45 ng/L or 65 ng/L for cTnT, 500 ng/L, preferably 900 ng/L, more preferably 1300 ng/L, even more preferably 1700 ng/L and most preferably 2100 ng/L or 2800 ng/L for NT-proBNP, 0.8 nmol/L or 1.0 nmol/L, preferably 1.25 nmol/L, more preferably 1.5 nmol/L, even more preferably 1.75 nmol/L and most preferably 2.0 nmol/L or 2.4 nmol/L for MR-proADM, 80 pmol/L, preferably 90 pmol/L, more preferably 100 pmol/L, even more preferably 110 pmol/L and most preferably 120 pmol/L for CT-proET-1, and 0.5 μg/L, preferably 1.0 μg/L, more preferably 1.5 μg/L, even more preferably 2.0 μgL and most preferably 2.5 μg/L or 3.0 μg/L for PCT.

22. The method according to claim 1, wherein the method comprises correlating the combined assessment to the risk of a MACCE in the patient within at least one of 30 days and 12 months after the gastrointestinal surgery.

23. The method according to claim 18, wherein the prognosis comprises the risk of mortality within at least one of 30 days and 12 months after the gastrointestinal surgery.

24. The method according to claim 1, wherein the MACCE is a myocardial injury after noncardiac surgery (MINS) and the method is a method for the diagnosis of a MINS in a patient who underwent gastrointestinal surgery.

25. The method according to claim 21, wherein a biomarker level determined to be above a specific threshold value is indicative of a MINS in the patient.

26. The method according to claim 23, wherein the specific threshold value is selected from the group consisting of 25 pmol/L, preferably 50 pmol/L or 75 pmol/L, more preferably 125 pmol/L, even more preferably 175 pmol/L and most preferably 225 pmol/L for copeptin, 10 ng/L, preferably 20 ng/L, more preferably 30 ng/L, even more preferably 40 ng/L and most preferably 50 ng/L or 60 ng/L for cTnT, 250 ng/L or 500 ng/L, preferably 750 ng/L, more preferably 1250 ng/L or 1500 ng/L, even more preferably 1750 ng/L and most preferably 2250 ng/L for NT-proBNP, 0.8 nmol/L or 1.0 nmol/L, preferably 1.25 nmol/L, more preferably 1.5 nmoVL, even more prefer-ably 1.75 nmol/L and most preferably 2.0 nmol/L for MR-proADM, 65 pmol/L or 75 pmol/L or 80 pmol/L, preferably 90 pmol/L, more preferably 100 pmol/L, even more preferably 110 pmol/L and most preferably 120 pmol/L for CT-proET-1, and 0.2 μg/L or 0.5 μg/L, preferably 0.75 μg/L or 0.8 μg/L, more preferably 1.0 μg/L, even more preferably 1.25 μg/L and most preferably 1.5 μg/L for PCT.

27. The method according to claim 17, wherein the determined biomarker levels taken at different times are evaluated using different threshold values.

28. The method according to claim 17, wherein the determined biomarker levels taken at different times are differently weighted.

29. The method according to claim 17, wherein a relative change in the biomarker level between two samples taken at different times is combined into the combined assessment.

30. The method according to claim 1, wherein a ratio between the levels of at least two biomarkers in the sample is determined and said ratio is combined into the combined assessment, wherein the biomarkers for determining the ratio are preferably selected from copeptin/tro-ponin, copeptin/BNP and BNP/tro-ponin.

31. The method according to claim 1, wherein step iv) comprises providing reference data for the determined biomarkers and at least one value selected from the group consisting of the determined level of at least one of the biomarkers, the differences in the level of at least one of the biomarkers taken at different times, the relative change in the levels of one of said biomarkers determined in two samples taken at different times the ratio between the levels of at least two biomarkers either taken at the same time or taken at different times and the relative change of the ratios of at least two biomarkers determined in at least two samples taken at different times is compared to the reference data, wherein the difference of the value as determined and the reference data is computed, and wherein the computed difference is preferably expressed in the form of a score, especially as a numerical value.

32. The method according to claim 31, wherein at least two different scores are determined and the combined assessment comprises a combined score determined from said at least two different scores indicative of the presence or absence of a MACCE in the patient.

33. The method according to claim 31, wherein the reference data pertains to patients who underwent gastrointestinal surgery and who did and/or did not have a MACCE or MINS.

34. The method according to claim 2, wherein the infection is selected from the group consisting of a fungal, a bacterial or a viral infection.

35. The method according to claim 2, wherein the infection is selected from the group consisting of a blood infection, a respiratory tract infection, a urinary tract infection, a skin infection or an abdominal cavity infection.

36. The method according to claim 2, wherein the infection is selected from the group consisting of a blood stream infection, sepsis, severe sepsis and/or septic shock.

37. Kit for carrying out the method according to any one of the preceding claims, comprising: at least one detection reagent for determining the level of at least one of the biomarkers copeptin, troponin and brain natriuretic peptide (BNP) in a sample of a bodily fluid from a patient, and reference data from patients who underwent gastrointestinal surgery, particularly reference levels, corresponding to at least one of copeptin, troponin and BNP levels, wherein said reference data is preferably stored on a computer-readable medium and/or employed in the form of computer-executable code configured for comparing the determined level of at least one of copeptin, troponin and BNP to said reference data.

