Pharmacological strategies for myocardial protection in cardiac surgery: current science and the emerging role of multi-omics and artificial intelligence

Perioperative myocardial ischaemia-reperfusion injury continues to represent a significant source of morbidity and mortality in patients undergoing cardiac surgery, despite considerable advances in cardiopulmonary bypass technology and operative technique. Contemporary cardioprotective approaches, including cardioplegia, offer only partial attenuation of this injury. Intraoperative protection strategies have evolved little over recent decades, and clinical trials investigating pharmacological agents directed at ischaemia-reperfusion pathways have yielded inconsistent results, though subgroup analyses frequently reveal benefit in specific patient populations. Such variability may reflect the inherent limitations of applying standardised interventions to physiologically diverse patient cohorts. Multi-omics profiling offers the capacity to identify distinct molecular signatures associated with susceptibility to ischaemia-reperfusion injury and severity of myocardial damage, and when combined with artificial intelligence, may predict individual therapeutic responses. These bioinformatic advances have implications not only for risk stratification and treatment selection but also for the design of future clinical trials through improved patient selection. This review synthesises current evidence regarding the mechanisms of ischaemia-reperfusion injury and evaluates pharmacological interventions targeting mitochondrial dysfunction, microvascular impairment, and inflammatory pathways. The potential role of multi-omics technologies integrated with artificial intelligence in enabling precision approaches to myocardial protection is subsequently examined.