Postprocedure creatine kinase-MB elevation and baseline left ventricular dysfunction predict one-year mortality after percutaneous coronary intervention

Mechanical Support Strategies for High-Risk Procedures in the Invasive Cardiac Catheterization Laboratory: A State-of-the-Art Review

Thanks to advancements in percutaneous cardiac interventions, an expanding patient population now qualifies for treatment through percutaneous endovascular procedures. High-risk interventions far exceed coronary interventions and include transcatheter aortic valve replacement, endovascular management of acute pulmonary embolism and ventricular tachycardia ablation. Given the frequent impairment of ventricular function in these patients, frequently deteriorating during percutaneous interventions, it is hypothesized that mechanical ventricular support may improve periprocedural survival and subsequently patient outcome. In this narrative review, we aimed to provide the relevant evidence found for the clinical use of percutaneous mechanical circulatory support (pMCS). We searched the Pubmed database for articles related to pMCS and to pMCS and invasive cath lab procedures. The articles and their references were evaluated for relevance. We provide an overview of the clinically relevant evidence for intra-aortic balloon pump, Impella, TandemHeart and ECMO and their role as pMCS in high-risk percutaneous coronary intervention, transcatheter valvular procedures, ablations and high-risk pulmonary embolism. We found that the right choice of periprocedural pMCS could provide a solution for the hemodynamic challenges during these procedures. However, to enhance the understanding of the safety and effectiveness of pMCS devices in an often high-risk population, more randomized research is needed.

The Prognostic Value of Creatine Kinase-MB Dynamics after Primary Angioplasty in ST-Elevation Myocardial Infarctions

BACKGROUND

In STEMIs, the evaluation of the relationship between biomarkers of myocardial injury and patients' prognoses has not been completely explored. Increased levels of CK-MB in patients with a STEMI undergoing primary angioplasty are known to be associated with higher mortality rates, yet the correlation of these values with short-term evolution remains unknown.

MATERIAL AND METHODS

The research encompassed a sample of 80 patients diagnosed with STEMIs, and its methodology entailed a retrospective analysis of the data collected during their hospital stays. The study population was then categorized into three distinct analysis groups based on the occurrence or absence of acute complications and fatalities.

RESULTS

The findings indicated that there is a notable correlation between rising levels of CK-MB upon admission and peak CK-MB levels with a reduction in left ventricular ejection fraction. Moreover, the CK-MB variation established a point of reference for anticipating complications at 388 U/L, and a cut-off value for predicting death at 354 U/L.

CONCLUSION

CK-MB values are reliable indicators of the progress of patients with STEMIs. Furthermore, the difference between the peak and admission CK-MB levels demonstrates a high accuracy of predicting complications and has a significant predictive power to estimate mortality risk.

Identification of patients at higher risk for myocardial injury following elective coronary artery intervention

OBJECTIVES

To evaluate myocardial injury and infarction (MI) following elective percutaneous coronary intervention (PCI).

BACKGROUND

The substantially higher analytical power of high-sensitivity troponin (hsTn) assays allows detection of minor cardiac troponin (cTn) levels, which may be useful in monitoring myocardial injury and guiding therapies.

METHODS

Serial hsTnT measurements were conducted in patients undergoing elective PCI and were related to the extent of coronary artery disease (CAD) as reflected by the SYNTAX score risk categories and American College of Cardiology/American Heart Association classification of coronary lesions. Myocardial injury and MI were diagnosed according to the second and third versions of universal MI definition.

RESULTS

The study population consisted of 530 patients, who were grouped into low (41.3%), intermediate (35.4%), and high (23.3%) SYNTAX risk categories. The treated coronary lesions were classified into A 7.8%, B1 24.1%, B2 21.1%, C1 24.6%, and C2 22.4%. Postprocedural hsTnT increases correlated significantly with the complexity of treated coronary lesions (p < .05) and CAD magnitude (p < .05). Rates of MI type 4a according to the second and third MI definition criteria were 98 (27.5%) and 15 (4.2%) cases in patients with normal baseline hsTnT values (N = 357, 67.4%), as well as 137 (79.2%) and 27 (15.6%) cases in those with elevated baseline hsTnT values (N = 173, 32.6%), respectively.

CONCLUSIONS

After elective PCI, cTn releases correlate significantly with lesion complexity and CAD extent. Use of hsTnT assay enables precise monitoring of PCI-related myocardial injury and may identify patients at higher risk for ischemic events, who may benefit from potent platelet inhibition, which needs to be investigated in randomized trials.

