Myocardial infarction after percutaneous coronary intervention: a meta-analysis of troponin elevation applying the new universal definition

Periprocedural myocardial infarction after percutaneous coronary intervention and long-term mortality: a meta-analysis

BACKGROUND AND AIMS

Conflicting data are available regarding the association between periprocedural myocardial infarction (PMI) and mortality following percutaneous coronary intervention. The purpose of this study was to evaluate the incidence and prognostic implication of PMI according to the Universal Definition of Myocardial Infarction (UDMI), the Academic Research Consortium (ARC)-2 definition, and the Society for Cardiovascular Angiography and Interventions (SCAI) definition.

METHODS

Studies reporting adjusted effect estimates were systematically searched. The primary outcome was all-cause death, while cardiac death was included as a secondary outcome. Studies defining PMI according to biomarker elevation without further evidence of myocardial ischaemia ('ancillary criteria') were included and reported as 'definition-like'. Data were pooled in a random-effect model.

RESULTS

A total of 19 studies and 109 568 patients were included. The incidence of PMI was progressively lower across the UDMI, ARC-2, and SCAI definitions. All PMI definitions were independently associated with all-cause mortality [UDMI: hazard ratio (HR) 1.61, 95% confidence interval (CI) 1.32-1.97; I2 34%; ARC-2: HR 2.07, 95% CI 1.40-3.08, I2 0%; SCAI: HR 3.24, 95% CI 2.36-4.44, I2 78%]. Including ancillary criteria in the PMI definitions were associated with an increased prognostic performance in the UDMI but not in the SCAI definition. Data were consistent after evaluation of major sources of heterogeneity.

CONCLUSIONS

All currently available international definitions of PMI are associated with an increased risk of all-cause death after percutaneous coronary intervention. The magnitude of this latter association varies according to the sensitivity and prognostic relevance of each definition.

ShOckwave ballooN or Atherectomy with Rotablation in calcified coronary artery lesions: Design and rationale of the SONAR trial

BACKGROUND

The percutaneous treatment of calcified coronary lesions remains challenging and is associated with worse clinical outcomes. In addition, coronary artery calcification is associated with more frequent peri-procedural myocardial infarction.

STUDY DESIGN AND OBJECTIVES

The ShOckwave ballooN or Atherectomy with Rotablation in calcified coronary artery lesions (SONAR) study is an investigator-initiated, prospective, randomized, international, multicenter, open label trial (NCT05208749) comparing a lesion preparation strategy with either shockwave intravascular lithotripsy (IVL) or rotational atherectomy (RA) before drug-eluting stent implantation in 170 patients with moderate to severe calcified coronary lesions. The primary endpoint is difference in the rate of peri-procedural myocardial infarction. Key secondary endpoints include rate of peri-procedural microvascular dysfunction, peri-procedural myocardial injury, descriptive study of IMR measurements in calcified lesions, technical and procedural success, interaction between OCT calcium score and primary endpoint, 30-day and 1-year major adverse clinical events.

CONCLUSIONS

The SONAR trial is the first randomized controlled trial comparing the incidence of peri-procedural myocardial infarction between 2 contemporary calcium modification strategies (Shockwave IVL and RA) in patients with calcified coronary artery lesions. Furthermore, for the first time, the incidence of peri-procedural microvascular dysfunction after Shockwave IVL and RA will be evaluated and compared.

Primary versus iatrogenic (post-PCI) coronary microvascular dysfunction: a wire-based multimodal comparison

BACKGROUND

Although there are studies examining each one separately, there are no data in the literature comparing the magnitudes of the iatrogenic, percutaneous coronary intervention (PCI)-induced, microvascular dysfunction (Type-4 CMD) and coronary microvascular dysfunction (CMD) in the setting of ischaemia in non-obstructed coronary arteries (INOCA) (Type-1 CMD).

OBJECTIVES

We aimed to compare the characteristics of Type-1 and Type-4 CMD subtypes using coronary haemodynamic (resistance and flow-related parameters), thermodynamic (wave energy-related parameters) and hyperemic ECG changes.

METHODS

Coronary flow reserve (CFR) value of <2.5 was defined as CMD in both groups. Wire-based multimodal perfusion markers were comparatively analysed in 35 patients (21 INOCA/CMD and 14 CCS/PCI) enrolled in NCT05471739 study.

RESULTS

Both groups had comparably blunted CFR values per definition (2.03±0.22 vs 2.11±0.37; p: 0.518) and similar hyperemic ST shift in intracoronary ECG (0.16±0.09 vs 0.18±0.07 mV; p: 0.537). While the Type-1 CMD was characterised with impaired hyperemic blood flow acceleration (46.52+12.83 vs 68.20+28.63 cm/s; p: 0.017) and attenuated diastolic microvascular decompression wave magnitudes (p=0.042) with higher hyperemic microvascular resistance (p<0.001), Type-4 CMD had blunted CFR mainly due to higher baseline flow velocity due to post-occlusive reactive hyperemia (33.6±13.7 vs 22.24±5.3 cm/s; p=0.003).

CONCLUSIONS

The perturbations in the microvascular milieu seen in CMD in INOCA setting (Type-1 CMD) seem to be more prominent than that of seen following elective PCI (Type-4 CMD), although resulting reversible ischaemia is equally severe in the downstream myocardium.

Cardiac Troponin I in Patients Undergoing Percutaneous and Surgical Myocardial Revascularization: Comparison of Analytical Methods

The myocardial infarction (MI) types 4a and 5 guidelines recommend cardiac troponin (cTn) diagnostic decision limits of 5 and 10 times the 99th percentile, respectively. Different cTn kits elicit different responses, so the MI diagnosis is still challenging. The study aimed to establish the cutoff values and the accuracy of three different cTnI kits in the diagnosis of post-procedural MI. We analyzed 115 patients with multivessel stable chronic coronary artery disease; 26 underwent percutaneous coronary intervention, and 89 underwent coronary artery bypass graft. Delayed-enhancement magnetic resonance imaging was performed before and after each intervention for definitive MI diagnoses. Two contemporary and one high-sensitivity cTnI immunoassays were used. ROC curves determined the accuracy of each assay. Low accuracy was observed after applying the current guidelines recommendations. The three cTnI assays accuracies improved when adjusted by the new ROC cutoffs, reaching 82% for MI type 5 for all assays, and 78%, 88%, and 87% for MI type 4 for Siemens, Beckman, and Abbott, respectively. The ultrasensitive and contemporary tests’ accuracy for MI types 4a and 5 diagnoses are equivalent when adjusted for these new cutoffs. The hs-cTnI assays had lower accuracy than contemporary tests for MI types 4a and 5 diagnoses.

Impact of coronary stenting on top of medical therapy and of inclusion of periprocedural infarctions on hard composite endpoints in patients with chronic coronary syndromes: a meta-analysis of randomized controlled trials

INTRODUCTION

Composite endpoints are pivotal when assessing rare outcomes over relatively short follow-ups. Most randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with stent implantation to optimal medical therapy (OMT) in chronic coronary syndromes (CCS) patients included both hard and soft outcomes in their primary endpoint, with periprocedural myocardial infarctions (MIs) systematically allocated to the PCI arm. We meta-analyzed the above RCTs for composite hard endpoints, with and without periprocedural MIs.

EVIDENCE ACQUISITION

This study is registered in PROSPERO CRD42020166754 and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Collaboration reporting. Patients had inducible ischemia, no left main disease nor severe left ventricular dysfunction.

EVIDENCE SYNTHESIS

Six RCTs involving 10,751 patients followed for a mean of 4.4 years were included. PCI+OMT versus OMT alone was associated with no difference in the two co-primary composite endpoints of all-cause death/MI/stroke and cardiovascular death/MI including all-MIs (IRR 0.99; 95% CI 0.90-1.08 and IRR 0.95; 95% CI 0.83-1.08 respectively). After inclusion of spontaneous rather than all-MIs (i.e., excluding periprocedural MIs), the odds showed benefit of PCI+OMT for both co-primary endpoints (IRR 0.88; 95% CI 0.80-0.97, P<0.01 and IRR 0.81; 95% CI 0.69-0.95, P=0.01 respectively) with numbers needed to treat of 42 in both cases.

