Myonecrosis after revascularization procedures

Magnetic resonance imaging and multi-detector computed tomography assessment of extracellular compartment in ischemic and non-ischemic myocardial pathologies

Myocardial pathologies are major causes of morbidity and mortality worldwide. Early detection of loss of cellular integrity and expansion in extracellular volume (ECV) in myocardium is critical to initiate effective treatment. The three compartments in healthy myocardium are: intravascular (approximately 10% of tissue volume), interstitium (approximately 15%) and intracellular (approximately 75%). Myocardial cells, fibroblasts and vascular endothelial/smooth muscle cells represent intracellular compartment and the main proteins in the interstitium are types I/III collagens. Microscopic studies have shown that expansion of ECV is an important feature of diffuse physiologic fibrosis (e.g., aging and obesity) and pathologic fibrosis [heart failure, aortic valve disease, hypertrophic cardiomyopathy, myocarditis, dilated cardiomyopathy, amyloidosis, congenital heart disease, aortic stenosis, restrictive cardiomyopathy (hypereosinophilic and idiopathic types), arrythmogenic right ventricular dysplasia and hypertension]. This review addresses recent advances in measuring of ECV in ischemic and non-ischemic myocardial pathologies. Magnetic resonance imaging (MRI) has the ability to characterize tissue proton relaxation times (T1, T2, and T2*). Proton relaxation times reflect the physical and chemical environments of water protons in myocardium. Delayed contrast enhanced-MRI (DE-MRI) and multi-detector computed tomography (DE-MDCT) demonstrated hyper-enhanced infarct, hypo-enhanced microvascular obstruction zone and moderately enhanced peri-infarct zone, but are limited for visualizing diffuse fibrosis and patchy microinfarct despite the increase in ECV. ECV can be measured on equilibrium contrast enhanced MRI/MDCT and MRI longitudinal relaxation time mapping. Equilibrium contrast enhanced MRI/MDCT and MRI T1 mapping is currently used, but at a lower scale, as an alternative to invasive sub-endomyocardial biopsies to eliminate the need for anesthesia, coronary catheterization and possibility of tissue sampling error. Similar to delayed contrast enhancement, equilibrium contrast enhanced MRI/MDCT and T1 mapping is completely noninvasive and may play a specialized role in diagnosis of subclinical and other myocardial pathologies. DE-MRI and when T1-mapping demonstrated sub-epicardium, sub-endocardial and patchy mid-myocardial enhancement in myocarditis, Behcet’s disease and sarcoidosis, respectively. Furthermore, recent studies showed that the combined technique of cine, T2-weighted and DE-MRI technique has high diagnostic accuracy for detecting myocarditis. When the tomographic techniques are coupled with myocardial perfusion and left ventricular function they can provide valuable information on the progression of myocardial pathologies and effectiveness of new therapies.

Myocardial protection with prophylactic oral metoprolol during coronary artery bypass grafting surgery: evaluation by troponin I

INTRODUCTION

Biochemical markers of myocardial injury are frequently altered after cardiac surgery. So far there is no evidence whether oral beta-blockers may reduce myocardial injury after coronary artery bypass grafting.

OBJECTIVE

To determine if oral administration of prophylactic metoprolol reduces the release of cardiac troponin I in isolated coronary artery bypass grafting, not complicated by new Q waves.

METHODS

A prospective randomized study, including 68 patients, divided in 2 groups: Group A (n=33, control) and B (n=35, beta-blockers). In group B, metoprolol tartrate was administered 200 mg/day. The myocardial injury was assessed by troponin I with 1 hour and 12 hours after coronary artery bypass grafting.

RESULTS

No significant difference between groups regarding pre-surgical, surgical, complication in intensive care (15% versus 14%, P=0.92) and the total number of hospital events (21% versus 14%, P=0.45) was observed. The median value of troponin I with 12 hours in the study population was 3.3 ng/ml and was lower in group B than in group A (2.5 ng/ml versus 3.7 ng/ml, P<0,05). In the multivariate analysis, the variables that have shown to be independent predictors of troponin I release after 12 hours were: no beta-blockers administration and number of vessels treated.

CONCLUSION

The results of this study in uncomplicated coronary artery bypass grafting, comparing the postoperative release of troponin I at 12 hours between the control group and who used oral prophylactic metoprolol for at least 72 hours, allow to conclude that there was less myocardial injury in the betablocker group, giving some degree of myocardial protection.

Impact on prognosis of periprocedural myocardial infarction after percutaneous coronary intervention

INTRODUCTION

Different definitions of periprocedural myocardial infarction (MI) after percutaneous coronary intervention (PCI) have been provided, but their impact on prognosis remains to be determined.

METHODS

Procedural data from consecutive patients undergoing PCI from 2009 to 2011 were revised to adjudicate diagnosis of periprocedural MI according to CK-MB increase (>3 × URL and >5 × URL), to troponin increase (>3 × 99th percentile URL and >5 × 99th percentile URL) and to recent 2012 Task Force and Society for Cardiovascular Angiography and Interventions (SCAI) definitions. Major adverse cardiovascular events (MACE) was the primary end-point.

RESULTS

Seven hundred twelve patients were enrolled; after 771 days, 115 (16.7%) patients experienced MACE. One hundred ninety patients were diagnosed with a periprocedural MI defined as elevation of troponin >5 × 99th percentile of URL. When adjudicating 2012 Task Force definition on these patients, 46 were excluded and 1.4% of them experienced a MACE and 0.3% died, while among 144 with periprocedural MI, 2.9% reported a MACE and 1.3% died. After appraisal of SCAI definition, 176 patients were excluded, 3.8% of them with a MACE and 1.4% died, and for those with periprocedural MI, 0.5% experienced a MACE and 0.1% died. Similar low performance was appraised after reclassification of patients from more than 3 of upper limit of CK-MB and of troponin. At multivariate analysis, none of these definitions related to adverse events.

CONCLUSION

Periprocedural MI represents a frequent complication for patients undergoing PCI. All present definitions share a still not satisfactory discrimination between patients with and without adverse events at follow-up, stressing the need for more accurate definitions.

Impact of metabolic syndrome on myocardial injury and clinical outcome after percutaneous coronary intervention

AIMS

This study tested the associations between metabolic syndrome, postprocedural myocardial injury, and clinical outcome after percutaneous coronary intervention.

PATIENTS AND METHODS

We evaluated 204 patients who fulfilled the study criteria and were scheduled for elective percutaneous coronary intervention. The patients were divided into a metabolic syndrome group and a control group according to the definition of metabolic syndrome. Creatine kinase-MB and troponin I levels were measured at baseline, at 8 h, and 24 h after the procedure, while clinical outcomes were followed up for 1 year.