Unprotected versus protected high-risk percutaneous coronary intervention with the Impella 2.5 in patients with multivessel disease and severely reduced left ventricular function

Selecting a revascularization strategy in patients with multivessel disease (MVD) and severely reduced left ventricular ejection fraction (LVEF) remains a challenge. PCI with Impella 2.5 may facilitate high-risk PCI, however long-term results comparing unprotected versus protected PCI are currently unknown. We sought to evaluate the outcome of patients undergoing protected compared to unprotected percutaneous coronary intervention (PCI) in the setting of MVD and severely reduced LVEF.We included patients with MVD and severely reduced LVEF (≤35%) in this retrospective, single-centre study. Patients that underwent unprotected PCI before the start of a dedicated protected PCI program with Impella 2.5 were compared to patients that were treated with protected PCI after the start of the program. The primary endpoint was defined as major adverse cardiac and cerebrovascular events (MACCE) during a 1-year follow-up. The secondary endpoints consisted of in-hospital MACCE and adverse events.A total of 61 patients (mean age 70.7 ± 10.9 years, 83.6% male) were included in our study, of which 28 (45.9%) underwent protected PCI. The primary endpoint was reached by 26.7% and did not differ between groups (P = .90). In-hospital MACCE (P = 1.00) and in-hospital adverse events (P = .12) also demonstrated no significant differences. Multivariate logistic regression identified procedural success defined as complete revascularization and absence of in-hospital major clinical complications as protective parameter for MACCE (OR 0.17, 95% CI 0.04-0.70, P = .02).Patients with MVD and severely depressed LVEF undergoing protected PCI with Impella 2.5 demonstrate similar in-hospital and one-year outcomes compared to unprotected PCI.

Protection from procedural myocardial injury by omega-3 polyunsaturated fatty acids (PUFAs): is related with lower levels of creatine kinase-MB (CK-MB) and troponin I?

OBJECTIVE

This study sought to investigate the effect of omega-3 polyunsaturated fatty acids (PUFAs) on cardiac biomarkers, CK-MB, and troponin I in patients undergoing PCI.

BACKGROUND

Restenosis remains as a major long-term complication following percutaneous coronary intervention (PCI). It appears that there is strong relationship between post-PCI creatine kinase-MB (CK-MB) and troponin I elevation and cardiovascular events after PCI.

METHODS

In this randomized clinical trial, a total of 90 patients planned to undergo PCI were randomly assigned into two groups: Group A-receiving omega-3 PUFAs (3 g, 12 h before PCI) plus standard treatment (n = 43) and Group B-control group, receiving only standard therapy (n = 47). Standard treatment included aspirin 325 mg and clopidogrel 600 mg loading dose. The plasma CK-MB level was measured before the procedure (baseline), at 8 and 24 h after PCI. The plasma troponin I was measured at baseline and 24 h after PCI.

RESULTS

In comparison with control, omega-3 PUFAs could significantly reduce the level of CK-MB in 8 (P = 0.001) and 24 h (P = 0.012) after its prescription in the omega-3 PUFAs group. Omega-3 PUFAs could not significantly decrease troponin I.

CONCLUSION

Our results revealed that omega-3 PUFAs can be considered as a safe adjunctive medication to the standard regimen before PCI for the aim of decreasing cardiovascular event after PCI.

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.

Consideration of a new definition of clinically relevant myocardial infarction after coronary revascularization: an expert consensus document from the Society for Cardiovascular Angiography and Interventions (SCAI)

Numerous definitions have been proposed for the diagnosis of myocardial infarction (MI) after coronary revascularization. The universal definition for MI designates post procedural biomarker thresholds for defining percutaneous coronary intervention (PCI)-related MI (type 4a) and coronary artery bypass grafting (CABG)-related MI (type 5), which are of uncertain prognostic importance. In addition, for both the MI types, cTn is recommended as the biomarker of choice, the prognostic significance of which is less well validated than CK-MB. Widespread adoption of a MI definition not clearly linked to subsequent adverse events such as mortality or heart failure may have serious consequences for the appropriate assessment of devices and therapies, may affect clinical care pathways, and may result in misinterpretation of physician competence. Rather than using an MI definition sensitive for small degrees of myonecrosis (the occurrence of which, based on contemporary large-scale studies, are unlikely to have important clinical consequences), it is instead recommended that a threshold level of biomarker elevation which has been strongly linked to subsequent adverse events in clinical studies be used to define a "clinically relevant MI." The present document introduces a new definition for "clinically relevant MI" after coronary revascularization (PCI or CABG), which is applicable for use in clinical trials, patient care, and quality outcomes assessment.