38. The kit according to claim 37, wherein the at least one detection reagent comprises reagents for determining the levels of the biomarkers copeptin, troponin and brain natriuretic peptide (BNP) and, optionally, at least one of MR-proADM, CT-proET-1 and PCT in a sample of a bodily fluid from said patient, and wherein the reference data comprises data corresponding to said biomarkers in patients who underwent gastrointestinal surgery.

39. Computer, comprising means for running computer-executable code, with the computer-executable code being configured to carry out steps iv) and/or v) of the method of claim 1.

40. Computer according to claim 39, wherein the computer is connected to an assay system, the assay system being configured to carry out step ii).

41. Computer program product comprising a set of computer instructions stored on at least one computer-readable medium, said set of computer instructions further comprising instructions executable by one or more processors to carry out steps iv) and/or v) of the method of claim 1.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

[0225] In the drawings, FIGS. 1-6 show the determined levels of the biomarkers copeptin (marked COP or COPAVP), cTnT (marked hsTnT for a high-sensitivity assay used, see below), NT-proBNP, MR-proADM, CTproET-1 and PCT in a patient population at different times of sampling and divided in patients who did and did not develop a MACCE.

[0226] FIGS. 7-12 show the determined levels of the biomarkers in analogy to FIGS. 1-6, wherein the patient population is divided in patients who did and did not develop a MINS.

[0227] FIGS. 13-18 show the determined levels of the biomarkers in analogy to FIGS. 1 to 6, wherein the patient population is divided in patients who did and did not develop an infection in addition to MACCE.

[0228] FIGS. 19-21 show the determined levels of MR-proADM, PCT and CT-proET-1, wherein the patient population is divided in patients who did and did not develop an infection.

[0229] FIGS. 22-24 show the determined levels of MR-proADM, PCT and CT-proET-1, wherein the patient population is divided in patients who did and did not develop a blood infection.

[0230] FIGS. 22-24 show the determined levels of MR-proADM, PCT and CT-proET-1, at different points in time, differentiated between different combinations of MACCE and infection.

EXAMPLE

[0231] A multicenter, prospective cohort study in several Swedish hospitals was conducted. Subjects were recruited consecutively between April 2017 and October 2018. Patients aged 50 or older, undergoing elective abdominal surgery rated as major or major/complex by SORT, Surgical Outcome Risk Tool [Protopapa et al., British Journal of Surgery, 101(13), pp. 1774-1783. doi: 10.1002/bjs.9638, 2014], were eligible. The procedure also had to be performed under general anesthesia and require at least one overnight stay. Eligible patients were identified by screening daily patient lists in preoperative assessment clinics. Patients were informed of the study objectives, methods, expected benefits, potential dangers and the possibility of withdrawal at any time before consenting to participate. Informed written consent was obtained from all patients before being included. Participants could be included only once and patients were excluded if they were not able to give an informed consent or underwent one of the following types of abdominal surgery: transplantation, trauma, endocrine, vascular or endovascular. Included patients were excluded if the elective surgery was cancelled because the patient died, or if another non-elective surgery was performed prior to the elective one. The predefined study endpoint was MACCE (as defined above) within 30 days. Overall patient characteristics are given in Table 1.

TABLE-US-00001 TABLE 1 Overall patient characteristics No No No Any No Blood Blood All MACCE MACCE MINS MINS Infection Infection Infection Infection No. of 387 350 37 293 94 282 105 376 11 Patients Avg Age 70 70 72 70 69 70 72 Women 44% 46% 30% 44% 45% 44% 45% Blood 11 6 5 10 1 0 11 0 11 infection (2.8%)  Any 105 88 17 73 32 0 105 94 11 infection (27%) ASA I-II 265 243 21 199 66 260 5 (68%) ASA 116 100 16 79 37 110 6 III-IV (30%) MINS 94 80 14 0 94 62 32 93 1 (24%) MACCE 37 0 37 23 14 20 17 32 5 (9.6%)  Deceased 5 0 5 0 5 3 2 (1.3%) 

[0232] Five sample points were defined: preoperatively (<24 h prior to anesthesia), postoperatively (within 24 hours of surgery) and on days 1, 2 and 3 after surgery. At these times, an arterial or venous blood sample was obtained using an 8.5 ml EDTA Vacutainer®. Blood samples were sent to the local clinical chemistry laboratory where they were centrifuged, plasma was frozen in aliquots at −80° C. and stored until batch-analyses of plasma concentration of the biomarkers were performed. Simultaneously, an ECG was taken from each patient at each sampling point.

[0233] The occurrence of MACCE was reviewed on day 1, 2 and 3 through medical charts and at 30 days after surgery via a telephone interview and/or by consulting the patient's medical records. The incidence of MINS was calculated from analyzed cTnT plasma levels [according to Sessler and Khanna; Intensive Care Med (2018) 44:811-822, https://doi.org/10.1007/s00134-018-5224-7]. The mortality rate was assessed using the Swedish population register. If a patient was discharged, dropped out or died before all samples had been obtained, the patient was not excluded and the collected samples were analyzed unless the patient asked not to be included in the data analyses.