RESULTS

The incidence of postprocedural myocardial injury was significantly higher in the metabolic syndrome group than in the control group as indicated by either blood creatine kinase-MB elevation (32.9 % vs. 17.2 %, p = 0.010) or troponin I elevation (34.2 % vs. 17.2 %, p = 0.006). Postprocedural peak values of creatine kinase-MB (5.724 ± 7.678 ng/ml vs. 3.097 ± 5.317 ng/ml, p < 0.001) and troponin I (0.066 ± 0.093 ng/ml vs. 0.038 ± 0.079 ng/ml, p < 0.001) were also significantly higher in the metabolic syndrome group than in the control group. On multiple regression analysis, metabolic syndrome was independently associated with troponin I elevation (odds ratio 2.24, 95 % confidence interval, CI, 1.04-4.80, p = 0.039). During the 1-year follow-up, cardiac events occurred in 28.9 % of patients with metabolic syndrome and 17.9 % of controls, and there was a trend toward increased adverse outcomes in the metabolic syndrome group (hazard ratio 1.67, 95 % CI 0.93-3.00, p = 0.071, log rank test).

CONCLUSION

The results of this study demonstrate that metabolic syndrome is associated with postprocedural myocardial injury and with increased cardiac events.

Intermittent warm blood versus cold crystalloid cardioplegia for myocardial protection: a propensity score-matched analysis of 12-year single-center experience

Objectives:

This study analyzes the efficacy in myocardial protection of two types of cardioplegia solutions, namely, blood and crystalloid cardioplegia, both given intermittently in patients undergoing coronary artery bypass grafting (CABG).

Methods:

Adult patients undergoing primary isolated coronary artery bypass grafting between January 1998 and January 2011 with cardiopulmonary bypass, using either blood or crystalloid cardioplegia, were identified in our database. Propensity score matching was performed to create comparable patient groups. Multivariate logistic regression analysis was performed to identify independent risk factors for perioperative myocardial damage. The primary endpoint of the study was the maximum creatine kinase-MB (CK-MB) value within 5 days postoperatively with a cut-off point of 100 U/L. Early mortality and perioperative low cardiac output syndrome in both groups were compared.

Results:

The study included 7138 CABG patients: 3369 patients using crystalloid cardioplegia and 3769 using blood cardioplegia. After propensity score matching, 2585 patients per study group remained for the analysis. Wilcoxon signed-rank test revealed significantly higher CK-MB levels in patients operated with the use of blood cardioplegia. Multivariate regression analysis identified blood cardioplegia as an independent risk factor for elevated CK-MB levels. However, it was associated with lower aspartate aminotransferase (AST) levels. The type of cardioplegia had no influence on early mortality, postoperative low cardiac output syndrome or intensive care unit stay.

Conclusions:

Blood cardioplegia was identified as an independent risk factor for elevated levels of CK-MB after CABG, but was associated with lower AST levels. The authors conclude that the type of cardioplegia had no significant influence on clinical outcome.

Safe and feasible immediate retransfer of patients to the referring hospital after acute coronary angiography and percutaneous coronary angioplasty for patients with acute coronary syndrome

BACKGROUND

The challenge with fast track (FT) is to avoid compromising medical safety. We aimed to investigate whether patients with acute coronary syndrome could be safely retransferred to the referral hospital on the same day after coronary angiography and/or percutaneous coronary angioplasty (PCI).

METHODS AND RESULTS

A total of 399 consecutive patients were prospectively randomized: 206 to ordinary care (OC) and 193 to the FT group. Of these, 30% of patients were admitted for unstable angina pectoris and 70% for non-ST-segment elevation myocardial infarction. The FT patients were evaluated for possible same-day return after angiography and/or PCI. Crossover, acute, and 30-day major events were recorded. The radial approach was used in 91 and 87% in the OC and FT group, respectively. Of the FT patients, 95% were returned on the same day and nine crossover patients (4.7%) the next day or later. Major events occurred in nine patients (2.2%); five in the OC and four in the FT group. There were a total of five events within 24 hours. No events were observed during transportation and there were no early retransfers.

CONCLUSIONS

Immediate written reports and good communication with the referring hospital enabled thoroughly selected patients to be safely returned on the same day as angiography and/or PCI.

The evolving role of cardiac troponin in the evaluation of cardiac disorders

Due to their tissue specificity and ease of detection, the cardiac troponins (cTn) have emerged as the most important and most utilized biomarkers for the diagnosis of acute myocardial infarction (AMI). The recent achievement of greater sensitivity by cTn assay systems, however, has resulted in the detection of cTn in a wide array of medical conditions, highlighting myocardial cellular necrosis as a feature in several, seemingly unrelated medical conditions, yet complicating the interpretation of a positive test. Since elevated cTn levels are associated with worse clinical outcomes and, thereby, influence medical decisions, careful consideration should be given to the method by which these biomarkers are measured, the patient population on which the test is being applied, and applicable thresholds based on particular clinical conditions. The objective of this review is to trace the clinical evolution of the cTn biomarker from a test for AMI to a general marker of myocardial cellular necrosis with clinically important prognostic information.

Diagnostic and prognostic value of minor elevated cardiac troponin levels for percutaneous coronary intervention-related myocardial injury: a prospective, single-center and double-blind study

Cardiac troponin-I (cTnI) and -T (cTnT) are sensitive and specific markers of myocardial injury. However, the role of increased cTnI and cTnT in percutaneous coronary intervention (PCI)-related myocardial injury remains controversial. In this prospective, single-center and double-blind study, we aimed to determine the diagnostic and prognostic value of cTnI as well as cTnT (cTns) in PCI-related myocardial injury in a Chinese population. A total of 1,008 patients with stable angina pectoris and non-ST-segment elevation acute coronary syndrome were recruited. The levels of cTnI and cTnT were examined before and after PCI. All patients were followed up for 26±9 months to observe the incidence of major adverse cardiac events (MACEs). Our results showed that post-PCI cTnI and/or cTnT levels were increased to more than the 99^th percentile upper reference limit (URL) in 133 (13.2%) patients, among which 22 (2.2%) were more than 5 × 99^th percentile URL. By univariate analysis, an elevation in cTns after PCI was not an independent predictor of increased MACEs, HR 1.35 (P  =  0.33, 95%CI: 0.74–2.46). In conclusion, our data demonstrate that the incidence of PCI-related myocardial injury is not common in a Chinese population and minor elevated cTns levels may not be a sensitive prognostic marker for MACEs.