The independent value of a direct stenting strategy on early and late clinical outcomes in patients undergoing elective percutaneous coronary intervention

OBJECTIVES

This study aimed to compare percutaneous coronary intervention (PCI) with direct stenting (DS) to balloon predilatation (PD) for patients undergoing elective PCI to determine whether there is an independent value for DS with regard to clinical outcomes.

BACKGROUND

The safety of PCI with DS has been established, but the independent advantages of this technique are not entirely clear.

METHODS

Patients undergoing elective PCI from January 2000 to December 2010 were included. The postprocedural and late clinical outcomes of 444 patients who underwent PCI with DS were compared with a propensity-matched population of 444 subjects treated with PD.

RESULTS

The two groups were well matched to 27 baseline clinical, procedural, and angiographic characteristics, thus allowing for a more accurate evaluation of the independent value of the stenting technique. Intravascular ultrasound was used in more than 60% of interventions in both groups. PCI performed with PD were longer (DS 45 ± 19.28 vs. PD 56 ± 23.72 minutes, P = 0.001), used more contrast (DS 154 ± 65.88 vs. PD 186 ± 92.84 cc, P = 0.001), and more frequently used balloon postdilation (DS 0% vs. PD 27.3%, P = 0.001). The incidence of periprocedural myocardial infarction (PPMI) was similar between DS- and PD patients (5.3% vs. 5.4%, P = 0.91). Likewise, the 1-year rates of major adverse cardiac events (8.4% vs. 6.3%, P = 0.25), target lesion revascularization (3.9% vs. 2.5%, P = 0.24), and definite stent thrombosis (0.2% vs. 0.9%, P = 0.37) were similar among DS and PD patients, respectively.

CONCLUSION

During elective PCI, DS decreases overall procedure time and resource utilization, but fails to reveal an independent clinical advantage as there is no demonstrable benefit in regard to the incidence of PPMI, restenosis, or overall clinical outcomes up to 1-year of follow-up.

Prognostic value of cardiac troponin-I or troponin-T elevation following nonemergent percutaneous coronary intervention: a meta-analysis

OBJECTIVES

The aim of this meta-analysis was to assess the prevalence and prognostic value regarding mortality of cTnT or cTnI elevations after nonemergent percutaneous coronary intervention (PCI) in a large number of cohort/registry studies.

BACKGROUND

Routine cardiac troponin measurement after elective PCI has been controversial among interventionalists. Recent studies have provided conflicting data in regard to predictive value of cardiac troponin-T (cTnT) and troponin-I (cTnI) elevation after non-emergent PCI.

METHODS

Electronic and manual searches were conducted of all published studies reporting on the prognostic impact of cTnT or cTnI elevation after elective PCI. A meta-analysis was performed with all-cause mortality at follow-up as the primary endpoint.

RESULTS

We identified 22 studies, involving 22,353 patients, published between 1998 and 2009. Postprocedural cTnT and cTnI were elevated in 25.9% and 34.3% of patients, respectively. Follow-up period ranged from 3 to 67 months (mean: 17.7 ± 14.9 months). The results showed no heterogeneity among the trials (Q-test: 25.39; I(2) : 17%; P = 0.23). No publication bias was detected (Egger's test: P = 0.16). The long-term all-cause mortality in patients with cTnI or cTnT elevation after PCI (5.8%) was significantly higher when compared to patients without cTnI or cTnT elevation (4.4%); OR 1.45 (95% CI: 1.22-1.72), P < 0.01. In addition, the postprocedural composite adverse clinical events of all-cause mortality or myocardial infarction (MI) in patients with cTnI or cTnT elevation after PCI (9.2%) was significantly higher when compared to patients without cTnI or cTnT elevation (5.3%); OR 1.77 (95% CI: 1.48-2.11), P < 0.01.

CONCLUSIONS

The current meta-analysis indicates that cTnI or cTnT elevation after nonemergent PCI is indicative of an increase in long-term all-cause mortality as well as the composite adverse events of all-cause mortality and MI. Efforts to routinely monitor periprocedural cTn levels along with more intensive outpatient monitoring/treatment of patients with cTn elevations may help to improve the long-term adverse outcomes in these patients following non-emergent PCI.