[0234] Copeptin, MR-proADM, CT-proET-1 and PCT were measured using a Thermo Scientific B⋅R⋅A⋅H⋅M⋅S Kryptor Compact plus according to the instructions of the manufacturer (B⋅R⋅A⋅H⋅M⋅S GmbH, Hennigsdorf, Germany). Cardiac troponin T (cTnT) and NT-proBNP were measured using a Cobas e 602/Cobas e 601/Cobas e 411 assay according to the instructions of the manufacturer (Roche Diagnostics, Mannheim, Germany).

[0235] Data analyses were performed using Graphpad PRISM 8. Data distribution was reviewed using D'Agostino & Pearson test. Comparisons between different groups were performed using Fisher's exact test and Kruskal Wallis test. P-values<0.05 were considered significant.

[0236] Patient- and clinical characteristics are presented in Table 2, wherein ASA stands for the physical status classification system according to the American Society of Anesthesiologists (ASA). 387 surgical patients were recruited and included in the analyses. It is noteworthy that only 43% of patients who suffered from MACCE were classified as high-risk patients (ASA III-IV), and only 38% were classified as having MINS.

TABLE-US-00002 TABLE 2 Patient and clinical characteristics for patients with and without MACCE. All No MACCE MACCE No. of patients 387 350  37 (9.6%) Age median  70  70 72 Women 44% 46% 30% ASA I-II 265 243 21 ASA III-IV 116 (30%) 100 (29%) 16 (43%) MINS  94 (24%)  80 (23%) 14 (38%) Deceased  5 (1.3%)  0  5 (13.5%)

[0237] The collected data did not pass the D'Agostino-Pearson normality test, therefore non-parametric tests were used in the analyses. Comparison of how plasma levels of the measured biomarkers varied between patients affected, and not affected, by MACCE was performed using a Kruskal Wallis test. FIGS. 1-6 show plasma levels of the measured biomarkers copeptin, cTnT, NT-proBNP, MR-proADM, CT-proET-1 and PCT in patients with and without MACCE at all sampling points/times. In the figures, PreOp designates the preoperative sampling point, PACU (post anesthesia care unit) designates the postoperative sampling point, POD1 designates the sampling point one day after surgery, POD2 designates the sampling point two days after surgery and POD3 designates the sampling point three days after surgery.

[0238] As can be seen from FIGS. 1-6, the biomarker levels of all measured biomarkers are increased in the group of patients who suffered a MACCE within 30 days from gastrointestinal surgery in comparison with the group of patients not suffering a MACCE.

[0239] The variation of the biomarker levels was also compared in patients with and without MINS using a Kruskal Wallis test. In analogy to FIGS. 1-6, FIGS. 7-12 show plasma levels of the measured biomarkers copeptin, cTnT, NT-proBNP, MR-proADM, CT-proET-1 and PCT in patients with and without MINS at all sampling points/times. Again, as can be seen from FIGS. 7-12, the biomarker levels of all measured biomarkers are increased in the group of patients who suffered a MINS within 30 days from gastrointestinal surgery in comparison with the group of patients not suffering a MINS.

[0240] With regard to an infection as a postsurgical adverse event 105 (27%) patients developed an infection of which 11 suffered of a blood infection. The overall mortality rate was 1.3% (5 deceased). Table 2 summarizes the patient characteristics in regard to the occurrence of an infection. Biomarkers levels were determined for all patients preoperatively (preOP), on the post-anesthesia care unit (PACU) as well as one day (POD1), two days (POD2) and three days (POD3) after surgery.

TABLE-US-00003 TABLE 3 Patient characteristics in regards to the incidence of any infection All No Infection Any Infection No. of Patients 387 282 105 (27%)   Avg Age  70  70 69 Women 44% 44% 45% ASA I-II 265 199 66 ASA III-IV 116 (30%)   79 (28%)  37 (35%)   MINS 94 (24%)  62 (22%)  32 (30.5%) MACCE 37 (9.6%) 20 (7.1%) 17 (16.2%) Deceased  5 (1.3%) 0 (0%)  5 (4.8%)

[0241] FIG. 13-18 show biomarker levels of patients with MACCE with or without an additional infection. All of the biomarkers show significantly higher levels in patients with a combination of MACCE and an infection, with the exception of PCT before the surgery. With the biomarkers troponin (FIG. 14), BNP (FIG. 15), proADM (FIG. 16), proET-1 (FIG. 17) and PCT (FIG. 18), the increase in biomarker level becomes even more pronounced at later points in time (i.e. POD2 and POD3), while copeptin (FIG. 13) shows a more constant increase compared with patients without infections over all points in time analysed. All of the biomarkers are therefore suitable for the differentiation between patients with MACCE alone and patients with both MACCE and an infection. The underlying data is presented in Table 4.