CONCLUSIONS

Among CCS patients with inducible myocardial ischemia without severely reduced ejection fraction or left main disease, adding PCI to OMT reduces hard composite outcomes only after exclusion of periprocedural MIs. Continued efforts to define periprocedural MIs reproducibly, to assess their prognostic relevance and to prevent them are warranted.

[The Revival of the "Ischemic" Approach in the Assessment of Ischemic Heart Disease: Analysis of Major World Research]

This analytical review focuses on large international studies on diagnostics of ischemic heart disease and addresses the role of radionuclide methods in evaluating myocardial perfusion and transient ischemia. Based on the reviewed data, the authors proposed a comprehensive instrumental approach to selecting a tactics for the management of patients with suspected or documented ischemic heart disease and for evaluating their prognosis.

Gensini score values for predicting periprocedural myocardial infarction: An observational study analysis

The Gensini score (GS) is a convenient, powerful tool for assessing the severity and complexity of coronary artery diseases. Our research investigated the relationship between the GS and periprocedural myocardial infarction (PMI). We recruited 4949 patients (3366 men, 1583 women; mean age 66.45 ± 10.09 years) with a single coronary artery revascularization. Based on the tertile of the GS 20 and 36, the population was divided into 3 groups: Low Group (0 < GS ≤ 20, N = 1809); Intermediate Group (20 < GS ≤ 36, N = 1579); High Group (GS > 36, N = 1561). PMI3 represented the endpoint for cTnI > 3-fold upper reference limit, while PMI5 represented the endpoint for cTnI > 5-fold upper reference limit. The incidence of PMI of High Group was statistically higher than that of Intermediate Group (P < .05), while that of Intermediate Group was statistically higher than Low Group (P < .05). With the adjustment of some general variables, GS was an independent significantly predictor for PMI3 (β = 0.006, P < .05) and PMI5 (β = 0.007, P < .05). Following receiver operating characteristic curve analysis, the optimal cut-off value to predict PMI are 22.5 for PMI3 and 27 for PMI5. The GS was an independent predictor of PMI in the single-coronary revascularization population. Additionally, the 22.5 of GS was the optimal cut-off value for determining the presence of PMI3, while the 27 of GS for PMI5.

Rosuvastatin Alleviates Coronary Microembolization-Induced Cardiac Injury by Suppressing Nox2-Induced ROS Overproduction and Myocardial Apoptosis

To explore the mechanism by which rosuvastatin prevents coronary microembolism (CME)-induced cardiac injury and cardiomyocyte apoptosis. Animal and cell models of CME were established and treated with different doses of rosuvastatin. Echocardiography and histological staining were applied to assess left ventricular function and cardiac injury. Masson trichrome staining was used to evaluate fibrin deposition in the myocardium. The activity of lactate dehydrogenase (LDH) in serum and cell culture supernatant was detected. TUNEL staining and flow cytometry were used to evaluate apoptosis in myocardium and cardiomyocytes, respectively. The activity of ROS was revealed by DHE staining. The expression levels of Nox2, cleaved caspase-3, cytochrome C, p53, Bax and Bcl-2 were also detected. Rosuvastatin pretreatment improved the left ventricular function of CME mice and reduced inflammatory cell infiltration and fibrin deposition in the myocardium. Rosuvastatin reduced the production of ROS by inhibiting the expression of Nox2. Rosuvastatin also downregulated pro-apoptotic proteins cleaved caspase-3, cytochrome C, p53 and Bax, and upregulated anti-apoptotic Bcl-2. Rosuvastatin mitigates CME-induced cardiac injury by inhibiting Nox2-induced ROS overproduction and alleviating p53/Bax/Bcl-2-dependent cardiomyocyte apoptosis.

Prognostically relevant periprocedural myocardial injury and infarction associated with percutaneous coronary interventions: a Consensus Document of the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

A substantial number of chronic coronary syndrome (CCS) patients undergoing percutaneous coronary intervention (PCI) experience periprocedural myocardial injury or infarction. Accurate diagnosis of these PCI-related complications is required to guide further management given that their occurrence may be associated with increased risk of major adverse cardiac events (MACE). Due to lack of scientific data, the cut-off thresholds of post-PCI cardiac troponin (cTn) elevation used for defining periprocedural myocardial injury and infarction, have been selected based on expert consensus opinions, and their prognostic relevance remains unclear. In this Consensus Document from the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI), we recommend, whenever possible, the measurement of baseline (pre-PCI) cTn and post-PCI cTn values in all CCS patients undergoing PCI. We confirm the prognostic relevance of the post-PCI cTn elevation >5× 99th percentile URL threshold used to define type 4a myocardial infarction (MI). In the absence of periprocedural angiographic flow-limiting complications or electrocardiogram (ECG) and imaging evidence of new myocardial ischaemia, we propose the same post-PCI cTn cut-off threshold (>5× 99th percentile URL) be used to define prognostically relevant ‘major’ periprocedural myocardial injury. As both type 4a MI and major periprocedural myocardial injury are strong independent predictors of all-cause mortality at 1 year post-PCI, they may be used as quality metrics and surrogate endpoints for clinical trials. Further research is needed to evaluate treatment strategies for reducing the risk of major periprocedural myocardial injury, type 4a MI, and MACE in CCS patients undergoing PCI.

SUPPORT-1 (Subjects Undergoing PCI and Perioperative Reperfusion Treatment): A Prospective, Randomized Trial of CMX-2043 in Patients Undergoing Elective Percutaneous Coronary Intervention

OBJECTIVE

The natural molecule α-lipoic acid has been shown to be partially cytoprotective through antioxidant and antiapoptotic mechanisms. To obtain an initial assessment of the safety and potential efficacy of a synthetic derivative, CMX-2043, in preventing ischemic complications of percutaneous coronary intervention (PCI) we conducted the Subjects Undergoing PCI and Perioperative Reperfusion Treatment (SUPPORT-1) trial, the first patient experience with this agent.

METHODS AND RESULTS

SUPPORT-1 was a phase 2a, 6-center, international, placebo-controlled, randomized, double-blind trial. A total of 142 patients were randomized to receive a single intravenous bolus dose of drug or placebo administered 15-60 minutes before PCI. Cardiac biomarker assessments included serial measurements of creatine kinase myocardial band (CK-MB) at 6, 12, 18, and 24 hours after PCI and a single measurement of troponin T (TnT) at 24 hours. Peak concentrations of CK-MB and TnT were significantly reduced in the 2.4 mg/kg group compared with placebo (P = 0.05 and 0.03, respectively). No subject administered 2.4 mg/kg of CMX-2043 had an increase of CK-MB to ≥3X upper limit of normal versus 16% for placebo (P = 0.02); 16% of the 2.4-mg/kg dose group developed an elevation of TnT to ≥3X upper limit of normal versus 39% in the placebo group (P = 0.05). No drug-related serious adverse events were observed in any group.

CONCLUSION

These data suggest that CMX-2043 may reduce PCI periprocedural myonecrosis and support further clinical evaluation of this novel agent for its potential cytoprotective effects.

Colchicine Inhibits Neutrophil Extracellular Trap Formation in Patients With Acute Coronary Syndrome After Percutaneous Coronary Intervention

Background

Release of neutrophil extracellular traps (NETs) after percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) is associated with periprocedural myocardial infarction, as a result of microvascular obstruction via pro‐inflammatory and prothrombotic pathways. Colchicine is a well‐established anti‐inflammatory agent with growing evidence to support use in patients with coronary disease. However, its effects on post‐PCI NET formation in ACS have not been explored.