A correlation between acute kidney injury and myonecrosis after scheduled percutaneous coronary intervention

Slight elevations in cardiac troponin I and T are frequently observed after percutaneous coronary intervention (PCI). Contrast-induced acute kidney injury (CI-AKI) is a complex syndrome induced by exposure to intravascular contrast media (CM). Currently, the relationships between the CM, pre-existing kidney insufficiency, CI-AKI, and myonecrosis after elective PCI are unclear. To investigate the relationship between CI-AKI and post-procedural myonecrosis (PMN) after PCI, we analyzed 327 non-ST-segment elevation acute coronary syndrome subjects undertaking elective PCI. The levels of cardiac troponins (cTns), cTnI and cTnT, at baseline and on at least one occasion 18-24 h after PCI were measured. We also recorded serum levels of creatinine (SCr) and the urine albumin:creatinine ratio (ACR) before coronary angiography, and 24-48 h and 48-72 h after contrast administration. A post-procedure increase in cTns was detected in 16.21% (53/327) of subjects with cTns levels >99th to 5×99th percentile upper reference limit (URL). Twenty-seven patients (8.26%) developed CI-AKI. CI-AKI occurred more often in subjects with PMN than in those without PMN (20.8% versus 5.8%, respectively, P=0.001). Multiple logistic regression analysis revealed that pre-existing microalbuminuria (MA) was an important independent predictor of PMN (OR: 3.31; 95% CI: 1.26-8.65, P=0.01). However, there was no correlation between the incidence of CI-AKI and PMN (OR: 2.38; 95% CI: 0.88-6.46, P=0.09). We conclude that pre-existing MA was not only an important independent predictor of CI-AKI but also of PMN.

The effect of intravenous vitamin C infusion on periprocedural myocardial injury for patients undergoing elective percutaneous coronary intervention

BACKGROUND

This small study has determined the effect of vitamin C on myocardial reperfusion in patients undergoing elective percutaneous coronary intervention (PCI). This study was to explore whether antioxidant vitamin C infusion before the procedure is able to affect the incidence of periprocedural myocardial injury (PMI) in patients undergoing PCI.

METHODS

In this prospective single-centre randomized study, 532 patients were randomized into 2 groups: the vitamin C group, which received a 3-g vitamin C infusion within 6 hours before PCI, and a control group, which received normal saline. The primary end point was the troponin I-defined PMI, and the second end point was the creatine kinase (CK)-MB-defined PMI. Separate analyses using both end points were performed. PMI was defined as an elevation of cardiac biomarker values (CK-MB or troponin I) > 5 times the upper limit of normal (ULN), alone or associated with chest pain or ST-segment or T-wave changes.

RESULTS

After PCI, the incidence of PMI was reduced, whether defined by troponin or by CK-MB, compared with the control group (troponin I, 10.9% vs 18.4%; P = 0.016; CK-MB, 4.2% vs 8.6%; P = 0.035). Logistic multivariate analysis showed that preprocedure use of vitamin C is an independent predictor of PMI either defined by troponin I (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.97; P = 0.037) or by CK-MB (OR, 0.37; 95% CI, 0.14-0.99; P = 0.048).

CONCLUSIONS

In patients undergoing elective PCI, preprocedure intravenous treatment with vitamin C is associated with less myocardial injury.

Cardiac markers following cardiac surgery and percutaneous coronary intervention

Differentiation between procedure-related necrosis and postprocedural myocardial infarction (MI) is challenging because of the inherent association of these procedures to varying levels of myocardial injury. To improve risk stratification of patients at risk of an acute MI, the universal definition of MI implemented cardiac biomarker thresholds. The cutoff points for these thresholds, however, are largely arbitrary and lack therapeutic implications. Measurement of cardiac marker concentrations after percutaneous coronary intervention and cardiac surgery should, therefore, be used as a marker of baseline risk, atherosclerosis burden, and procedural complexity rather than a conclusive marker to diagnose acute MI.

Periprocedural myocardial injury in chronic total occlusion percutaneous interventions: a systematic cardiac biomarker evaluation study

OBJECTIVES

This study sought to evaluate the incidence, correlates, and clinical implications of periprocedural myocardial injury (PMI) during percutaneous coronary intervention (PCI) of chronic total occlusions (CTO).

BACKGROUND

The risk of PMI during CTO PCI may be underestimated because systematic cardiac biomarker measurement was not performed in published studies.

METHODS

We retrospectively examined PMI among 325 consecutive CTO PCI performed at our institution between 2005 and 2012. Creatine kinase-myocardial band fraction and troponin were measured before PCI and 8 to 12 h and 18 to 24 h after PCI in all patients. PMI was defined as creatine kinase-myocardial band increase ≥ 3 x the upper limit of normal. Major adverse cardiac events during mid-term follow-up were evaluated.

RESULTS

Mean age was 64 ± 8 years. The retrograde approach was used in 26.8% of all procedures. The technical and procedural success was 77.8% and 76.6%, respectively. PMI occurred in 28 patients (8.6%, 95% confidence intervals: 5.8% to 12.2%), with symptomatic ischemia in 7 of those patients. The incidence of PMI was higher in patients treated with the retrograde than the antegrade approach (13.8% vs. 6.7%, p = 0.04). During a median follow-up of 2.3 years, compared with patients without PMI, those with PMI had a higher incidence of major adverse cardiac events (hazard ratio [HR]: 2.25, p = 0.006). Patients with only asymptomatic PMI also had a higher incidence of major adverse cardiac events on follow-up (HR: 2.26, p = 0.013).

CONCLUSIONS

Systematic measurement of cardiac biomarkers post-CTO PCI demonstrates that PMI occurs in 8.6% of patients, is more common with the retrograde approach, and is associated with worse subsequent clinical outcomes during mid-term follow-up.

Platelet-larger cell ratio and the risk of periprocedural myocardial infarction after percutaneous coronary revascularization

Periprocedural myocardial infarction (PMI) represents a frequent complication in patients undergoing percutaneous coronary revascularization. Despite great attention focused on pharmacological prevention of periprocedural damage, very little is known about using biomarkers to potentially predict the risk of PMI. Larger platelets have been associated with enhanced reactivity, increased cardiovascular risk, and higher rates of complications after coronary stenting. The platelet-larger cell ratio (P-LCR) identifies the largest-sized fraction of platelets, the proportion potentially more closely related to thrombotic events. The present study evaluated the relationship between P-LCR and PMI. We included 1,285 patients undergoing PCI. Myonecrosis biomarkers were dosed at intervals from 6 to 48 h after PCI. Periprocedural myonecrosis was defined as troponin I increase by three times the upper limit of normal (ULN) or by 50 % of an elevated baseline value, whereas PMI was defined as an increase in creatine kinase MB by 3 × ULN or 50 % of baseline. We grouped patients according to tertile values of P-LCR (<27.5; ≥35.1). Higher P-LCR was associated with age (P = 0.01), diabetes (P = 0.001), previous cerebrovascular accidents (P = 0.007), therapy with statins (P < 0.001), angiotensin receptor blockers (P < 0.001), aspirin (P = 0.002), and nitrates (P = 0.01). P-LCR was related to hemoglobin levels (P < 0.001), and inversely related to platelet count (P < 0.001) and glycemia (P = 0.05). Patients with higher P-LCR had a lower presence of coronary thrombus (P = 0.003). Higher P-LCR values did not increase the risk of PMI (P = 0.10; adjusted odds ratio (OR) (95 % confidence interval (CI)) = 0.97 (0.69-1.38)), P = 0.89) or periprocedural myonecrosis (P = 0.96; adjusted OR (95 % CI) = 1.003 (0.76-1.32), P = 0.99). Results were confirmed even in higher-risk subgroups of patients. P-LCR does not increase the risk of periprocedural myocardial infarction and myonecrosis in patients undergoing coronary stenting.