Use of clopidogrel in the reduction of myocardial damage during percutaneous coronary intervention

It is estimated that approximately a quarter of patients undergoing coronary intervention may have significant post-procedural creatinine (CK)/creatinine kinase myocardial band (CK-MB) elevations and approximately half may have post-procedural troponin elevations. Current data suggest that periprocedural infarction is associated with short-, intermediate-, and long-term adverse outcomes, most notably mortality. This review examines the role of clopidogrel in decreasing periprocedural myonecrosis following percutaneous coronary intervention (PCI). Clopidogrel is an important pharmacologic agent used to reduce myocardial infarction post-coronary intervention as assessed directly by the evaluation of cardiac biomarkers and indirectly by the evaluation of short-term ischemic events. The optimal dose of clopidogrel is considered to be at least 300 mg given 6 to 15 hours prior to PCI but there is considerable evidence to suggest that a loading dose of 600 mg given 2 to 6 hours prior to PCI may be more efficacious in limiting post-coronary intervention events. The benefit obtained from clopidogrel appears independent of and incremental to that of other antiplatelet and antithrombotic agents used during and after coronary intervention.

Evolution of anticoagulant and antiplatelet therapy: benefits and risks of contemporary pharmacologic agents and their implications for myonecrosis and bleeding in percutaneous coronary intervention

Periprocedural myonecrosis, as evidenced by elevated creatine kinase-myocardial bound (CK-MB) levels, occurs in up to 25% of patients undergoing percutaneous coronary intervention (PCI) and has been linked with an increased risk of adverse short- and long-term clinical outcomes. Such myonecrosis arises from three main pathophysiological mechanisms: procedure-related complications, lesion-specific characteristics (e.g., large thrombus burden, plaque volume), and patient-specific characteristics (e.g., genetic predisposition, arterial inflammation). Periprocedural myonecrosis has not been definitively identified as the cause of postprocedural ischemic events, although agents that reduce or prevent thrombosis--including aspirin, thienopyridines, heparin, low-molecular-weight heparins, glycoprotein IIb/IIIa inhibitors, and direct thrombin inhibitors--have been shown to reduce the incidence of ischemic outcomes in this population, as have agents that reduce inflammation (aspirin, statins). At the same time, antithrombotic agents are known to increase the risk of bleeding and the use of transfusions, which have likewise been associated with worse outcomes in these patients. Thus, optimal management of patients undergoing PCI represents a balance between minimizing the risk of ischemic outcomes and simultaneously minimizing the risk of major bleeding. It may be that patients who have only minor, untreated postprocedural elevations in CK-MB level (with no clinical or angiographic signs of ischemia) might have a better prognosis than patients who have normal CK-MB levels but who suffer major bleeding complications.

Peri-procedural myocardial injury: 2005 update

During the past three decades, percutaneous coronary intervention has become one of the cardinal treatment strategies for stenotic coronary artery disease. Technical advances, including the introduction of new devices such as stents, have expanded the interventional capabilities of balloon angioplasty. At the same time, there has been a decline in the rate of major adverse cardiac events, including Q-wave acute myocardial infarction, emergency coronary artery bypass grafting, and cardiac death. Despite these advances, the incidence of post-procedural cardiac marker elevation has not substantially decreased since the first serial assessment 20 years ago. As of now, these post-procedural cardiac marker elevations are considered to represent peri-procedural myocardial injury (PMI) with worse long-term outcome potential. Recent progress has been made for the identification of two main PMI patterns, one near the intervention site (proximal type, PMI type I) and one in the distal perfusion territory of the treated coronary artery (distal type, PMI type II) as well as for preventive strategies. Integrating these new developments into the wealth of clinical information on this topic, this review aims at giving a current perspective on the entity of PMI.

Use of abciximab prevents microcirculatory impairment in patients treated with coronary angioplasty for unstable angina: Results of a prospective randomized study

The use of abciximab during percutaneous coronary angioplasty (PTCA) in patients with unstable angina (UA) prevents the postintervention enzyme surge and improves clinical outcomes, possibly by improving microcirculatory function. The aim of this quantitative myocardial blush grade (MBG) study was to verify whether abciximab improves postintervention microcirculation in patients with UA. This prospective randomized open-label study involved 140 UA patients scheduled to undergo PTCA of the target coronary lesion: 140 patients were randomized to receive either abciximab during PTCA (group 1, 70 patients) or conventional treatment without GP IIb/IIIa inhibitor (group 2, 70 patients). The exclusion criteria included above normal CK-MB levels. MBG was calculated by means of quantitative software that evaluates video intensity in a given region of interest: assuming that greater peak video intensity reflects a larger myocardial blood volume, a perfusion scale of 1-6 points (poor to optimal) was devised. The groups were homogeneous in terms of their demographic, procedural, and angiographic characteristics. Stents were used in 98% of the patients in both groups. The MBG score significantly increased in group 1 from 3.04 +/- 2.17 to 3.71 +/- 2.02 (P = 0.045) and slightly decreased in group 2 from 3.13 +/- 2.07 to 2.93 +/- 2.03 (P = 0.42). Consequently, group 1 showed a significantly greater postintervention MBG score (3.71 +/- 2.02 vs. 2.93 +/- 2.03; P = 0.022) and had a significantly greater MBG score change (P = 0.025). The results of this randomized study show that the administration of abciximab prevents microcirculatory impairment in patients undergoing angioplasty for acute coronary syndromes.