TABLE-US-00004 TABLE 4 Biomarker values for patients developing MACCE with or without infection PreOP PACU POD1 POD2 POD3 Copeptin [pmol/L] No inf + MACCE 15 195 33 20 18 Inf + MACCE 25 230 47 37 27 hsTnT [ng/L] No inf + MACCE 9 8 14 15 15 Inf + MACCE 12 14 23 30 90 NT-proBNP [ng/L] No inf + MACCE 260 270 550 760 950 Inf + MACCE 330 300 700 1330 2050 MR-proADM [nmol/L] No inf + MACCE 0.74 1.12 1.48 1.42 1.28 Inf + MACCE 0.83 1.40 1.93 2.09 2.20 CT-proET-1 [pmol/L] No inf + MACCE 70 92 100 90 88 Inf + MACCE 78 118 125 127 123 PCT [μg/L] No inf + MACCE 0.06 0.10 0.83 0.98 0.85 Inf + MACCE 0.04 0.14 1.98 3.29 3.09

[0242] From the values given in Table 4, the skilled person can easily infer which test parameters, for example, cut-off values, to use in the inventive method. These can then be chosen with regard to the actual application at hand. It also becomes clear that the measured biomarker levels should expediently be evaluated with respect to the point in time the samples were taken. For example, a copeptin level of above 15 pmol/L, preferably above 20 pmol/L or above 25 pmol/L, in a sample taken preoperatively (PreOP) is indicative of an increased risk of the patient developing both MACCE and an infection after surgery. At other points in time of sampling, these values may vary, and for example be above 195 pmol/L or above 200 pmol/L or above 205 pmol/L or above 210 pmol/L or above 215 pmol/L or above 220 pmol/L or above 225 pmol/L or above 230 pmol/L at PACU, above 30 pmol/L or above 35 pmol/L or above 40 pmol/L or above 45 pmol/L at POD1, above 20 pmol/L or above 25 pmol/L or above 30 pmol/L or above 35 pmol/L at POD2, above 15 pmol/L or above 20 pmol/L or above 25 pmol/L at POD3. Of course, for any biomarker evaluative values other than cut-off values may be calculated which relate the measured biomarker level to the biomarker level established for patients having MACCE without an infection and/or having no symptoms at all. For example, a factor may be established by which the measured biomarker level differs from the level of patients with MACCE but without an infection.

[0243] For hsTnT, a level of above 8 ng/L or above 9 ng/L or above 10 ng/L or above 11 ng/L or above 12 ng/L in a sample taken at PreOP and/or at PACU is indicative of an increased risk of the patient developing both MACCE and an infection after surgery. At other points in time of sampling, these values may vary, and, for example, be above 10 ng/L or above 15 ng/L or above 20 ng/L or above 25 ng/L or above 30 ng/L at POD1 and/or POD2 and/or POD3. A global cut-off value for all points in time could for example be chosen at above 10 ng/L or above 15 ng/L, depending on the desired sensitivity and specificity as well as other factors of the application at hand.

[0244] For NT-proBNP, a level of above 260 ng/L or above 280 ng/L or above 300 ng/L or above 320 ng/L in a sample taken at PreOP and/or at PACU is indicative of an increased risk of the patient developing both MACCE and an infection after surgery. At other points in time of sampling, these values may vary, and, for example, be above 500 ng/L or above 550 ng/L or above 600 ng/L or above 650 ng/L or above 700 ng/L or above 750 ng/L or above 800 ng/L or above 850 ng/L at POD1 and/or POD2 and/or POD3. A global cut-off value for all points in time could for example be chosen at above 300 ng/L or above 500 ng/L, depending on the desired sensitivity and specificity as well as other factors of the application at hand.

[0245] For MR-proADM, a level of above 0.70 nmol/L or above 0.75 nmol/L above 0.80 nmol/L in a sample taken at PreOP is indicative of an increased risk of the patient developing both MACCE and an infection after surgery. At other points in time of sampling, these values may vary, and, for example, be above 1.00 nmol/L or above 1.10 nmol/L or above 1.20 nmol/L or above 1.30 nmol/L or above 1.40 nmol/L or above 1.50 nmol/L or above 1.60 nmol/L at PACU and/or POD1 and/or POD2 and/or POD3. A global cut-off value for all points in time could, for example, be chosen at above 0.8 nmol/L or above 1.5 nmol/L, depending on the desired sensitivity and specificity as well as other factors of the application at hand.

[0246] For CT-proET-1, a level of above 65 pmol/L or above 70 pmol/L or above 75 pmol/L above 80 pmol/L in a sample taken at PreOP is indicative of an increased risk of the patient developing both MACCE and an infection after surgery. At other points in time of sampling, these values may vary, and, for example, be above 85 pmol/L or above 90 pmol/L or above 95 pmol/L or above 100 pmol/L or above 105 pmol/L or above 110 pmol/L or above 115 pmol/L or above 120 pmol/L or above 125 pmol/L at PACU and/or POD1 and/or POD2 and/or POD3. A global cut-off value for all points in time could, for example, be chosen at above 80 pmol/L or above 100 pmol/L, depending on the desired sensitivity and specificity as well as other factors of the application at hand.

