Incidence and determinants of myocardial infarction following percutaneous coronary interventions according to the revised Joint Task Force definition of troponin T elevation

Alcock, R.; Roy, Probal; Adorini, Katrina; Lau, George T.; Kritharides, L.; Lowe, Harry C.; Brieger, David; Freedman, Ben

doi:10.1016/j.ijcard.2008.11.005

Cited by 22 publications

(18 citation statements)

References 36 publications

(54 reference statements)

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“…Approximately one-third of patients undergoing even seemingly uncomplicated elective PCI experience a rise in troponin levels consistent with the diagnosis of myocardial necrosis. 24 The risk for unstable angina patients is higher, with 53% experiencing a post-PCI troponin elevation. 24 There is debate whether or not such troponin increases are of independent prognostic significance.…”

Section: Potential Risksmentioning

confidence: 99%

“…24 The risk for unstable angina patients is higher, with 53% experiencing a post-PCI troponin elevation. 24 There is debate whether or not such troponin increases are of independent prognostic significance. 25 The mechanisms of injury are likely to include necrosis of myocardial tissue adjacent to stent insertion and microembolisation to the distal vasculature.…”

Section: Potential Risksmentioning

confidence: 99%

“…There are no data available that tell us the frequency of 'new' injury in the non-IRA with multivessel PPCI, but we can anticipate this will be significantly higher than in patients undergoing elective PCI. 24 Even without myocardial necrosis, resting perfusion 28 and myocardial perfusion reserve 29 are reduced following PCI, potentially impairing collateral flow to the area at risk (AAR) and decreasing the amount of salvaged myocardium. 2.…”

Section: Potential Risksmentioning

confidence: 99%

“…24 Such type 4a MI 81 can be detected on CMR scans and have been associated with adverse prognosis. 27 In this substudy of the CvLPRIT, the prevalence of > 1 CMR imaging-detected infarct in patients receiving CR was double that in the IRA-only arm (23.8% vs. 11.2% respectively), and more than threefold for the acute non-IRA infarcts (17.1% CR vs. 4.8% IRA only).…”

Section: Safety End Pointsmentioning

confidence: 99%

“…However, this proportion is less than that might have been expected from previous studies in elective PCI. 24,27 The extent of acute non-IRA infarction was generally small (median 2.5% of LVM). Importantly, total IS was not increased at baseline or at follow-up, and there were no significant differences in LV volumes or ejection fraction between the treatment groups.…”

Section: Safety End Pointsmentioning

confidence: 99%

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The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

et al. 2016

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BackgroundComplete revascularisation in patients with multivessel disease who are treated with primary percutaneous coronary intervention (PPCI) may improve outcomes compared with an infarct-related artery (IRA)-only strategy. However, non-IRA percutaneous coronary intervention (PCI) may result in additional myocardial infarction (MI).ObjectivesTo determine whether or not in-hospital complete revascularisation was associated with increased total infarct size (IS) in patients participating in the Complete versus Lesion-only PPCI trial (CvLPRIT). Secondary objectives were to assess whether or not myocardial salvage index, myocardial ischaemia and final IS at follow-up were different with a complete revascularisation versus an IRA-only strategy.DesignMulticentre, prospective, randomised, controlled and open-label trial with blinded end-point analysis.SettingSeven PPCI centres in England, UK.ParticipantsST-segment elevation MI (STEMI) patients with multivessel disease (angiographic stenosis > 70% in one view or > 50% in orthogonal views) presenting within 12 hours of symptom onset and treated with the PPCI. Coronary artery bypass surgery, cardiogenic shock and contraindications to cardiovascular magnetic resonance (CMR; substudy only) imaging were exclusions.InterventionsPatients were randomised to either complete in-hospital revascularisation or an IRA-only strategy.Main outcome measuresThe primary outcome was IS as measured by CMR undertaken at 48–72 hours post PPCI. Secondary outcome measures included microvascular obstruction, myocardial salvage index, left ventricular volumes and ejection fraction and final IS on the acute and follow-up CMR carried out at 9 months post STEMI.ResultsPatients were recruited from May 2011 until May 2013 and followed up for 12 months. Of 296 patients randomised in the main CvLPRIT, 205 consented to participate in the CMR substudy and 203 had analysable images for the primary end point. Patients in the IRA-only group (n = 105) were well matched to those in the complete revascularisation group (n = 98) for all baseline characteristics {mean age 64.1 years [standard deviation (SD) 10.8 years] vs. 63.1 years (SD 11.3 years); male sex 89% vs. 79%, respectively}. Total IS was not significantly different in the IRA-only and complete revascularisation groups {median 13.5% [interquartile range (IQR) 6.2–21.9%] of left ventricular (LV) mass vs. median 12.6% (IQR 7.2–22.6%) LV mass, respectively; 95% confidence interval –4.09% to 31.17%;p = 0.57}. Myocardial salvage index was also not significantly different in the IRA-only and complete revascularisation groups [median 58.5% (IQR 32.8–74.9%) vs. median 60.5% (IQR 40.6–81.9%), respectively;p = 0.14]. The prevalence of non-IRA MI on acute CMR was higher in the complete revascularisation group than in the IRA-only group (22/98 vs. 11/105, respectively;p = 0.02). There was no difference in total IS, ischaemic burden or LV volumes between treatment groups at follow-up CMR.LimitationsThe CMR substudy population may not be a true representation of the overall study population. The optimal timing of CMR to measure IS post PPCI is uncertain. Myocardial salvage was assessable in only 70% of patients.ConclusionsMultivessel PCI, compared with an IRA-only revascularisation, in the setting of STEMI led to a small increase in CMR imaging-detected non-IRA MI, but total IS was not increased.Future workLarger studies are required to (1) confirm that death and MI are reduced by a complete revascularisation strategy; (2) assess whether or not functional assessment of non-IRA lesions results in similar outcomes to a pragmatic angiographic-based revascularisation strategy; and (3) assess the timing of in-hospital versus staged outpatient complete revascularisation.Trial registrationCurrent Controlled Trials ISRCTN70913605.FundingThis project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership. The main CvLPRIT was funded by the British Heart Foundation (SP/10/001) with support from the NIHR Comprehensive Local Research Networks.