Methods and Results

Sixty patients (40 ACS; 20 stable angina pectoris) were prospectively recruited and allocated to colchicine or no treatment. Within 24 hours of treatment, serial coronary sinus blood samples were collected during PCI. Isolated neutrophils from 10 patients with ACS post‐PCI and 4 healthy controls were treated in vitro with colchicine (25 nmol/L) and stimulated with either ionomycin (5 μmol/L) or phorbol 12‐myristate 13‐acetate (50 nmol/L). Extracellular DNA was quantified using Sytox Green and fixed cells were stained with Hoechst 3342 and anti‐alpha tubulin. Baseline characteristics were similar across both treatment and control arms. Patients with ACS had higher NET release versus patients with stable angina pectoris (P<0.001), which was reduced with colchicine treatment (area under the curve: 0.58 versus 4.29; P<0.001). In vitro, colchicine suppressed unstimulated (P<0.001), phorbol 12‐myristate 13‐acetate–induced (P=0.009) and ionomycin‐induced (P=0.002) NET formation in neutrophils isolated from patients with ACS post‐PCI, but not healthy controls. Tubulin organization was impaired in neutrophils from patients with ACS but was restored by colchicine treatment.

Conclusions

Colchicine suppresses NET formation in patients with ACS post‐PCI by restoring cytoskeletal dynamics. These findings warrant further investigation in randomized trials powered for clinical end points.

Registration

URL: https://anzctr.org.au; Unique identifier: ACTRN12619001231134.

A machine learning-based approach for the prediction of periprocedural myocardial infarction by using routine data

Background

Periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) is associated with the bad prognosis in patients. Current approaches to predict PMI fail to identify many people who would benefit from preventive treatment, and machine learning (ML) offers opportunity to improve the performance of ML models for PMI based on the big routine data.

Methods

By using electronic medical records, we retrospectively extracted all records of patients from 2007 to 2019 in our cardiovascular center. The main enrollment criterion was that inpatients with one single coronary stenosis with stents implantation this time. The primary outcome was PMI [PMI3: cTnI >3-fold upper reference limit (URL); PMI5: cTnI >5-fold URL]. Four different ML algorithms [Support Vector Machine (SVM), Logistic Regression (LR), Random Forest (RF), Artificial Neural Networks (ANN)] were evaluated and their diagnostic accuracy measures were compared.

Results

A total of (10,886) patients who were admitted in our hospital. PMI3 and PMI5 results were analyzed respectively. The incidence of PMI3 and PMI5 was 20.9% and 13.7%. In PMI3 Drop group, ANN (accuracy: 0.72; AUC: 0.77) showed the best power to predict the presence of PMI; In PMI3 Mean Group, RF (accuracy: 0.72; AUC: 0.77) showed the best power; In PMI5 Drop group, RF (accuracy: 0.67; AUC: 0.67) showed the best power; In PMI5 Mean group, RF (accuracy: 0.61; AUC: 0.67) showed the best power.

Conclusions

ML methods may provide accurate prediction of PMI in CAD patients, and could be used as a precise model in the preventive treatment of PMI.

The clinical effect of recombinant human brain natriuretic peptide on asymptomatic peri-procedural myocardial injury after percutaneous transluminal coronary angioplasty

To determine the effect of intravenous injection of recombinant human brain natriuretic peptide (rhBNP) on lowering the incidence of asymptomatic peri-procedural myocardial injury (PMI) in patients who underwent coronary stent implantation. In this retrospective observational study, data pooled from a tertiary hospital electronic medical records were used to quantify the troponin enzyme change after patients with coronary artery disease (CAD) were pretreated with rhBNP infusion one day prior to percutaneous coronary intervention (PCI). The primary end point was to analyze the incidence of the elevated high-sensitivity cardiac troponin I serum levels above the upper normal limit after PCI. A total of 156 CAD patients were enrolled into rhBNP group (n = 76) and control group (n = 80). The incidence of asymptomatic PMI was 33% in the rhBNP group versus 51% in the control group (P = 0.02) after PCI. At eight months, the incidences of composite endpoints were 25.3% in the control group and 13% in the rhBNP group (difference, 12.3 percentage points; 95% confidence interval (CI), 0.197 to 1.048; P = 0.061). There were 7 visits in the rhBNP group and 15 visits in the control group for recurrent angina (difference, 10 percentage points; 95% CI 0.168-1.147; P = 0.087). A time-to-event analysis of the composite clinical endpoints and the recurrent angina between the control group and rhBNP group showed that the hazard ratios were 2.566 (95% CI 1.187-5.551; P = 0.017) and 2.607 (95% CI 1.089-6.244; P = 0.032) respectively. The decreased incidence of asymptomatic PMI after PCI and the reduced episodes of recurrent angina at eight months follow-up were associated with the administration of rhBNP infusion prior to PCI.

Development of a percutaneous coronary intervention patient level composite measure for a clinical quality registry

BACKGROUND

Composite measures combine data to provide a comprehensive view of patient outcomes. Despite composite measures being a valuable tool to assess post-intervention outcomes, the patient perspective is often missing. The purpose of this study was to develop a composite measure for an established cardiac outcome registry, by combining clinical outcomes following percutaneous coronary interventions (PCI) with a patient-reported outcome measure (PROM) developed specifically for this population (MC-PROM).

METHODS

Two studies were undertaken. Study 1: Patients who had undergone a PCI at one of the three participating registry hospital sites completed the 5-item MC-PROM. Clinical outcome data for the patients (e.g. death, myocardial infarction, repeat vascularisation, new bleeding event) were collected 30 days post-intervention as part of routine data collection for the cardiac registry. Exploratory factor analysis of clinical outcomes and MC-PROM data was conducted to determine the minimum number of constructs to be included in a composite measure. Study 2: Clinical experts participated in a Delphi technique, consisting of three rounds of online surveys, to determine the clinical outcomes to be included and the weighting of the clinical outcomes and MC-PROM score for the composite measure.

RESULTS

Study 1: Routine clinical outcomes and the MC-PROM data were collected from 266 patients 30 days post PCI. The MC-PROM score was not significantly correlated with any clinical outcomes. Study 2: There was a relatively consistent approach to the weighting of the clinical outcomes and MC-PROM items by the expert panel (n = 18) across the three surveys with the exception of the clinical outcome of 'deceased at 30 days'. The final composite measure included five clinical outcomes within 30 days weighted at 90% (new heart failure, new myocardial infarction, new stent thrombosis, major bleeding event, new stroke, unplanned cardiac rehospitalisation) and the MC-PROM score (comprising 10% of the total weighting).

CONCLUSIONS

A single patient level composite score, which incorporates weighted clinical outcomes and a PROM was developed. This composite score provides a more comprehensive reported measure of individual patient wellbeing at 30 days post their PCI-procedure, and may assist clinicians to further assess and address patient level factors that potentially impact on clinical recovery.

Predicting mortality with cardiac troponins: recent insights from meta-analyses

The introduction of cardiac troponin (cTn) testing in clinical practice has been one of the most important breakthroughs that have occurred in the recent history of laboratory medicine. Although it is now uncontestable that cTn values are essential for diagnosing acute coronary syndrome (ACS), solid evidence is also emerging that assessment of either cardiac troponin I (cTnI) or T (cTnT) may provide valuable prognostic information in the general healthy population, as well as in patients with a vast array of cardiac and extra-cardiac diseases. We have hence performed a critical review of the scientific literature for identifying meta-analyses which have investigated the potential contribution of cTns in predicting the risk of death in health and disease. According to the articles identified with our research, we can conclude that increased cTn values may be considered independent risk factors for all-cause mortality in the general population, as well as in patients with ACS, in those undergoing revascularization procedures, or with stable coronary artery disease (CAD), heart failure (HF) and atrial fibrillation (AF). Measurement of cTn may then be helpful for stratifying the mortality risk in non-cardiac hospitalized patients, in those with critical illness or sepsis, syncope, stroke, acute aortic dissection, pulmonary diseases, brain injury, renal failure, vascular and non-cardiac surgery. Although this evidence has notable clinical implications, the cost-effectiveness of population screening with high-sensitivity (hs) cTn immunoassays has not been proven so far.