[0247] For PCT, a level of above 0.06 μg/L or above 0.08 μg/L or above 0.10 μg/L or above 0.12 μg/L in a sample taken at PreOP and/or at PACU is indicative of an increased risk of the patient developing both MACCE and an infection after surgery. At other points in time of sampling, these values may vary, and, for example, be above 0.8 μg/L or above 0.9 μg/L or above 1.0 μg/L or above 1.1 μg/L or above 1.2 μg/L or above 1.3 μg/L or above 1.4 μg/L or above 1.5 μg/L at POD1 and/or POD2 and/or POD3. A global cut-off value for all points in time could, for example, be chosen at above 0.1 μg/L or above 1.0 μg/L or above 1.5 μg/L, depending on the desired sensitivity and specificity as well as other factors of the application at hand.

[0248] FIG. 19-21 summarize the results concerning infections for MR-proADM, PCT and CT-proET-1. The levels of all biomarkers, but in particular MR-proADM and PCT, were elevated in the group of patients that suffered an infection after surgery. This trend is visible for all sample points preOP, PACU, as well as PODs 1-3.

[0249] The level of MR-proADM for patients postsurgically developing an infection is elevated compared to the level in patients with no infection for sample points early on at PACU and even mildly preoperatively. The difference becomes more pronounced postsurgically from POD1 and in particular POD2 and POD3 (FIG. 19). The level of MR-proADM in patients without any infection falls after POD1 from approximately 1.25 nmol/L to below 1.2 nmol/L at POD3. In patients having an infection the level is steadily maintained above 1.5 nmol/L for all PODs 1-3.

[0250] For PCT as a marker for an occurrence of an infection a particular pronounced difference can be seen postsurgically from POD1 through POD3 (FIG. 20). While the level of PCT in postsurgical patients with no infection remains around or below 0.75 μg/L, the level of PCT in patients having an infection continuously rises from POD 1 (approximately 1.0 μg/L) to more than approximately 1.25 μg/L for PODs 2 and 3. Notably, also preoperatively and early on at PACU a mild difference is visible.

[0251] For CT-proET-1 the difference between patients with and without infections are less pronounced than for the markers PCT and MR-proADM. However, in particular at later sample points two or three days after surgery, a visible difference allows for a reliable distinction (FIG. 21).

[0252] The results demonstrate that in particular MR-proADM and PCT, but, to a somewhat lesser extent, also CT-proET-1 can be used for providing a reliable prediction or diagnosis for the incidence of infection in postsurgical patients and therefore can advantageously be combined with measurements of copeptin, troponin and BNP. The prediction or diagnosis can be established with a single threshold value for all sample points or at individual sample points (e.g. preOP, PACU, POD1-3) by comparison to sample point specific values.

[0253] In addition, the different temporal development of the levels of the biomarkers in patients with and without any infection allow for a further reliable prognosis or diagnosis, when taking samples at at least two points in time and analyzing the ratio or absolute difference for the different sample points.

[0254] Table 5 summarizes the patient characteristics in regard to the occurrence of a blood infection. Biomarkers levels were determined for all patients preoperatively (preOP), on the post-anesthesia care unit (PACU) as well as one day (POD1), two days (POD2) and three days (POD3) after surgery.

TABLE-US-00005 TABLE 5 Patient characteristics in regards to the incidence of a blood infection All No Blood Id Blood Id No. of Patients 387 376 11 (2.8%)  Avg Age  70  70 72 Women 44% 44% 45% ASA I-II 265 260  5 ASA III-IV 116 (30%)  110 (29%)  6 (55%)   MINS  94 (24%)   93 (25%)  1 (9.1%)  MACCE  37 (9.6%)  32 (8.5%) 5 (45.5%) Deceased  5 (1.3%)  3 (0.8%) 2 (18.2%)

[0255] FIGS. 22-24 summarize the results for MR-proADM, PCT and CT-proET-1. The levels of all biomarkers, but in particular MR-proADM and PCT, were elevated in the group of patients that suffered a blood infection after surgery. This trend is visible for all sample points preOP, PACU, as well as PODs 1-3.

[0256] The level of MR-proADM for patients postsurgically developing a blood infection is elevated compared to the level in patients with no infection for sample points early on at PACU and notably even preoperatively. The difference becomes more pronounced postsurgically from POD1 to POD3 (FIG. 22). The level of MR-proADM in patients without any infection falls after POD1 from approximately 1.3 nmol/L to below 1.2 nmol/L at POD3. For patients having a blood infection the level is steadily maintained above approximately 1.75 nmol/L for all PODs 1-3.

[0257] Similar to the incident of an infection for the occurrence of a blood infection, a particularly pronounced difference in the level of PCT can be seen postsurgically from POD1 through POD3 (FIG. 23). While the level of PCT in postsurgical patients with no blood infection remains around or below 0.75 μg/L, the level of PCT in patients having a blood infection continuously rises from POD 1 (approximately 2.0 μg/L) to more than approximately 2.5 μg/L for PODs 2 and 3. Notably, also preoperatively and early on at PACU a mild difference is visible.

[0258] For CT-proET-1 the difference between patients with and without a blood infection are less pronounced than for the markers PCT and MR-proADM. However, in particular at later sample points two or three days after surgery, a visible difference allows for a distinction. While patients with a blood infection at POD2 and 3 had a level of CT-proET-1 of more than 100 pmol/L, the level of patients with no blood infection at POD2 and POD3 was around or below approximately 0.75 pmol/L (FIG. 24).