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Section: Potential Risksmentioning

confidence: 99%

Section: Potential Risksmentioning

confidence: 99%

Section: Potential Risksmentioning

confidence: 99%

Section: Safety End Pointsmentioning

confidence: 99%

Section: Safety End Pointsmentioning

confidence: 99%

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The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

et al. 2016

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2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention

Levine¹,

Bates²,

Blankenship³

et al. 2011

Cathet Cardio Intervent

152

106

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Lack of association between peri-procedural myocardial damage and CYP2C19 gene variant in elective percutaneous coronary intervention

et al. 2014

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Peri-procedural myocardial damage (MD) is associated with increased risk of major in-hospital complications and adverse clinical events. The aim of this study was to evaluate the effects of on-clopidogrel platelet aggregation and CYP2C19-reduced-function gene variants on elective percutaneous coronary intervention (PCI)-related MD. We measured changes in serum high-sensitive troponin T (hs-TnT) levels, CYP2C19 genotype, and on-clopidogrel platelet aggregation (PA) using VerifyNow(®) P2Y12 system in 91 patients who received stent implantation (stent group). The control group comprised 30 patients who did not receive PCI. Blood samples were obtained before and 24 h after PCI or coronary angiography (CAG). Patients of the stent group were divided into high and low MD groups based on the median value of hs-TnT level at 24 h after PCI. Serum hs-TnT levels were significantly higher 24 h after PCI (86.8 ± 121.5 pg/ml) compared with before PCI (9.4 ± 5.3, p < 0.001), whereas the levels were identical before and 24 h after CAG in the control group. Simple logistic regression analysis demonstrated that MD correlated with age (p = 0.014), estimated GFR (p = 0.003), hemoglobin A1c (p = 0.015), baseline serum hs-TnT (p = 0.049), and stent length (p < 0.001). Multiple logistic regression analysis identified old age, high hemoglobin A1c level, and long stent, but not CYP2C19 reduced-function allele or high on-clopidogrel PA, as independent predictors of elective PCI-related MD. The present study demonstrated no significant relation between peri-procedural MD and high on-clopidgrel PA associated with CYP2C19 reduced-function allele in patients undergoing elective PCI.

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Incidence and determinants of myocardial infarction following percutaneous coronary interventions according to the revised Joint Task Force definition of troponin T elevation

Cited by 22 publications

References 36 publications

The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

The randomised Complete versus Lesion-only PRimary percutaneous coronary Intervention Trial: Cardiovascular Magnetic Resonance imaging substudy (CvLPRIT-CMR)

2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention

Lack of association between peri-procedural myocardial damage and CYP2C19 gene variant in elective percutaneous coronary intervention

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