Prognostic implications of procedural vs spontaneous myocardial infarction: results from the Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry

BACKGROUND

In randomized clinical trials, procedural myocardial infarction (MI) or spontaneous MI is often weighted equally as a component of a composite clinical end point. An underlying assumption of this approach is that procedural and spontaneous MIs have similar prognostic impact. Our aim was to evaluate the prognostic impact of procedural vs spontaneous MI in patients undergoing percutaneous coronary intervention (PCI).

METHODS

We used data from the EVENT registry to examine the relative prognostic impact of procedural vs spontaneous MI. For the purposes of this study, patients undergoing initial PCI were stratified into 3 groups-no MI, procedural MI, or spontaneous MI-based on standard definitions applied at the time of the index procedure and followed for 1 year for outcomes of all-cause mortality and cardiovascular mortality. Multiple propensity score adjustment analysis was used to adjust for differences in baseline covariates among the 3 groups.

RESULTS

Among 7,380 patients included in this analysis, 4,568 (62%) patients had no MI, 580 (8%) patients had procedural MI at the time of their index procedure, and 2,232 (30%) patients presented with a spontaneous MI before PCI. In unadjusted analyses, there was a graded increase in risk of 1-year mortality (1.9% vs 3.1% vs 3.9%; P < .0001) and cardiovascular death (0.5% vs 1.0% vs 1.7%; P < .0001) across the 3 groups. After adjusting for propensity scores, spontaneous MI (adjusted hazard ratio [HR] 1.62, 95% CI 1.11-2.37, P = .01) but not procedural MI (adjusted HR 1.51, 95% CI 0.89-2.54, P = .12) was independently associated with death at 12 months when compared with the no-MI group. Findings were similar when the analysis was limited to cardiovascular death (adjusted HRs 3.14 [95% CI 1.68-5.90, P < .001] and 1.74 [95% CI 0.69-4.40, P = .24], respectively).

CONCLUSIONS

Among patients undergoing PCI, spontaneous but not procedural MI was independently associated with death and cardiovascular death at 1 year. These finding suggest that the prognostic impact of procedural MI may be less than that of spontaneous MI and should be considered in designing end points for future studies of coronary revascularization.

High-dose atorvastatin pretreatment could diminishes microvascular impairment in patients undergoing elective percutaneous coronary intervention

OBJECTIVES

High-dose statins pretreatment is reasonable before percutaneous coronary intervention (PCI) to reduce the risk of periprocedural myocardial injury. However, the mechanism underlying this protective effect has not been elucidated. The aim of this study is to evaluate the effects of high-dose atorvastatin pretreatment on microvascular function and myocardial injury after elective PCI.

METHODS

Eighty four patients underwent elective PCI were randomly assigned to high-dose atorvastatin (40 mg/d) and low-dose atorvastatin (20 mg/d) treatment for 7 days before PCI. The index of microcirculatory resistance (IMR) was measured by an intracoronary ressure/temperature sensor-tipped guidewire at maximal hyperemia after PCI. Fractional flow reserve (FFR) was measured before and after procedure. Troponin I levels were obtained at baseline and 20-24 h after procedure.

RESULTS

IMR values were significantly lower in high-dose group when compared to low-dose group (16.5 ± 6.1 vs. 31.2 ± 16.0, P < 0.001). Pre-PCI troponin I levels between the two groups were similar (0.028 ± 0.05 vs. 0.022 ± 0.04, P = 0.55). However, post-PCI troponin I levels in high-dose group were significantly lower than low-dose group (0.11 ± 0.02 vs. 0.16 ± 0.09, P < 0.001). Multivariate analysis identified maximum inflation pressure > 20 atm as an independent predictor of IMR > 32 (Odds ratio (OR): 3.3, 95% confidence intervals (95%CI): 1.3-8.5, P = 0.02). High-dose atorvastatin was the only independent protective factor of IMR > 32 (OR: 0.29, 95%CI: 0.11-0.74, P = 0.01).

CONCLUSIONS

The present study confirmed that diminishing microvascular impairment is one of the mechanism underlying protecting effect of high-dose statins pretreatment from myocardial injury during PCI. These suggest that high-dose statin pretreatment is reasonable in patients undergoing elective PCI.

Changes of cardiac troponin I and operative mortality of coronary artery bypass

Background

Recently, cardiac troponin I has been used to detect myocardial injury because of its superior cardiac specificity. However, there has been debate about the appropriate timing and cutoff level of cardiac troponin I to detect perioperative myocardial injury after coronary artery bypass grafting. The objective of this study was to define the relationship between operative mortality and changes in cardiac troponin I after isolated coronary artery bypass.

Patients and methods

A retrospective analysis was carried out on data of 218 isolated coronary artery bypass patients who were operated on between June 2009 and February 2012. All patients followed an institutional perioperative management protocol that included 6 cardiac troponin I measurements (preoperatively and 0, 12, 24, 36, and 48 h after coronary artery bypass). According to the patterns of cardiac troponin I, the patient cohort was divided into 2 groups. Group 1 was patients in whom cardiac troponin I levels decreased 24 h after the operation, and group 2 comprised the patients with cardiac troponin I levels that did not decrease or even increased after 24 h.

Results

The operative mortality was 4.1% (9/218). Group 2 showed significantly higher mortality (5/25, 20%) than group 1 (4/193, 2.1%).

Conclusion

An elevated cardiac troponin I level is common after coronary artery bypass. A persistently high level of cardiac troponin I after 24 h is an important predictor of operative mortality after coronary artery bypass surgery.

Platelet HPA-1 a/HPA-1 b polymorphism and the risk of periprocedural myocardial infarction in patients undergoing elective PCI

Periprocedural myocardial infarction (PMI) represents a relatively common complication of percutaneous coronary intervention (PCI) and large interests have been focused on platelets in order to prevent such a complication. The single nucleotide polymorphism Leu33Pro of platelet glycoprotein IIIa has been related to an increased platelet reactivity, a lower response to antiplatelet agents and higher risk of stent restenosis. Therefore, aim of our study was to evaluate the impact of this polymorphism on PMI in elective patients undergoing PCI. Our population is represented by 422 consecutive patients with cardiac biomarkers within normality undergoing elective PCI. We measured cardiac biomarkers (CK-MB and Troponin I) at baseline, and 8, 24 and 48 hours after the procedure. For all subjects, we performed genetic analysis to assess the presence of Leu33Pro polymorphism. A total of 136 patients (32.2%) were polymorphic. Those patients were younger (p = 0.03) and more often dislypidemic (p = 0.01). Angiographic features did not differ according to genetic status. Pharmacological treatment pre and during angioplasty was similar. PCI-related complications did not differ according to genotype, with the only exception of higher rate of distal embolization in polymorphic patients. However, Leu33Pro polymorphism was not associated with increased risk of periprocedural myonecrosis and PMI even after correction for baseline differences, (respectively OR = 1.22 [0.81-1.84], p = 0.34 for myonecrosis and OR = 1.66 [0.85-3.23]; p = 0.14 for PMI). At subgroup analysis, the Leu33Pro substitution was associated with higher risk of PMI only among diabetics (adjusted OR = 4.46 [1.12-17.76], p = 0.03). Among patients undergoing elective PCI, the polymorphism Leu33Pro of platelet glycoprotein IIIa is associated with increased risk of PMI only in diabetic patients.