Prognostic Value of Coronary Microvascular Function Measured Immediately After Percutaneous Coronary Intervention in Stable Coronary Artery Disease

Background:

The prognostic impact of coronary microvascular dysfunction after percutaneous coronary intervention (PCI) remains unclear in patients with stable coronary artery disease. This study sought to investigate the prognostic value of microvascular function measured immediately after PCI in patients with stable coronary artery disease.

Methods:

We enrolled 572 patients with stable coronary artery disease who underwent PCI and elective measurement of the index of microcirculatory resistance (IMR) immediately after PCI from 8 centers in 4 countries. Impaired microvascular function was defined as IMR≥25 (high IMR). Major adverse cardiac events, including death, myocardial infarction (MI) and target vessel revascularization, were evaluated.

Results:

During a median follow-up duration of 4.0 years, the cumulative major adverse cardiac events rate was significantly higher in the high IMR group (n=66/148) compared with the low IMR group (n=128/424; hazard ratio [HR], 1.56; 95% CI, 1.16−2.105; P =0.001), primarily due to a higher rate of periprocedural MI (HR, 1.59; 95% CI, 1.11−2.28; P =0.004) but also due to higher rates of mortality (HR, 1.59; 95% CI, 0.76−3.35; P =0.22), spontaneous MI (HR, 2.10; 95% CI, 0.67−6.63; P =0.20) and target vessel revascularization (HR, 1.40; 95% CI, 0.77−2.54; P =0.27). Cumulative risk for death, spontaneous MI, and target vessel revascularization was higher in the high IMR group (HR, 1.55; 95% CI, 0.99−2.43; P =0.056), as was death and spontaneous MI alone (HR, 1.79; 95% CI, 0.96−3.36; P =0.065). On multivariable analysis, high IMR post-PCI was an independent predictor of major adverse cardiac events.

Conclusions:

IMR measured immediately after PCI predicts adverse events in patients with stable coronary artery disease.

Curcumin for the prevention of myocardial injury following elective percutaneous coronary intervention; a pilot randomized clinical trial

Due to the potential benefits of curcumin in the ischemic heart disease, this study was performed to evaluate whether pretreatment with curcumin may reduce myocardial injury following elective percutaneous coronary intervention (PCI). A randomized clinical trial was performed on 110 patients undergoing elective PCI. The intervention group (n = 55) received a single dose of 480 mg nanomicelle curcumin orally and the standard treatment before PCI, while the control group (n = 55) received only the standard treatment., Serum concentrations of CK-MB and troponin I was measured before, 8 and 24 h after the procedure to assess myocardial damage during PCI. The results showed that the raise of CK-MB in curcumin group was half of the control group (4 vs. 8 cases) but was not significant. There were no significant differences in CK-MB levels at 8 (P = .24) and 24 h (P = .37) after PCI between the curcumin and the control group. No significant difference was also found in troponin I levels at 8 (P = 1.0) and 24 h (P = .35) after PCI between the groups. This study did not support the potential cardioprotective benefit of curcumin against pre-procedural myocardial injury in patients undergoing elective PCI.

Impact of High-Sensitivity Cardiac Troponin Elevation in Relation to Diagnostic Invasive Intravascular Imaging for the Assessment of Coronary Artery Disease

Recent studies reported that cardiac troponin elevation after percutaneous coronary intervention is related to adverse cardiac events. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are often used to assess lesion characteristics in the coronary arteries. However, little is known about the trend of cardiac troponin elevation after diagnostic invasive intracoronary examination and the prognostic influence. We assessed the relationship between myocardial injury manifested by the high-sensitivity cardiac troponin T (hs-cTnT) level after invasive intracoronary examination and future adverse cardiac outcomes. We evaluated 115 patients with stable coronary artery disease who underwent IVUS or OCT for detailed coronary assessment during coronary angiography (CAG). Baseline and post-procedural (within 24 hours after examination) hs-cTnT were measured. In consequence, post-procedural hs-cTnT level and percentage increase were higher in patients with IVUS or OCT during CAG than in those without. Periprocedural myocardial injury (PMI, defined as post-procedural hs-cTnT with upper reference limit greater than five-fold) occurred in 10 (8.6%) patients. There were no significant differences in baseline characteristics between patients with and without PMI, except for left-ventricular diastolic dimension. Only two major adverse cardiac events (MACE, defined as cardiovascular death, nonfatal myocardial infarction, and target lesion revascularization) occurred in non-PMI during a mean observation period of 32 ± 18 months. On Kaplan-Meier analysis, MACE-free survival rate was similar between PMI and non-PMI. In conclusion, a few imperceptible PMI derived by hs-cTnT assay occurred after diagnostic invasive intracoronary examination. However, it was not associated with subsequent poor cardiac outcome.

Periprocedural Myocardial Infarction in Contemporary Practice

"Periprocedural myocardial infarction (MI) occurs infrequently in the current era of percutaneous coronary interventions (PCI) and is associated with an increased risk of mortality and morbidity. Periprocedural MI can occur due to acute side branch occlusion, distal embolization, slow flow or no reflow phenomenon, abrupt vessel closure, and nonidentifiable mechanical processes. Therapeutic strategies to reduce the risk of periprocedural MI include dual antiplatelet therapy, intravenous cangrelor in the periprocedural setting, intravenous glycoprotein IIb/IIIa inhibitor in high-risk patients, anticoagulation with unfractionated heparin, low-molecular-weight heparin or bivalirudin, and embolic protection devices during saphenous vein graft interventions."

Change in cardiac troponin T level after intravitreal anti-vascular endothelial growth factor treatment: Prospective pilot study

Background:

Evaluate subclinical myocardial injury associated with intravitreal anti-vascular endothelial growth factor therapy by measuring serum high-sensitivity cardiac troponin T.

Methods:

This is a prospective pilot comparative study conducted at American University of Beirut Medical Center, Beirut, Lebanon. In total, 40 consecutive patients were randomized to receive either intravitreal bevacizumab or ranibizumab. Patients received three consecutive monthly injections of the assigned drug, then continued treatment as needed. Systemic concentrations of high-sensitivity cardiac troponin T and vascular endothelial growth factor were obtained at baseline, week 9, and week 24. Primary endpoint measure was change in high-sensitivity cardiac troponin T levels compared to baseline. Secondary endpoint measure was change in systemic vascular endothelial growth factor levels.

Results:

There was no significant difference in high-sensitivity cardiac troponin T levels over time ( p = 0.227) within each treatment group and no significant difference between treatments at any time point ( p = 0.276). There was a significant decrease in plasma vascular endothelial growth factor levels at week 9 ( p = 0.001) and week 24 ( p < 0.001) compared to baseline. In the ranibizumab group, vascular endothelial growth factor levels were not significantly different at weeks 9 and 24 compared to baseline ( p = 0.708 and p = 0.117, respectively). There was a significant association between the number of bevacizumab injections from weeks 8 to 24 and the decrease in vascular endothelial growth factor levels at week 24 ( R = −0.67, p = 0.032). This correlation was not observed in the ranibizumab group ( R = −0.341, p = 0.141).

Conclusion:

Repeated intravitreal bevacizumab or ranibizumab did not influence serum high-sensitivity cardiac troponin levels. Intravitreal bevacizumab but not ranibizumab lowered free-systemic vascular endothelial growth factor levels, which was observed in this study to be inversely related to the number of bevacizumab injections.

Effects of high dose atorvastatin before elective percutaneous coronary intervention on highly sensitive troponin T and one year major cardiovascular events; a randomized clinical trial

Introduction

Some studies have demonstrated that post-PCI elevated cardiac enzymes are associated with worse outcomes. In this study, we aimed to determine if high-dose treatment with atorvastatin before planned elective PCI reduces PMI or MACE at 1-year median follow-up.