[0259] The results demonstrate that in particular MR-proADM and PCT, but, to a lesser extent, also CT-proET1 may serve for a reliable prediction or diagnosis for the incidence of a blood infection in postsurgical patients and therefore may advantageously be combined with measurements of copeptin, troponin and BNP. The prediction or diagnosis can be established with a single threshold value for all sample points or at individual sample points (e.g. preOP, PACU, POD1-3) by comparison to sample point specific values.

[0260] In addition, the different temporal developments of the levels of the biomarkers in patients with and without a blood infection allow for a further reliable prognosis or diagnosis when taking samples at two or more points of time and analyzing the ratio or absolute difference for the different sample points.

[0261] Table 6 summarizes the patient characteristics in regard to the postsurgical occurrence of an infection and MACCE. Biomarkers levels were determined for all patients preoperatively (preOP), on the post-anesthesia care unit (PACU) as well as one day (POD1), two days (POD2) and three days (POD3) after surgery.

TABLE-US-00006 TABLE 6 Patient characteristics in regards to the incidence of an infection and MACCE No. of Patients No infection infection No MACCE 262 88 MACCE  20 17

[0262] FIGS. 25-27 summarize the results for MR-proADM, PCT and CT-proET-1.

[0263] Strikingly, the levels of all biomarkers were particularly elevated in the group of patients that suffered both an infection as well as a MACCE. This trend was clearly visible for all sample points preOP, PACU, as well as PODs 1-3.

[0264] For MR-proADM the level of patients that suffered of an infection and a MACCE exhibit clear differences compared to patients that did not suffer any of these events or that suffered of only one of the adverse events across all sample points (FIG. 25). The difference is particularly pronounced postsurgically. While patients that neither developed an infection nor experienced MACCE postsurgically showed a level of MR-proADM of 1 nmol/L or below at PACU or POD 1-3, patients that suffered both adverse events showed a steady increase in the level of MR-proADM from approximately 1.5 nmol/L at PACU to approximately 2.3 nmol/L at POD3.

[0265] PCT appears to be a particularly valuable marker for the combined prognosis or diagnosis of infections and MACCE. This is particularly the case for sample points postsurgically from POD1 to POD3 (FIG. 26). The PCT levels of patients that developed an infection and suffered a MACCE events at POD1 through POD3 were consistently above 2 μg/L, averaging on POD3 even at approximately 3.5 μg/L. On the contrary, for patients who postsurgically neither experienced a MACCE nor an infection, PCT levels of around or below 0.5 μg/L were determined. The more than 4-fold difference on POD1 and more than 7-fold difference on POD3 indicate a strong synergistic effect for the combined diagnosis or prediction of an infection plus MACCE using PCT as a marker.

[0266] Likewise, for CT-proET-1 across all sample points considerably higher levels were determined in patients suffering postsurgically both from an infection as well as a MACCE than in patients that experienced neither one of these adverse events (FIG. 27). While for the former group CT-proET-1 levels remained at or below approximately 80 pmol/L, in the latter group the postsurgical level of CT-proET-1 from PACU to POD3 was at or above approximately 125 pmol/L.

[0267] The data demonstrate that the prognosis and/or diagnosis of an infection and a MACCE using one of the described biomarkers can be achieved with a particularly high accuracy and reliability. These biomarkers may therefore advantageously be combined with measurements of copeptin, troponin and BNP. From the predictive potential of the markers for one of the adverse events such a strong predictive power could not have been expected, pointing towards a functional synergy of these biomarkers in regard to the diagnosis or prediction of these distinct adverse events.

[0268] The prediction or diagnosis can be established with a single threshold value for all sample points or at individual sample points (e.g. preOP, PACU, POD1-3) by comparison to sample point specific values.

[0269] In addition, the different temporal development of the level of the biomarkers in patients with and without an infection and a MACCE allow for a further reliable prognosis or diagnosis, when taking samples at two points in time or more and analyzing the ratio or absolute difference for the different sample points.