Increased thin-cap neoatheroma and periprocedural myocardial infarction in drug-eluting stent restenosis: multimodality intravascular imaging of drug-eluting and bare-metal stents

BACKGROUND

Re-endothelialization is delayed after drug-eluting stent (DES) implantation. In this setting, neointima is more prone to become lipid laden and develop neoatherosclerosis (NA), potentially increasing plaque vulnerability.

METHODS AND RESULTS

Optical coherence tomography and near-infrared spectroscopy with intravascular ultrasound were used to characterize NA in 65 (51 DES and 14 bare-metal stents) consecutive symptomatic patients with in-stent restenosis. Median duration poststent implantation was 33 months. Optical coherence tomography-verified NA was observed in 40 stents with in-stent restenosis (62%), was more prevalent in DES than bare-metal stents (68% versus 36%; P=0.02), and demonstrated significantly higher prevalence of thin-cap neoatheroma (47% versus 7%; P=0.01) in DES. Near-infrared spectroscopy assessment demonstrated that the total lipid core burden index (34 [interquartile range, 12-92] versus 9 [interquartile range, 0-32]; P<0.001) and the density of lipid core burden index (lipid core burden index/4 mm, 144 [interquartile range, 60-285] versus 26 [interquartile range, 0-86]; P<0.001) were higher in DES compared with bare-metal stents. Topographically, NA was classified as I (thin-cap NA), II (thick-cap NA), and III (peri-strut NA). Type I thin-cap neoatheroma was more common in DES (20% versus 3%; P=0.01) and in areas of the stented segment without significant in-stent restenosis (71%). Periprocedural myocardial infarction occurred only in DES (11 versus 0; P=0.05), of which 6 (55%) could be attributed to segments with >70% in-stent restenosis. By logistic regression, prior DES was the only independent predictor of both NA (odds ratio, 7.0; 95% confidence interval, 1.7-27; P=0.006) and periprocedural myocardial infarction (odds ratio, 1.8; 95% confidence interval, 1.1-2.4; P=0.05).

CONCLUSIONS

In-stent thin-cap neoatheroma is more prevalent, is distributed more diffusely across the stented segment, and is associated with increased periprocedural myocardial infarction in DES compared with bare-metal stents. These findings support NA as a mechanism for late DES failure.

Incidence and short-term clinical outcomes of small side branch occlusion after implantation of an everolimus-eluting bioresorbable vascular scaffold: an interim report of 435 patients in the ABSORB-EXTEND single-arm trial in comparison with an everolimus-eluting metallic stent in the SPIRIT first and II trials

OBJECTIVES

The aim of this study was to investigate the incidence and clinical sequelae of small side branch occlusion (SBO) after Absorb (Abbott Vascular, Santa Clara, California) bioresorbable vascular scaffold (BVS) implantation.

BACKGROUND

The thicker strut of metallic stents potentially contributes to a higher incidence of SBO.

METHODS

We performed a post-hoc angiographic assessment of 1,209 side branches in 435 patients enrolled in the ABSORB-EXTEND single-arm trial (ABSORB EXTEND Clinical Investigation: A Continuation in the Clinical Evaluation of the ABSORB Bioresorbable Vascular Scaffold [BVS] System in the Treatment of Subjects With de Novo Native Coronary Artery Lesions), in comparison with 682 side branches in 237 patients treated with the everolimus-eluting metallic stent (EES) in the SPIRIT (A Clinical Evaluation of an Investigational Device. The Abbott XIENCE V Everolimus Eluting Coronary Stent System in the Treatment of Patients With de Novo Native Coronary Artery Lesions) first and II trials. Any visible side branches originating within the device implantation site or the 5-mm proximal and distal margins were included in the angiographic assessment. The SBO was defined as a reduction in Thrombolysis In Myocardial Infarction flow grade 0 or 1.

RESULTS

Post-procedural SBO was observed in 73 side branches (6.0%) in BVS group and 28 side branches (4.1%) in EES group (p = 0.09). Patients with post-procedural SBO were significantly associated with an increased incidence of in-hospital myocardial infarction (6.5% in SBO group vs. 0.5% in non-SBO group, p < 0.01). Multivariable analysis revealed that BVS was an independent predictor of post-procedural SBO (odds ratio: 2.09; 95% confidence interval: 1.18 to 3.68). By stratified analysis, BVS demonstrated a higher incidence of post-procedural SBO compared with EES only in small side branches with a reference vessel diameter ≤0.5 mm (10.5% vs. 3.9%, p = 0.03 between the groups, p for interaction = 0.08).

CONCLUSIONS

Bioresorbable vascular scaffold was associated with a higher incidence of post-procedural SBO compared with EES. This effect was more pronounced with small side branches with a reference vessel diameter ≤0.5 mm. (ABSORB EXTEND Clinical Investigation: A Continuation in the Clinical Evaluation of the ABSORB Bioresorbable Vascular Scaffold [BVS] System in the Treatment of Subjects With de Novo Native Coronary Artery Lesions: NCT01023789).

Effects of intravenous diltiazem in a rat model of experimental coronary thrombotic microembolism

The aim of this study was to assess the feasibility of evaluating the therapeutic effects of intravenous diltiazem in a newly established rat model of coronary thrombotic micro-embolism (CME). CME was induced by injecting 0.199 ml saline containing 5 mg of automicrothrombotic particulates (∼10 μm) into the aorta of Sprague Dawley rats. The injection was carried out over 10 sec using a tuberculin syringe with a 28-gauge needle. The CME model rats were randomly divided into untreated (CME, n=38) and diltiazem-treated (CME+DIL, n=38) groups. Diltiazem (1 mg/ml, 50 μg/min/kg) was intravenously injected using an infusion pump through the tail vein for 175 min, 5 min following the injection of the automicrothrombotic particulates. Hemodynamic measurements, echocardiography and pathohistological examinations were performed at various time-points (3 h, 24 h and 7 and 28 days) postoperatively. Arteriolar thrombosis, multifocal myocardial necrosis, inflammatory cell infiltration with markedly increased myocardial tumor necrosis factor α (TNF-α) and interleukin-6 (IL-6) expression, reduced left ventricular (LV) systolic function and increased plasma von Willebrand factor (vWF), endothelin-1 (ET-1) and serum c-troponin I (c-TnI) levels (indicating vascular endothelial injury and myocardial necrosis) were observed in the CME model rats. These pathological responses in CME rats were partly attenuated by intravenous diltiazem treatment. The present CME model is suitable for evaluating the therapeutic effects of intravenous diltiazem; intravenous diltiazem treatment significantly improved cardiac function through alleviating inflammatory responses and microvascular thrombotic injury in this rat model of CME.