Usefulness of hyperglycemia in predicting renal and myocardial injury in patients with diabetes mellitus undergoing percutaneous coronary intervention

A retrospective analysis of 165 patients who had diabetes mellitus and underwent percutaneous coronary intervention (PCI) between 1998 and 2003 demonstrated that those whose plasma glucose levels were >/=200 mg/dl before PCI exhibited greater creatine phosphokinase release and serum creatinine increases after PCI. These observations identified hyperglycemia as a potentially modifiable mediator of myocardial and renal injuries in patients who have diabetes and have undergone PCI.

Mortality risk conferred by small elevations of creatine kinase-MB isoenzyme after percutaneous coronary intervention

OBJECTIVES

The aim of this study was to assess whether small creatine kinase-MB isoenzyme (CK-MB) elevations after percutaneous coronary intervention (PCI) affect the subsequent mortality risk.

BACKGROUND

Several studies have evaluated the relationship of CK-MB levels after PCI with the subsequent risk of death. While there is consensus that elevations exceeding 5 times the upper limit of normal increase mortality significantly, there is uncertainty about the exact clinical impact of smaller CK-MB elevations.

METHODS

We performed a meta-analysis of seven studies with CK-MB measurements and survival outcomes on 23230 subjects who underwent PCI. Data were combined with random effects models.

RESULTS

Mean follow-up was 6 to 34 months per study. By random effects, 19% (95% confidence interval [CI], 16% to 23%) had one- to five-fold CK-MB elevations, while only 6% (95% CI, 5% to 9%) had >5-fold elevations. Compared with subjects with normal CK-MB, there was a dose-response relationship with relative risks for death being 1.5 (95% CI, 1.2 to 1.8, no between-study heterogeneity) with one- to three-fold CK-MB elevations, 1.8 (95% CI, 1.4 to 2.4, no between-study heterogeneity) with three- to five-fold CK-MB elevations, and 3.1 (95% CI, 2.3 to 4.2, borderline between-study heterogeneity) with over five-fold CK-MB elevations (p < 0.001 for all).

CONCLUSIONS

Any increase in CK-MB after PCI is associated with a small, but statistically and clinically significant, increase in the subsequent risk of death.

Stenting of culprit lesions in unstable angina leads to a marked reduction in plaque burden: a major role of plaque embolization? A serial intravascular ultrasound study

BACKGROUND

Intravascular ultrasound (IVUS) studies have shown that a mechanism of plaque compression/embolization contributes toward the poststenting increase in lumen area. The aim of this IVUS study was to compare the mechanisms of lumen enlargement after coronary stenting in 54 consecutive patients with unstable angina (UA) (group 1) and 56 with stable angina (group 2) to verify whether plaque embolization plays a major role in the former.

METHODS AND RESULTS

Both groups underwent the IVUS assessment (speed, 0.5 mm/sec) before the intervention and after stent implantation. The lumen area, the external elastic membrane area, and the plaque+media area (PA) were measured at 0.5-mm intervals. PA reduction in the lesion site was significantly greater in group 1 (-2.50+/-1.97 versus -0.53+/-1.43 mm2, P<0.001). After stenting, 47% of the lumen area increase in group 1 was obtained by means of PA reduction, and 53% was attributable to external elastic membrane area increase; the corresponding figures in group 2 were 13% and 87% (P<0.05). Decrease in PA after stenting was the only significant predictor of the MB fraction of creatinine kinase (CK-MB) release in a multiple regression model (P=0.047).

CONCLUSIONS

Serial volumetric IVUS assessment revealed in UA lesions a marked poststenting reduction in plaque volume, which is significantly greater than in stable angina and is associated with postprocedural CK-MB release. The decrease in PA during the procedure predicts CK-MB release in a multiple regression model. These findings suggest that stent deployment is often associated with plaque embolization in patients with UA.