Material and methods

Eligible participants were randomly allocated to group A (80 mg atorvastatin 12 h and 40 mg 2 h before PCI) and group B (40 mg atorvastatin daily). Blood samples were obtained before and at 24 h after PCI to measure hsTnT. All patients were followed regarding MACE (combination of death, re-hospitalizations for ACS, and unplanned coronary revascularization) during one year after PCI.

Results

207 patients randomly assigned to Group A (n = 97) or group B (n = 110). The rate of PMI was lower in group A (5.2%) compared to group B (10.9%); despite near to 50% lower rate of PMI in group A, binary logistic regression showed no significant association between atorvastatin recapture and PMI. The occurrence of MACE in 97 patients of group A was 11 (11.3%), higher than 11 (10%) cases of 110 patients in group B. Cox proportional hazards regression model shows no significant difference in MACE of study groups.

Conclusion

Pretreatment of patients with stable angina who were planned to undergo an elective PCI with 120 mg of atorvastatin before the procedure confer them the same benefit in terms of PMI and MACE as 40 mg routine daily dosage of this statin does.

Selective coronary angiography, percutaneous coronary intervention and asymptomatic peri-procedural myocardial injury

BACKGROUND

While there have been a number of studies reporting the incidence and implications of elevated troponin levels after percutaneous coronary intervention (PCI), the body of information about the incidence, associations, and implications of elevated troponin levels following coronary angiography (CAG) is limited.

MATERIALS AND METHODS

A total of 220 consecutive patients with stable coronary artery disease or intermediate or low-risk acute coronary syndrome without persistent ST-segment elevation (NSTE-ACS) were included in our study. High-sensitivity cardiac troponin I (hs-cTnI) levels were measured before and after coronary angiography (CAG) in patients with or without PCI and correlated with a number of clinical variables.

RESULTS

Hs-cTnI elevations above the 99^th percentile upper reference limit (URL), or above 20% of the initially positive, yet already declining values, were found in 60 (37.2%) patients after CAG and in 45 (76.2%) patients undergoing PCI. Significant correlations of hs-cTnI elevation were found with the following variables: volume of contrast, fluoroscopy time, dose-area product, amount of contrast agent injected directly into the coronary arteries, total time of balloon dilation and the number and total length of implanted stents (P<0.001 for all).

CONCLUSION

While an asymptomatic elevation of hs-cTnI is a common finding after PCI, it does occur, quite surprisingly, also after CAG. Despite contradictory views regarding the clinical relevance of asymptomatic post-procedural elevated hs-cTnI levels, it is generally believed that a mild elevation is not associated with an increased risk. Still, it may pose a diagnostic quandary following a successful interventional procedure and even more so after an uncomplicated CAG.

TRIAL REGISTRATION

Clinicaltrials.gov - NCT02960321.

State-of-the-art diagnosis of myocardial infarction

The current version of the Universal Definition of Myocardial Infarction (MI) was published in 2012. An acute myocardial infarction (AMI) is characterized by evidence of myocardial necrosis in a clinical setting of acute myocardial ischemia. Diagnostic criteria include a rise and/or fall of serially tested cardiac biomarkers (preferentially cardiac troponins) with at least one value above the 99th percentile of the upper reference limit combined with symptoms of ischemia, new changes on electrocardiogram (ECG), imaging evidence of a new loss of viable myocardium or new regional wall motion abnormalities or the identification of an intracoronary thrombus by angiography or autopsy. Compared to previous versions, the current definition of MI includes minor modifications regarding ECG criteria and subtypes of MI as well as the use of cardiac imaging and high sensitivity troponin assays. This article summarizes the Universal MI definition and includes recommendations from the current guidelines for the management of patients with acute coronary syndrome. Strategies for "early rule-in" and "rule-out" of non-ST-elevation MI with high sensitivity cardiac troponin assays, risk scores for assessment of ischemic and bleeding risk and criteria for optimal timing of angiography are presented.

Predictive value of plaque morphology assessed by frequency-domain optical coherence tomography for impaired microvascular perfusion after elective stent implantation: the intracoronary electrocardiogram study

Aims

This study was undertaken to assess the association between plaque features at culprit lesions assessed by frequency-domain optical coherence tomography (FD-OCT) and impaired microvascular perfusion estimated by intracoronary electrocardiogram (IcECG) after elective percutaneous coronary intervention (PCI). Furthermore, we investigated whether IcECG could predict future cardiac events.

Methods and results

This study consisted of 84 patients who underwent both FD-OCT and IcECG during PCI. Patients were classified into two groups based on ST-segment elevation (ST-E) on IcECG after the procedure; ST-E (-) group (n = 53) and ST-E (+) group (n = 31). Minimum fibrous cap thickness was significantly thinner in the ST-E (+) group than in the ST-E (-) group (240 μm [IQR 180 to 310] vs. 100 μm [IQR 60 to 120], P < 0.001). Plaque rupture (7.5% vs. 35.5%, P = 0.001), lipid-rich plaque (75.5% vs. 100%, P < 0.001), the thin cap fibroatheroma (0% vs. 25.8%, P < 0.001) on pre-FD-OCT, protrusion (18.9% vs. 56.7%, P < 0.001), and intra-stent dissection (15.1% vs. 50.0%, P < 0.001) on post-FD-OCT were significantly more frequently found in the ST-E (+) group than in the ST-E (-) group. The incidence of MACE (cardiac death, myocardial infarction, revascularization, hospitalization for heart failure) during 1-year was significantly higher in the ST-E (+) group than in the ST-E (-) group (5.7% vs. 19.4%, P < 0.05).

Conclusion

Plaque features assessed by FD-OCT might be associated with impaired microvascular perfusion and ST-segment elevation on IcECG after the procedure could predict 1-year cardiac events after elective PCI.

Abnormal elevation of myocardial necrosis biomarkers after coronary artery bypass grafting without established myocardial infarction assessed by cardiac magnetic resonance

BACKGROUND

The diagnosis of peri-procedural myocardial infarction is complex, especially after the emergence of high-sensitivity markers of myocardial necrosis.

METHODS

In this study, patients with normal baseline cardiac biomarkers and formal indication for elective on-pump coronary bypass surgery were evaluated. Electrocardiograms, cardiac biomarkers, and cardiac magnetic resonance imaging with late gadolinium enhancement were performed before and after procedures. Myocardial infarction was defined as more than ten times the upper reference limit of the 99th percentile for troponin I and for creatine kinase isoform (CK-MB) and by the findings of new late gadolinium enhancement on cardiac magnetic resonance. We assessed the release of cardiac biomarkers in patients with no evidence of myocardial infarction on cardiac magnetic resonance.

RESULTS

Of 75 patients referred for on-pump coronary bypass surgery, 54 (100%) did not have evidence of myocardial infarction on cardiac magnetic resonance. However, all had a peak troponin I above the 99th percentile; 52 (96%) had an elevation 10 times higher than the 99th percentile. Regarding CK-MB, 54 (100%) patients had a peak CK-MB above the 99th percentile limit, and only 13 (24%) had an elevation greater than 10 times the 99th percentile. The median value of troponin I peak was 3.15 (1.2 to 3.9) ng/mL, which represented 78.7 times the 99th percentile.

CONCLUSION

In this study, different from CK-MB findings, troponin was significantly increased in the absence of myocardial infarction on cardiac magnetic resonance. Thus, CK-MB was more accurate than troponin I for excluding procedure-related myocardial infarction. These data suggest a higher troponin cutoff for the diagnosis of coronary bypass surgery related myocardial infarction.

CLINICAL TRIAL REGISTRATION

http://www.isrctn.com/ISRCTN09454308 . Registered 08 May 2012.

Value of the SYNTAX score for periprocedural myocardial infarction according to WHO and the third universal definition of myocardial infarction: insights from the TWENTE trial

AIMS

The SYNTAX score is a tool to quantify the complexity of coronary artery disease. We investigated the relation between the SYNTAX score and the occurrence of a periprocedural myocardial infarction (PMI) according to the historical definition of the World Health Organization (WHO) and the recently updated universal definition of MI.