Incidence, correlates, and significance of abnormal cardiac enzyme rises in patients treated with surgical or percutaneous based revascularisation: a substudy from the Synergy between Percutaneous Coronary Interventions with Taxus and Cardiac Surgery (SYNTAX) Trial

AIMS

The aim of the present investigation was to determine the long-term prognostic association of post-procedural cardiac enzyme elevation within the randomised Synergy between Percutaneous Coronary Intervention (PCI) with TAXUS and Cardiac Surgery (SYNTAX) Trial.

METHODS

1800 patients with unprotected left main or de novo three-vessel coronary artery disease were randomised to undergo coronary artery bypass graft (CABG) surgery or PCI. Per protocol patients underwent post-procedural blood sampling with creatine kinase (CK), and the cardiac specific MB iso-enzyme (CK-MB) only if the preceding CK ratio was ≥ 2 × the upper limit of normal (ULN). An independent chemistry laboratory evaluated all collected blood samples.

RESULTS

Post-procedural CK sampling was available in 1629 of 1800 patients (90.5%). As per protocol, CK-MB analyses were undertaken in 474 of 491 patients (96.5%) in the CABG arm, and 53 of 61 patients (86.9%) in the PCI arm. Within the CABG arm, despite the limitations of incomplete data, a post-procedural CK-MB ratio <3/≥3 ULN separated 4-year mortality into low- and high-risk groups (2.3% vs. 9.5%, p=0.03). Additionally, in the CABG arm, a post-procedural CK-MB ratio ≥3 ULN was associated with an increased frequency of a high SYNTAX Score (≥33) tertile (high [≥33] SYNTAX Score: 39.5%, intermediate [23-32] SYNTAX Score 31.0%, low [≤22] SYNTAX Score 29.5%, p=0.02). Within the PCI arm, a post-procedural CK ratio of <2 or ≥2 ULN separated 4-year mortality into low- and high-risk groups (10.8% vs. 23.3%, p=0.001). Notably, there was an early (within 6 months) and late (after 2 years) peak in mortality in patients with a post-PCI CK ratio of ≥2 ULN. Lack of pre-procedural thienopyridine, carotid artery disease, type 1 diabetes, and presence of coronary bifurcations were independent correlates of a CK ratio ≥2 ULN post-PCI.

CONCLUSION

Cardiac enzyme elevations post-CABG or post-PCI are associated with an adverse long-term mortality; the causes of which are multifactorial.

Association of baseline C-reactive protein levels with periprocedural myocardial injury in patients undergoing percutaneous bifurcation intervention: a CACTUS study subanalysis

OBJECTIVES

To assess the predictive value of C-reactive protein (CRP) on periprocedural myocardial injury (PMI), evaluated by creatine kinase-myocardial band isoform (CK-MB) elevation in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation for the treatment of coronary bifurcation lesions is actually unknown.

BACKGROUND

Systemic inflammation as assessed by CRP has been associated with averse events after DES implantation. After PCI, the occurrence of PMI is common and has also been associated with worse outcomes. Finally, bifurcations are frequently encountered anatomically complex lesions which the treatment is associated with higher complication rate compared with simple lesions.

METHODS

A total of 96 patients (66 ± 10 years, 70 men) from the Coronary bifurcations: Application of the Crushing Technique Using Sirolimus-eluting stents (CACTUS) trial who had baseline CRP dosage and both baseline and postprocedural CK-MB measurement were included.

RESULTS

A complex bifurcation strategy was implemented in 53 (55%) patients, and angiographic success was achieved in all but two (2%) patients. Periprocedural myocardial necrosis (increase of CK-MB between one and three times the upper limit of normal [ULN]) was observed in 12 (13%) patients, and four (4%) patients had PCI-related myocardial infarction (increase of CK-MB more than three times ULN). Notably, progressively higher CRP levels were observed in patients with different increase in CK-MB (P = 0.041). Moreover, CRP >1 mg/L significantly predicted CK-MB rise (odds ratio 5.6, 95% confidence interval 1.5-4.3, P = 0.011).

CONCLUSION

In the setting of true coronary bifurcations treated by DES, baseline CRP levels were significantly associated with both the incidence and the extent of PMI.

Remote ischemic preconditioning: the surgeon's perspective

Since cardiac surgery began, surgeons have aimed to find methods of minimizing myocardial injury resulting from ischemia and reperfusion. The concept of somehow conditioning the heart in order to attenuate ischemia and reperfusion-related injury has evolved in cardiovascular research over decades, from ischemic preconditioning and postconditioning to, more recently, remote ischemic preconditioning (and postconditioning). Although many strategies have proven to be beneficial in the experimental arena, a few have been successfully translated into clinical practice. Remote ischemic preconditioning, with the use of brief episodes of ischemia and reperfusion of vascular territories remote from the heart, has been shown convincingly to decrease myocardial injury. To date, the translation of this powerful innate mechanism of myocardial and/or multiorgan protection from the animal lab to the operating theatre, using transient occlusion of blood flow to the upper limb with a blood-pressure cuff before cardiac surgery, has shown promising results, with several proof-of-principle and first randomized controlled clinical trials reporting benefits for patients undergoing cardiac surgery. If the efficacy of remote ischemic preconditioning can be conclusively proven, the clinical applications in cardiac surgery could be almost infinite, providing multiorgan protection in various surgical scenarios.

Evaluation of XIENCE V everolimus-eluting and Taxus Express2 paclitaxel-eluting coronary stents in patients with jailed side branches from the SPIRIT IV trial at 2 years

The aim of this study was to determine whether patients from the Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System in the Treatment of Patients With de Novo Native Coronary Artery Lesions (SPIRIT) IV trial who underwent percutaneous coronary intervention, who had target lesions with jailed side branches, had improved clinical outcomes when treated with the XIENCE V versus Taxus Express(2) drug-eluting stent. In the SPIRIT III randomized trial, patients with target lesions with jailed side branches after XIENCE V compared with Taxus Express(2) implantation had lower 2-year rates of major adverse cardiac events. The SPIRIT IV trial represents a larger more diverse patient population compared with SPIRIT III. In the large-scale, prospective, multicenter, randomized SPIRIT IV trial, 3,687 patients who underwent coronary stenting with up to 3 de novo native coronary artery lesions were randomized 2:1 to receive XIENCE V versus Taxus Express(2) stents. Two-year clinical outcomes of patients with or without jailed side branches after stenting were compared. A jailed side branch was defined as any side branch >1.0 mm in diameter within the target segment being stented, excluding bifurcations deemed to require treatment. Of the 3,687 patients in SPIRIT IV, a total of 1,426 had side branches that were jailed during angioplasty of the target lesion. Patients with jailed side branches after XIENCE V compared with Taxus Express(2) implantation had significantly lower 2-year rates of target lesion failure (6.5% vs 11.9%, p = 0.001), major adverse cardiac events (6.6% vs 12.2%, p = 0.0008), ischemia-driven target vessel revascularization (4.1% vs 7.9%, p = 0.004), and stent thrombosis (0.6% vs 2.8%, p = 0.001). In conclusion, patients with jailed side branches after stenting with XIENCE V compared to Taxus Express(2) devices had superior clinical outcomes at 2 years in the large-scale randomized SPIRIT IV trial.