TABLE-US-00007 SEQUENCES (amino acid sequence of pre-pro-AVP): SEQ ID NO: 1 1 MPDTMLPACF LGLLAFSSAC YFQNCPRGGK RAMSDLELRQ CLPCGPGGKG 51 RCFGPSICCA DELGCFVGTA EALRCQEENY LPSPCQSGQK ACGSGGRCAA 101 FGVCCNDESC VTEPECREGF HRRARASDRS NATQLDGPAG ALLLRLVQLA 151 GAPEPFEPAQ PDAY (amino acid sequence of pro-AVP): SEQ ID NO: 2 1 CYFQNCPRGG KRAMSDLELR QCLPCGPGGK GRCFGPSICC  ADELGCFVGT 51 AEALRCQEEN YLPSPCQSGQ KACGSGGRCA AFGVCCNDES CVTEPECREG 101 FHRRARASDR SNATQLDGPA GALLLRLVQL AGAPEPFEPA QPDAY (amino acid sequence of CT-pre-proAVP or copeptin): SEQ ID NO: 3 1 ASDRSNATQL DGPAGALLLR LVQLAGAPEP FEPAQPDAY (amino acid sequence of Neurophysin II): SEQ ID NO: 4 1 AMSDLELRQC LPCGPGGKGR CFGPSICCAD ELGCFVGTAE ALRCQEENYL 51 PSPCQSGQKA CGSGGRCAAF GVCCNDESCV TEPECREGFH RRA (amino acid sequence of cTnT (Isoform-6)): SEQ ID NO: 5 1 MSDIEEVVEE YEEEEQEEAA VEEQEEAAEE DAEAEAETEE TRAEEDEEEE 51 EAKEAEDGPM EESKPKPRSF MPNLVPPKIP DGERVDFDDI HRKRMEKDLN 101 ELQALIEAHF ENRKKEEEEL VSLKDRIERR RAERAEQQRI RNEREKERQN 151 RLAEERARRE EEENRRKAED EARKKKALSN MMHFGGYIQK QAQTERKSGK 201 RQTEREKKKK ILAERRKVLA IDHLNEDQLR EKAKELWQSI YNLEAEKFDL 251 QEKFKQQKYE INVLRNRIND NQKVSKTRGK AKVTGRWK (amino acid sequence of cTnI): SEQ ID NO: 6 1 MADGSSDAAR EPRPAPAPIR RRSSNYRAYA TEPHAKKKSK ISASRKLQLK 51 TLLLQIAKQE LEREAEERRG EKGRALSTRC QPLELAGLGF AELQDLCRQL 101 HARVDKVDEE RYDIEAKVTK NITEIADLTQ KIFDLRGKFK RPTLRRVRIS 151 ADAMMQALLG ARAKESLDLR AHLKQVKKED TEKENREVGD WRKNIDALSG 201 MEGRKKKFES (amino acid sequence of TnC): SEQ ID NO: 7 1 MDDIYKAAVE QLTEEQKNEF KAAFDIFVLG AEDGCISTKE LGKVMRMLGQ 51 NPTPEELQEM IDEVDEDGSG TVDFDEFLVM MVRCMKDDSK GKSEEELSDL 101 FRMFDKNADG YIDLDELKIM LQATGETITE DDIEELMKDG DKNNDGRIDY 151 DEFLEFMKGV E (amino acid sequence of pre-pro-BNP): SEQ ID NO: 8 1 MDPQTAPSRA LLLLLFLHLA FLGGRSHPLG SPGSASDLET SGLQEQRNHL 51 QGKLSELQVE QTSLEPLQES PRPTGVWKSR EVATEGIRGH RKMVLYTLRA 101 PRSPKMVQGS GCFGRKMDRI SSSSGLGCKV LRRH (amino acid sequence of pro-BNP): SEQ ID NO: 9 1 HPLGSPGSAS DLETSGLQEQ RNHLQGKLSE LQVEQTSLEP LQESPRPTGV 51 WKSREVATEG IRGHRKMVLY TLRAPRSPKM VQGSGCFGRK MDRISSSSGL 101 GCKVLRRH (amino acid sequence of NT-pro-BNP): SEQ ID NO: 10 1 HPLGSPGSAS DLETSGLQEQ RNHLQGKLSE LQVEQTSLEP LQESPRPTGV 51 WKSREVATEG IRGHRKMVLY TLRAPR (amino acid sequence of BNP): SEQ ID NO: 11 1 SPKMVQGSGC FGRKMDRISS SSGLGCKVLR RH (amino acid sequence of pre-pro-ADM): SEQ ID NO: 12 1 MKLVSVALMY LGSLAFLGAD TARLDVASEF RKKWNKWALS RGKRELRMSS 51 SYPTGLADVK AGPAQTLIRP QDMKGASRSP EDSSPDAARI RVKRYRQSMN 101 NFQGLRSFGC RFGTCTVQKL AHQIYQFTDK DKDNVAPRSK ISPQGYGRRR 151 RRSLPEAGPG RTLVSSKPQA HGAPAPPSGS APHFL (amino acid sequence of pro-ADM): SEQ ID NO: 13 1 ARLDVASEFR KKWNKWALSR GKRELRMSSS YPTGLADVKA GPAQTLIRPQ 51 DMKGASRSPE DSSPDAARIR VKRYRQSMNN FQGLRSFGCR FGTCTVQKLA 101 HQIYQFTDKD KDNVAPRSKI SPQGYGRRRR RSLPEAGPGR TLVSSKPQAH 151 GAPAPPSGSA PHFL (amino acid sequence of MR-pro-ADM): SEQ ID NO: 14 1 ELRMSSSYPT