METHODS AND RESULTS

The SYNTAX score was calculated in 1,243 patients enrolled in TWENTE, a randomised trial which assessed second-generation drug-eluting stents. PMI was defined by the WHO definition and the third universal definition of MI. Patients were divided into tertiles of the SYNTAX score: ≤7 (n=430); >7 and <15 (n=390); ≥15 (n=423). PMI according to the WHO definition occurred more frequently in patients in the highest SYNTAX score tertile (7.3% vs. 3.1% vs. 1.6%, p<0.001) compared to the mid and lowest tertile. Similar findings were seen for universal PMI (9.9% vs. 7.7% vs. 3.7%, p<0.01). After multivariate analysis, SYNTAX score was a significant independent correlate of PMI for both definitions: the highest SYNTAX score tertile had an almost five times higher risk for WHO PMI, and a three times higher risk for universal PMI.

CONCLUSIONS

In a broad patient population treated with second-generation DES, the SYNTAX score was able to stratify the risk of PMI.

Troponin I elevation after elective percutaneous coronary interventions: Prevalence and risk factors

Troponin elevation after coronary angioplasty is a prognostic marker associated with significant morbidity and mortality, although its prevalence varies according to clinical and procedural characteristics. We analyzed the frequency of post-procedural enzyme elevation among 112 elective interventions between 2013 and 2014 in a private hospital in Brazil. Troponin increase was observed in 62.5% of the procedures, and was related to age, female sex, low pre-procedural hemoglobin, prior angiotensin converting enzyme inhibitor or angiotensin receptor blocker use and multivessel angioplasty. PCI is not a risk free procedure and these results underscore the importance of a careful clinical assessment before its utilization.

Impact of multi-vessel therapy to the risk of periprocedural myocardial injury after elective coronary intervention: exploratory study

Backgrounds

Periprocedural myocardial injury (PMI) after elective percutaneous coronary intervention (PCI) significantly influences the prognosis of coronary artery disease (CAD). However, it was unclear whether the occurrence of PMI was associated with a series of controllable factors, such as PCI strategy or severity of CAD.

Methods

A total of 544 consecutive stable CAD patients underwent elective PCI were enrolled. The main outcome is PMI, defined as troponin T after PCI was at least one value above the 99th percentile upper reference limit. Major adverse cardiac events (MACE), including all-cause death, repeat myocardial infarction and target vessel revascularization were record in the period of follow-up. Univariate and multivariate analysis was applied to assess predictors for the occurrence of PMI.

Results

The incidence of PMI was 38.8% in the study. Compared with non-PMI patients (n = 333), PMI patients (n = 211) had more diseased vessels, higher Gensini and Syntax score. Meanwhile, there were higher incidence of MACE in PMI groups (9.5% vs. 3.2%, P < 0.01). We found that PMI patients underwent higher proportion of multi-vessel PCI simultaneously (32.2% vs. 10.5%, P < 0.01) and had more stents implanted (1.8 ± 0.8 vs. 1.4 ± 0.6, P < 0.01). Importantly, after simultaneously adjusted by other factors (such as age, diabetes, total cholesterol, number of diseased vessels, Gensini score and stent length), the risk of PMI was still increased 84% by multi-vessel PCI independently (OR = 1.654, 95% CI = 1.004–2.720, P < 0.05).

Conclusions

The phenomenon of PMI occurred more commonly in stable CAD patients underwent multi-vessel PCI. Multi-vessel international therapy could increase the risk of PMI in elective PCI.

The randomized clinical trial of coenzyme Q10 for the prevention of periprocedural myocardial injury following elective percutaneous coronary intervention

INTRODUCTION

Periprocedural myocardial injury (PMI) following elective percutaneous coronary intervention (PCI) is an important therapeutic concern with remaining some mortality and morbidity. To the best of our knowledge, there is no published study that investigates the potential benefit of CoQ10 in preventing PMI following elective PCI.

METHODS

In a randomized, clinical trial, 100 patients who scheduled for elective PCI were allocated in to the intervention (n=50) and control group (n=50). The intervention received a 300 mg loading dose CoQ10 12 hours before procedure. The level of CK-MB and troponin-I was measured before procedure, and 8 and 24 hours after. Furthermore, hs-CRP was measured at baseline and 24 hours after. All patients were assessed for the incidence of major adverse cardiac effects (MACEs) after 1 month.

RESULTS

The CK-MB elevation (above the upper limit normal) was occurred in 22% (n=11) of CoQ10 and 20% (n=10) of control (P=.806). The elevation of troponin-I was documented in 8% (n=4) of both groups. No significant change in the level of cardiac biomarkers was noted. However, the significant reduction in hs-CRP level was occurred in CoQ10 group (P=.032).

CONCLUSION

The results showed that pretreatment with 300 mg CoQ10 12 hours before procedure could not reduce PMI following elective PCI, however, significantly decreased hs-CRP.

Troponin I elevation and all-cause mortality after elective percutaneous coronary interventions

BACKGROUND/PURPOSE

Although troponin I (TnI) elevation and myocardial injury after percutaneous coronary interventions (PCI) are frequent findings, their prognoses remain controversial. We aimed to determine the association between any or ≥5 times TnI elevation after elective PCI and subsequent one year mortality rates and long term survival.

METHODS

Consecutive patients admitted for elective PCI between January 2013 and December 2014 were retrospectively analyzed by chart review in two hospitals in Rio de Janeiro. Only patients with post-PCI TnI measurements were included. Clinical, angiographic and procedural characteristics were correlated with any or ≥5 times TnI elevation, as well as 1year mortality and long term survival.

RESULTS

A total of 407 interventions were included in the analysis. Post-PCI TnI elevation was observed in 74.7% of cases and ≥5 times elevations occurred in 41.3%. Age≥70years, female gender and multistenting were predictors of enzyme elevation. Prior aspirin or hypoglycemic therapy were protective factors. One year mortality was significantly associated with any TnI elevation (6.6% vs 1.05%, p=0.035) and values ≥5 times above the normal limit predicted the highest mortality rates (8.13% vs 3.14%, p=0.031). Survival of patients with single vessel disease was also adversely affected by ≥5 times enzyme elevation (log-rank: p=0.039).

CONCLUSION

Troponin I elevation after elective PCI is frequent and associated with progressively higher mortality rates at 1year. A cutoff value ≥5 times the 99th percentile, currently defined as myocardial injury, appears to be an even more significant predictor of this outcome, even in lower risk subgroups.

Morphine Post-Conditioning Effect on QT Dispersion in Patients Undergoing Primary Percutaneous Coronary Intervention on Anterior Descending Cardiac Artery: A Cohort Study

Introduction

QT dispersion is the difference between the maximum and minimum QTc interval in a 12-lead electrocardiogram (ECG). Some researchers have demonstrated the effects of an increase of QT-d in STEMI and its reduction with successful therapy. The aim of this study was to investigate the morphine post-conditioning effect on the QT dispersion in patients undergoing primary percutaneous coronary intervention (PCI) on anterior descending cardiac artery.

Methods

This cohort study was conducted on STEMI patients admitted to the Hospital of Imam Reza (AS), Mashhad, Iran, from March 2015 to February 2016 who were undergoing primary angioplasty on the anterior descending cardiac artery. The patients were divided into two groups based on the intake or non-intake of morphine (5 mg morphine for the period of 30 minutes prior to PCI). Parameters, including age, gender, history of diabetes, and blood pressure as well as admission and 24 hours after PCI ejection fraction (EF) and QT-d, were recorded in all patients and compared between the two intervention and control groups. Independent and paired t-tests and chi-square test were used to compare the qualitative and quantitative data between the two groups using SPSS version 19 software.