PERIPROCEDURAL MYOCARDIAL DAMAGE

Percutaneous coronary intervention (PCI), as a method of myocardial revascularisation, is widely and effectively used for the treatment of coronary heart disease (CHD), with immediate success rates of >90%. Depending on the diagnostic criteria, 5–30% of these patients could develop the signs of periprocedural myocardial damage (PMD) or periprocedural myocardial infarction (PMI). PMD predictors, mechanisms of PMD development, and its specific clinical features play an important role in the PMI prevention. At present, there is no universal agreement on the definition and diagnostics of periprocedural myocardial necrosis and PMI, or on their impact on the clinical outcomes. According to the results of the recent studies, which are presented in this review, the current criteria of PMI might need to be modified, due to the increasingly high sensitivity of the modern threshold levels of troponin. 

Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Prevention of Spontaneous Myocardial Infarction in Subjects With Stable Ischemic Heart Disease

Background—

Contemporary studies have shown that spontaneous but not procedural myocardial infarction (MI) is related to subsequent mortality. Whether percutaneous coronary intervention (PCI) reduces spontaneous (nonprocedural) MI is unknown.

Methods and Results—

PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials until October 2012 comparing PCI with optimal medical therapy (OMT) for stable ischemic heart disease and reporting MI outcomes: spontaneous nonprocedural MI, procedural MI, and all MI, including procedure-related MI. Given the varying length of follow-up between trials, a mixed-effect Poisson regression meta-analysis was used. From 12 randomized clinical trials with 37 548 patient-years of follow-up, PCI compared with OMT alone was associated with a significantly lower incident rate ratio (IRR) for spontaneous nonprocedural MI (IRR=0.76; 95% confidence interval [CI], 0.58–0.99) at the risk of a higher rate of procedural MI (IRR=4.11; 95% CI, 2.53–6.88) without any difference in the risk of all MI (IRR=0.96; 95% CI, 0.74–1.21). The point estimate for PCI versus OMT for all-cause mortality (IRR=0.88; 95% CI, 0.75–1.03) and cardiovascular mortality (IRR=0.70; 95% CI, 0.44–1.09) paralleled that for spontaneous nonprocedural MI (but not procedural or all nonfatal MI), although these were not statistically significant.

Conclusions—

PCI compared with OMT reduced spontaneous MI at the risk of procedural MI without any difference in all MI. Consistent with prior studies showing that spontaneous MI but not procedural MI is related to subsequent mortality, in the present report the point estimate for reduced mortality with PCI compared with OMT paralleled the prevention of spontaneous MI with PCI. Further studies are needed to determine whether these associations are causal.

Mean platelet volume and the risk of periprocedural myocardial infarction in patients undergoing coronary angioplasty

BACKGROUND

Periprocedural myocardial infarction (PMI) represents a relatively common complication of percutaneous coronary intervention (PCI). Mean platelet volume (MPV) has been proposed as a marker for platelet activation, as larger sized platelets have been associated with higher pro-thrombotic risk. Therefore, aim of the current study was to evaluate whether MPV is associated with increased risk of PMI after PCI.

METHODS

We included 1056 consecutive patients undergoing PCI. We measured myonecrosis biomarkers at intervals from 6 to 48 h after PCI. Periprocedural myonecrosis was defined for troponin I increase by 3 times the ULN or by 50% if elevated at the time of the procedure. PMI was defined as CK-MB increase by 3 times the ULN or 50% if elevated at the time of the procedure.

RESULTS

We grouped patients according to tertiles values of MPV (<10.4 fl; 10.5-11.3 fl; >11.4 fl). High MPV was associated with diabetes (p = 0.025) and higher prevalence of cerebrovascular events (p = 0.005). MPV significantly related with haemoglobin levels (p < 0.001), but inversely to platelet count (p < 0.001) and higher presence of thrombus (p = 0.03). Larger sized platelets did not increase risk of periprocedural myonecrosis (p = 0.91; OR[95% CI] = 1.04[0.90-1.2], p = 0.64) or PMI (p = 0.09; OR[95%IC] = 1.13[0.93-1.37]; p = 0.20). Subgroup analysis confirmed no impact of MPV on periprocedural MI also in high-risk subsets of patients, such as those with ACS at presentation (OR[95%CI] = 1.09 [0.87-1.38]; p = 0.44), diabetes (OR[95% CI] = 1.02[0.71-1.47], p = 0.91), female gender (OR [95% CI] = 1.15 [0.78-1.71], p = 0.48), elderly patients (age ≥ 75 years) (OR[95%CI] = 1.21[0.87-1.69], p = 0.25) or with renal failure (OR[95%CI] = 1.55[0.91-2.61], p = 0.1).

CONCLUSIONS

This study demonstrates that MPV does not predict the risk of PMI in patients undergoing PCI.

Incidence of periprocedural myocardial infarction and cardiac biomarker testing after percutaneous coronary intervention in Japan: results from a multicenter registry

Periprocedural myocardial infarction (pMI) is an important complication associated with percutaneous coronary intervention (PCI). However, data on the frequency of biomarker testing and the incidence of pMI remain unclear. Using the multicenter Japan Cardiovascular Database, we identified 2182 patients who underwent PCI without preprocedural cardiac biomarker elevation (silent ischemia, stable angina, or unstable angina without biomarker elevation) from September 2008 to August 2011. Of these, 550 patients (25.2 %) underwent cardiac biomarker testing within 6-24 h after PCI. The incidence of pMI was 2.7 % among all identified patients and 7.5 % among those who underwent cardiac marker testing. Of note, cardiac biomarker testing was performed more frequently than no testing in patients with a higher risk profile such as unstable angina (32.7 vs 24.7 %, P < 0.001), higher symptom scaling (28.2 vs 22.5 %, P = 0.008), urgent or emergent procedures (19.3 vs 15.0 %, P = 0.022 or 4.2 vs 1.0 %, P < 0.001, respectively), and type C lesion (31.3 vs 25.2 %, P = 0.006). Presentation with silent ischemia (odds ratio = 1.51, 95 % confidence interval (CI) 1.16-1.97) and nonemergent PCIs (odds ratio = 3.45, 95 % CI 1.79-6.67) were associated with no postprocedural cardiac biomarker testing. The real-world multicenter PCI registry in Japan revealed an incidence of 2.7 % for pMI; however, cardiac biomarkers were assessed in only 25.2 % of patients after PCI. The results suggest an underuse of postprocedural biomarker testing and room for procedural quality improvement, particularly in cases of silent ischemia and nonemergent cases.