GLADVKAGPA QTLIRPQDMK GASRSPEDSS PDAARIRV (amino acid sequence of pre-pro-ET-1): SEQ ID NO: 15 1 MDYLLMIFSL LFVACQGAPE TAVLGAELSA VGENGGEKPT PSPPWRLRRS 51 KRCSCSSLMD KECVYFCHLD IIWVNTPEHV VPYGLGSPRS KRALENLLPT 101 KATDRENRCQ CASQKDKKCW NFCQAGKELR AEDIMEKDWN NHKKGKDCSK 151 LGKKCIYQQL VRGRKIRRSS EEHLRQTRSE TMRNSVKSSF HDPKLKGKPS 201 RERYVTHNRA HW (amino acid sequence of pro-ET-1): SEQ ID NO: 16 1 APETAVLGAE LSAVGENGGE KPTPSPPWRL RRSKRCSCSS LMDKECVYFC 51 HLDIIWVNTP EHVVPYGLGS PRSKRALENL LPTKATDREN RCQCASQKDK 101 KCWNFCQAGK ELRAEDIMEK DWNNHKKGKD CSKLGKKCIY QQLVRGRKIR 151 RSSEEHLRQT RSETMRNSVK SSFHDPKLKG KPSRERYVTH NRAHW (amino acid sequence of ET-1): SEQ ID NO: 17 1 CSCSSLMDKE CVYFCHLDII W (amino acid sequence of CT-pro-ET-1): SEQ ID NO: 18 1 RSSEEHLRQT RSETMRNSVK SSFHDPKLKG KPSRERYVTH NRAHW (amino acid sequence of Big-ET-1): SEQ ID NO: 19 1 CSCSSLMDKE CVYFCHLDII WVNTPEHVVP YGLGSPRS (amino acid sequence of PCT): SEQ ID NO: 20 1 APFRSALESS PADPATLSED EARLLLAALV QDYVQMKASE LEQEQEREGS 51 SLDSPRSKRC GNLSTCMLGT YTQDFNKFHT FPQTAIGVGA PGKKRDMSSD 101 LERDHRPHVS MPQNAN (amino acid sequence of pre-pro-ANP (Homo sapiens)): SEQ ID NO: 21 1 MSSFSTTTVS FLLLLAFQLL GQTRANPMYN AVSNADLMDF KNLLDHLEEK 51 MPLEDEVVPP QVLSEPNEEA GAALSPLPEV PPWTGEVSPA QRDGGALGRG 101 PWDSSDRSAL LKSKLRALLT APRSLRRSSC FGGRMDRIGA QSGLGCNSFR 151 YRR (amino acid sequence of pro-ANP (Homo sapiens)): SEQ ID NO: 22 1 NPMYNAVSNA DLMDFKNLLD HLEEKMPLED EVVPPQVLSE PNEEAGAALS 51 PLPEVPPWTG EVSPAQRDGG ALGRGPWDSS DRSALLKSKL RALLTAPRSL 101 RRSSCFGGRM DRIGAQSGLG CNSFRY (amino acid sequence of NT-proANP): SEQ ID NO: 23 1 NPMYNAVSNA DLMDFKNLLD HLEEKMPLED EVVPPQVLSE PNEEAGAALS 51 PLPEVPPWTG EVSPAQRDGG ALGRGPWDSS DRSALLKSKL RALLTAPR (MR-proANP = amino acid sequence of amino acids 53-90 of proANP): SEQ ID NO: 24 1 PEVPPWT GEVSPAQRDG GALGRGPWDS SDRSALLKSK L (Myoglobin (Homo sapiens)) SEQ ID NO: 25 1 MGLSDGEWQL VLNVWGKVEA DIPGHGQEVL IRLFKGHPET LEKFDKFKHL 51 KSEDEMKASE DLKKHGATVL TALGGILKKK GHHEAEIKPL AQSHATKHKI 101 PVKYLEFISE CIIQVLQSKH PGDFGADAQG AMNKALELFR KDMASNYKEL 151 GFQG (Creatine kinase (Homo sapiens)) SEQ ID NO: 26 1 MPFSNSHNAL KLRFPAEDEF PDLSAHNNHM AKVLTPELYA ELRAKSTPSG 51 FTLDDVIQTG VDNPGHPYIM TVGCVAGDEE SYEVFKDLFD PIIEDRHGGY 101 KPSDEHKTDL NPDNLQGGDD LDPNYVLSSR VRTGRSIRGF CLPPHCSRGE 151 RRAIEKLAVE ALSSLDGDLA GRYYALKSMT EAEQQQLIDD HFLFDKPVSP 201 LLLASGMARD WPDARGIWHN DNKTFLVWVN EEDHLRVISM QKGGNMKEVF 251 TRFCTGLTQI ETLFKSKDYE FMWNPHLGYI LTCPSNLGTG LRAGVHIKLP 301 NLGKHEKFSE VLKRLRLQKR GTGGVDTAAV GGVFDVSNAD RLGFSEVELV 351 QMVVDGVKLL IEMEQRLEQG QAIDDLMPAQ K (C reactive Protein (Homo sapiens)) SEQ ID NO: 27 1 MEKLLCFLVL TSLSHAFGQT DMSRKAFVFP KESDTSYVSL KAPLTKPLKA 51 FTVCLHFYTE LSSTRGYSIF SYATKRQDNE ILIFWSKDIG YSFTVGGSEI 101 LFEVPEVTVA PVHICTSWES ASGIVEFWVD GKPRVRKSLK KGYTVGAEAS 151 IILGQEQDSF GGNFEGSQSL VGDIGNVNMW DFVLSPDEIN TIYLGGPFSP 201 NVLNWRALKY EVQGEVFTKP QLWP