Results

The present research was performed on 77 patients (61 males) with mean age of 58.71±11.84 years in the two groups of morphine consumption before PCI (n=46) and control (n=31). No statistical difference was found among the groups in age, gender, diabetes, hypertension, and onset of symptoms until primary PCI. Admission electrocardiogram QT-d value in the positive exposure group showed no significant difference with the control group, but QT-d value at 24 hours after PCI was lower in the positive exposure group than in the control group (morphine versus control: 40.32±6.98 versus 59.64±8.89; p=0.000). QT-d value 24 hours after PCI compared with the admission QT-d value was significantly reduced in both groups. The mean decrease of admission QT-d relative to QT-d 24 hours after PCI was higher in the positive exposure group than in the control group, and this difference was also statistically significant (morphine versus control: 48.65±9.95 versus 25.74±6.66; p=0.000).

Conclusion

The findings of the current survey demonstrated that morphine consumption before PCI can further reduce QT-d value in an electrocardiogram for PCI as compared to patients who did not take morphine before PCI.

Consensus or Controversy?: Evolution of Criteria for Myocardial Infarction After Percutaneous Coronary Intervention

BACKGROUND

The definition and the clinical implications of myocardial infarction (MI) occurring in the setting of percutaneous coronary intervention have been subjects of unresolved controversy. As a result of the use of more sensitive diagnostic tools such as cardiac troponin, the expanding evidence, and the ensuing debate, the definition of procedural MI (pMI) has evolved, leading to several revisions, different proposed definitions, and lack of standardization in randomized clinical trials.

CONTENT

In this review, we will describe the key clinical data on cardiac biomarkers, creatine kinase isoenzyme MB and cTn, in the setting of percutaneous coronary intervention and the main issues that have lead to various consensus documents with a proposed definition of pMI. We will focus on the rationale of the current “Third Universal Definition of Myocardial Infarction” and of the alternative approach proposed by the Society for Cardiovascular Angiography and Interventions.

SUMMARY

The definition of pMI is an evolving field where the Third Universal MI definition represents the best attempt to date to incorporate available evidence along with scientific and clinical judgment into criteria to ensure adequate specificity in the diagnosis and the relevant prognostic significance, while trying to maintain sensitivity. Questions on the recommended criteria and their practical implementation remain, but the Third Universal definition document represents an important milestone toward a better standardization and enhanced consensus on the pMI definition.

Association of chronic kidney disease with periprocedural myocardial injury after elective stent implantation: A single center prospective cohort study

Coronary artery disease (CAD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Patients with CKD who undergo percutaneous coronary intervention (PCI) may have more ischemic events than patients without CKD. The aim of our study was to determine the incidence of periprocedural myocardial injury (PMI) after elective stent implantation in patients with CKD using the Third Joint ESC/ACCF/AHA/WHF PMI definition.In a single center prospective cohort study, we enrolled 344 consecutive patients who underwent elective PCI in a period of 39 months. Serum troponin I (cTnI) concentrations were measured at baseline and at 8 and 16 hours after PCI. Periprocedural increase of cTnI, according to the most recent PMI definition, was used to define both the presence and intensity of PMI. Patients were further stratified according to the estimated glomerular filtration rate (eGFR) using 4 variable Modification of Diet in Renal Disease (MDRD) equation: control group with eGFR >90 mL/min/1.73 m and the CKD group with eGFR < 90 mL/min/1.73 m, with further subdivision according to the CKD stage.We found no significant difference in the incidence as well as intensity of the PMI in the control (>90 mL/min/1.73 m) and the CKD group (<90 mL/min/1.73 m) both 8 and 16 hours after PCI. When the CKD patients were further subdivided according to their CKD stage, there was again no difference in the intensity or incidence of PMI compared to the control group. Further analyses of our data showed angina pectoris CCS IV, bare metal stent (BMS) implantation, and treatment with angiotensin-converting enzyme inhibitors (ACEI) as independent predictors of PMI. Furthermore, the presence of hypertension was inversely related to the occurrence of PMI.Applying the new guidelines for PMI and using the eGFR equation most suitable for our patients, we found no association between PMI and CKD. Further analyses showed other factors that could potentially influence the occurrence of PMI.

Elevated preoperative HMGB1 as predictor of myocardial injury post-percutaneous coronary intervention

In this study, we evaluated the impact of preoperative high mobility group box 1 (HMGB1) on myocardial injury post-percutaneous coronary intervention.We evaluated 302 consecutive patients who underwent percutaneous coronary intervention. They were divided into equal tertiles based on their preoperative HMGB1 levels. Creatine kinase-MB and troponin I levels were measured at baseline, 8- and 24-hours after the procedure, while clinical outcomes were followed up for 1 year.The occurrence of post-procedural myocardial injury was significantly higher in the tertile comprising of patients with elevated HMGB1 levels. Moreover, these patients showed significantly higher post-procedural peak values of creatine kinase-MB and troponin I in comparison to patients with lower HMGB1 levels. Event-free survival was significantly associated with HMGB1 levels, with worst event-free survival in patients with elevated HMGB1 levels.Elevated preoperative HMGB1 was a predictor of myocardial injury after percutaneous coronary intervention, and was associated with the worst clinical outcomes during 1-year follow up.

Infarct size and left ventricular remodelling after preventive percutaneous coronary intervention

Objective

We hypothesised that, compared with culprit-only primary percutaneous coronary intervention (PCI), additional preventive PCI in selected patients with ST-elevation myocardial infarction with multivessel disease would not be associated with iatrogenic myocardial infarction, and would be associated with reductions in left ventricular (LV) volumes in the longer term.

Methods

In the preventive angioplasty in myocardial infarction trial (PRAMI; ISRCTN73028481), cardiac magnetic resonance (CMR) was prespecified in two centres and performed (median, IQR) 3 (1, 5) and 209 (189, 957) days after primary PCI.

Results

From 219 enrolled patients in two sites, 84% underwent CMR. 42 (50%) were randomised to culprit-artery-only PCI and 42 (50%) were randomised to preventive PCI. Follow-up CMR scans were available in 72 (86%) patients. There were two (4.8%) cases of procedure-related myocardial infarction in the preventive PCI group. The culprit-artery-only group had a higher proportion of anterior myocardial infarctions (MIs) (55% vs 24%). Infarct sizes (% LV mass) at baseline and follow-up were similar. At follow-up, there was no difference in LV ejection fraction (%, median (IQR), (culprit-artery-only PCI vs preventive PCI) 51.7 (42.9, 60.2) vs 54.4 (49.3, 62.8), p=0.23), LV end-diastolic volume (mL/m², 69.3 (59.4, 79.9) vs 66.1 (54.7, 73.7), p=0.48) and LV end-systolic volume (mL/m², 31.8 (24.4, 43.0) vs 30.7 (23.0, 36.3), p=0.20). Non-culprit angiographic lesions had low-risk Syntax scores and 47% had non-complex characteristics.

Conclusions

Compared with culprit-only PCI, non-infarct-artery MI in the preventive PCI strategy was uncommon and LV volumes and ejection fraction were similar.

Elective percutaneous coronary intervention leads to significant changes in serum resistin, leptin, and adiponectin levels regardless of periprocedural myocardial injury: an observational study

Objective:

Bioactive roles of adipokines in coronary atherosclerosis and acute coronary syndromes have been demonstrated previously. However, there is a lack of data regarding the relationship between serum adipokines and periprocedural myocardial injury (PMI) following elective percutaneous coronary intervention (PCI). Therefore, we aimed to investigate the association between serum adipokines and PMI related to elective PCI.

Methods:

In total, 153 consecutive patients (aged 60.6±8.2 years, 98 men) with stable angina pectoris undergoing elective PCI were enrolled in this observational cross-sectional study. Serum resistin, leptin, adiponectin, and high-sensitive Troponin T (hscTnT) levels were measured immediately before PCI and after 12-h PCI. The no-injury, PMI, and type 4a myocardial infarction (type 4a MI) groups were defined as groups consisting patients with post-procedural hscTnT concentrations <14 ng/L, between 14–70 ng/L, and >70 ng/L, respectively.