Prognostic value of creatine kinase-myocardial band isoenzyme elevation following percutaneous coronary intervention: a meta-analysis

OBJECTIVES

To assess whether different degrees of creatine kinase-myocardial band isoenzyme (CK-MB) elevation after percutaneous coronary intervention (PCI) affect the subsequent risk of death.

BACKGROUND

While there is consensus that extensive cardiac enzyme elevation increase mortality significantly, there is uncertainty about the exact clinical impact of smaller CK-MB elevations after PCI.

METHODS

The published literature was scanned by formal searches of electronic databases such as PubMed and MEDLINE from January 1999 to October 2011. Risk ratio (RR) was used as summary estimate.

RESULTS

Ten studies have been included totaling 48,022 patients who underwent PCI (12,246 patients with CK-MB elevation and 35,776 patients without CK-MB elevation). Mean followup duration for each study ranged from 6 to 48 months. CK-MB elevation >1× the upper limit of normal (ULN) conferred a significant increase in the risk of mortality with an overall RR of 1.74 (95% confidence interval [CI], 1.42 to 2.13, P < 0.001). Compared with patients without CK-MB elevation, there was a dose-response relationship with RR for death being 1.48 (95% CI, 1.25-1.77, P < 0.001) with CK-MB elevation 1 to <3× ULN, 1.71 (95% CI, 1.23-2.37, P = 0.001) with CK-MB elevation 3 to 5× ULN, and 2.83 (95% CI, 1.98-4.04, P < 0.001) with CK-MB elevation ≥ 5× ULN.

CONCLUSIONS

Even a small increase in CK-MB levels after PCI is associated with significantly higher risk of late mortality. Monitoring cardiac enzymes after PCI may help predict the long term clinical outcome.

Rosuvastatin pretreatment in patients undergoing elective PCI to reduce the incidence of myocardial periprocedural necrosis: the ROMA trial

OBJECTIVES

The aim of this study is to assess the efficacy of the high-dose rosuvastatin preadministration in reducing periprocedural myocardial necrosis and major adverse cardiovascular and cerebrovascular events (MACCE) in patients undergoing elective percutaneous coronary intervention (PCI).

BACKGROUND

Elective PCI may be complicated with an elevation of cardiac biomarkers. Several studies suggested that pretreatment with statins may be associated with a reduction in periprocedural myocardial necrosis.

METHODS

One hundred and sixty patients with stable angina who underwent elective PCI were randomly assigned to receive either a preprocedural loading dose (40 mg) of rosuvastatin group (RG, n = 80) or a standard treatment [control group (CG), n = 80].The primary endpoint was the incidence of periprocedural myocardial necrosis. The secondary endpoint was the assessment of MACCE [cardiac death, all-myocardial infarction (MI), stroke, and target vessel revascularization (TVR)] at a 30-day and 12-month follow-up, as well as the rate of periprocedural rise of Troponin T-serum levels >3× upper limit of normal.

RESULTS

Twelve and 24-hr post-PCI creatinine kinase MB isoform elevation >3× occurred more frequently in the CG than in the RG (22.7 vs. 7.1; P = 0.034 and 26.4 vs. 8.7; P = 0.003). At the 30-day and 12-month follow-up, the incidence of cumulative MACCE was higher in CG than in the RG (30.0% vs. 8.7%; P = 0.001 and 35.0% vs. 12.5%; P = 0.001).The difference between the groups was mainly due to the periprocedural MI incidence (26.4% vs. 8.7%; P = 0.003).The rate of cardiac death, spontaneous MI, TVR, and stroke were similar in the two groups.

CONCLUSIONS

High loading dose of rosuvastatin within 24 hr before elective PCI seems to decrease the incidence of periprocedural myocardial necrosis during a period of 12-months compared to the standard treatment.

Suppression of Myocardial Injury Markers following Percutaneous Coronary Interventions by Pre-treatment with Carvedilol

BACKGROUND

Retrospective studies and clinical trials have indicated that β-receptor blockers have an influential role in improving survival and reducing risk of recurrent infarction in patients with myocardial infarction. However, there is still controversy regarding the effects of β-receptor blockers on the markers of myocardial infarction following percutaneous coronary interventions (PCI).

OBJECTIVE

The aim of this study was to evaluate the pre-treatment effect of Carvedilol on markers of myocardial injury in patients undergoing elective PCI.

METHOD AND MATERIALS

In this clinical trial patients undergoing elective PCI were categorized randomly in the Carvedilol group including 100 patients who received two doses of 12.5 mg, 6 and 12 hours prior to PCI, and the control group (105 patients). Blood samples were obtained to analyse cardiac biomarker, 12 and 24 hours after PCI.

RESULTS

The clinical features were not significantly different between the two groups. A increase in the level of Troponin I was observed in the control group 24 hours following PCI (P=0.042), whereas this rise in troponin I was slight and insignificant in the Carvedilol group (P>0.05). some difference was observed between the two groups in regard to the level of CPK-MB after PCI (P=0.041).

CONCLUSION

The findings of our study indicate that pre-treatment with Carvedilol confers cardio-protection by limiting the rise of markers of myocardial injury following PCI.

Under-prescribing and non-adherence to medications after coronary bypass surgery in older adults: strategies to improve adherence

The focus for this clinical review is under-prescribing and non-adherence to medication guidelines in older adults after coronary artery bypass grafting (CABG) surgery. Non-adherence occurs in all age groups, but older adults have a unique set of challenges including difficulty hearing, comprehending, and remembering instructions; acquiring and managing multiple medications; and tolerating drug-drug and drug-disease interactions. Still, non-adherence leads to increased morbidity, mortality, and costs to the healthcare system. Factors contributing to non-adherence include failure to initiate therapy before hospital discharge; poor education about the importance of each medication by hospital staff; poor education about medication side effects; polypharmacy; multiple daily dosing; excessive cost; and the physician's lack of knowledge of clinical indicators for use of medications. To improve adherence, healthcare systems must ensure that (i) all patients are prescribed the appropriate medications at discharge; (ii) patients fill and take these medications post-operatively; and (iii) patients continue long-term use of these medications. Interventions must target central administrative policies within healthcare institutions, the difficulties facing providers, as well as the concerns of patients. Corrective efforts need to be started early during the hospitalization and involve practitioners who can follow patients after the date on which surgical care is no longer needed. A solid, ongoing relationship between patients and their primary-care physicians and cardiologists is essential. This review summarizes the post-operative medication guidelines for CABG surgery, describes barriers that limit the adherence to these guidelines, and suggests possible avenues to improve medication adherence in older cardiac surgery patients.