Results:

Serum hscTnT, resistin, and leptin concentrations significantly (p<0.001) increased while serum adiponectin levels decreased (p<0.001) after 12-h elective PCI. However, no correlation was found between post-procedural hscTnT concentrations and resistin, leptin, and adiponectin levels. The no-injury group consisted of 65 patients (42.4%), whereas PMI and type 4a MI were observed in 70 (45.8%) and 18 (11.8%) patients, respectively. The average pre-procedural and post-procedural resistin, leptin, and adiponectin levels did not show any significant difference in the no-injury, PMI, and type 4a MI groups.

Conclusion:

There is no correlation between serum adipokine levels and post-procedural troponin elevations reflecting PMI or type 4a MI. However, serum resistin and leptin levels increase, whereas adiponectin levels decrease significantly after elective PCI.

Coronary angiography-related myocardial injury as detected by high-sensitivity cardiac troponin T assay

AIMS

We sought to evaluate rates and mechanisms of myocardial injury and type 4a myocardial infarction (MI) after an elective diagnostic coronary angiography (CAG) as detected by high-sensitivity cardiac troponin T (hsTnT) assay.

METHODS AND RESULTS

Cardiac troponin concentrations were measured in consecutive patients before and after undergoing an elective CAG -with or without coronary intervention (PCI)- using an hsTnT assay. The study population consisted of 545 patients: 320 (58.7%) patients received only an elective CAG and another 225 patients (41.3%) received an additional PCI. Significant hsTnT increases occurred in 97 (30.3%) cases within the CAG group and in 152 (67.6%) cases within the PCI group. Rates of normal baseline hsTnT values (<99th percentile upper reference limit) were 75.9% in the CAG group and 71.6% in the PCI group. In cases with normal baseline hsTnT values, peak levels meeting criteria of MI type 4a according to the second or third version of the universal MI definition were observed in five (1.6%) and one (0.3%) cases within the CAG group, as well as in 32 (14.2%) and 22 (9.8%) cases within the PCI group, respectively.

CONCLUSIONS

Use of the hsTnT assay may allow identification of myocardial injury during an uneventful diagnostic coronary angiography in the absence of any coronary or non-coronary interventions.

Incidence and impact on prognosis of peri-procedural myocardial infarction in 2760 elective patients with stable angina pectoris in a historical prospective follow-up study

BACKGROUND

The clinical significance of myocardial infarction related to treatment with percutaneous coronary intervention (PCI) has been subject of great discussion. This subject has been studied for many years using different definitions of peri-procedural myocardial infarction and different biomarkers, the results have varied greatly depending on methods and time of the study. This study was to determine the incidence and prognostic significance of elevated cardiac biomarkers after elective PCI in patients with stable angina pectoris using the current cut-off set by the Third Universal Definition of Myocardial Infarction and current biomarkers.

METHODS

We performed a historical prospective follow-up study of all patients with stable angina pectoris who underwent elective PCI at Aalborg University Hospital, Denmark from January 1(st) 2000 to December 31(st) 2012. We stratified patients according to peak post-PCI troponin T (cTnT) and Creatine Kinase MB mass (CK-MBmass).

RESULTS

Follow-up for time to all-cause mortality was mean 5.8 years and total 15,891 years and mean 3.7 years and total 10,160 years for the combined endpoint of all-cause mortality and new onset heart failure. During the follow up period 399 of 2760 patients died (14.5 %) and 1095 (39.7 %) suffered the combined endpoint. Post-PCI concentration of cTnT and CK-MBmass was elevated above the defined cut-off in 419 patients (15.2 %) and 113 patients (4.1 %) respectively. There was no statistically significant difference between the groups in stratified analysis of the hazard rates by time regarding all-cause mortality for cTnT nor CK-MBmass. Regarding the combined endpoint the results were ambiguous. The results were unchanged in multivariable analyses that included age and gender.

CONCLUSION

The incidence of elevated biomarkers after elective PCI in patients with stable angina pectoris using the defined cut-off (>5 x URL) was 15.2 % using cTnT and 4.1 % using CK-MBmass. The independent prognostic value for both cardiac biomarkers of any cut-off showed no statistical significance for all-cause mortality, whereas the combined endpoint (all-cause mortality or new-onset heart failure) were ambiguous in both short- and long-term follow-up.

Thirty-day readmission rates after PCI in a metropolitan center in Europe: incidence and impact on prognosis

INTRODUCTION

Thirty-day readmission rates after percutaneous coronary intervention (PCI) have been related to adverse prognosis, and represent one of the most investigated indicators of quality of care. These data, however, derive from non-European centers evaluating all-cause readmissions, without stratification for diagnosis.

METHODS

All consecutive patients undergoing PCI at our center from January 2009 to December 2011 were enrolled. Thirty-day readmissions related to postinfarction angina, myocardial infarction, unstable angina or heart failure were defined as acute coronary syndrome (ACS) or heart failure rehospitalizations. Major cardiac adverse event (MACE) was the primary outcome, and its single components (death, myocardial infarction and repeated revascularization) the secondary ones.

RESULTS

A total of 1192 patients were included; among them, 53 (4.7%) were readmitted within 30 days, and 25 (2.1%) were classified as ACS/heart failure related. During hospitalization, patients with ACS/heart failure readmissions were more likely to suffer a periprocedural myocardial infarction (22 vs. 4%; P = 0.012), and to undergo PCI at 30 days (52 vs. 0.5%; P < 0.001). Logistic regression analysis indicated that periprocedural myocardial infarction represented the only independent predictor of an ACS/heart failure readmission [odds ratio (OR) 4.5; 1.1-16.8; P = 0.047]. After a median follow-up of 787 days (434-1027; first and third quartiles), patients with a 30-day ACS/heart failure readmission experienced higher rates of MACE, all-cause death and myocardial infarction (64 vs. 21%, P < 0.001; 28 vs. 6%, P = 0.017; and 20 vs. 2.7%, P < 0.001, respectively). Cox multivariate analysis indicated that ACS/heart failure 30-day readmissions were independently related to an increased risk of all-cause death (OR 3.3; 1.1-8.8; P = 0.02), differently from 30-day non-ACS/heart failure readmissions (OR 3.1; 0.7-12.9; P = 0.12).

CONCLUSION

Thirty-day readmissions after PCI in an Italian center are infrequent, and only those patients with ACS/heart failure show a detrimental impact on prognosis who have periprocedural myocardial infarction as the only independent predictor.

Impact of increased admission lipid levels on periprocedural myocardial injury following an elective percutaneous coronary intervention

OBJECTIVE

Periprocedural myocardial injury (PMI) is known to be a predictor of in-hospital cardiac events and long-term adverse outcomes following a percutaneous coronary intervention (PCI). We aimed to evaluate the correlation between preprocedural serum lipid levels and PMI in patients undergoing elective PCI.

PATIENTS AND METHODS

The final study group included 195 patients (60.1±0.7 years old, 68 women and 127 men). Serum high-sensitive troponin T (hscTnT) concentrations were measured immediately before PCI and 12 h after PCI. Serum total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C), and triglyceride (TG) levels were determined immediately before PCI. Serum hscTnT concentrations were adjusted for the clinical and procedural characteristics of the patients using the weighted least-square regression analysis.

RESULTS

The average preprocedural hscTnT concentration was 8.1±0.2 ng/l. The average serum hscTnT concentration increased to 34.1±2.8 ng/l (P<0.001) 12 h after PCI. Postprocedural hscTnT concentrations were correlated positively to serum concentrations of TC (r=0.435; P<0.001), LDL-C (r=0.349; P<0.001), and TG (r=0.517; P<0.001). There was also a positive correlation (r=0.205; P<0.01) between postprocedural hscTnT and lesion length. Mild-moderate PMI (postprocedural hscTnT≥14 to <70 ng/l) and severe PMI (postprocedural hscTnT≥70 ng/l) were observed in 122 (48.7%) and 27 (13.9%) patients, respectively. The patients with severe PMI had higher serum TC (P<0.001), LDL-C (P<0.001), and TG (P<0.001) concentrations.

CONCLUSION

The present study indicates that increased preprocedural TC, LDL-C, and TG serum levels are associated with PMI and its severity following elective PCI.