Intracoronary ST-Segment Shift Soon After Elective Percutaneous Coronary Intervention Accurately Predicts Periprocedural Myocardial Injury

Abstract

Background-Elevation of cardiac biomarkers after coronary angioplasty (percutaneous coronary intervention [PCI])reflects periprocedural myocardial damage and is associated with adverse cardiac events. We assessed whether periprocedural myocardial damage that occurs despite successful PCI could be rapidly and easily identified by intracoronary ST-segment recording with the use of a catheter guidewire. Methods and Results-In 108 consecutive stable patients undergoing elective single-vessel PCI, we recorded unipolar ECG from the intracoronary guidewire in the distal coronary before PCI and 2 minutes after the last balloon inflation. After PCI, intracoronary ST-segment shift Ն1 mm from baseline was considered significant. Troponin I levels were measured at baseline and at 8 and 24 hours after intervention, and myocardial damage was defined as troponin I increase above the upper normal value after intervention. All patients had normal cardiac marker values before PCI, and PCI was successful in all (residual stenosis Ͻ20%, Thrombolysis in Myocardial Infarction grade 3 flow). After PCI, long-term follow-up data were collected; myocardial damage was detected in 50 patients (46%), although abnormal creatine kinase-MB values were documented in only 11 (10%). Significant intracoronary ST-segment shift after PCI was present in 40 patients (37%; group A) and absent in the remaining 68 (63%; group B). Procedural myocardial damage was documented in 37 group A patients (93%) and in 13 group B patients (19%; PϽ0.001); significant ECG changes were found on standard ECG after intervention in only 5 patients (13%) and 1 patient (1%) (PϽ0.05). Sensitivity of intracoronary ST-segment shift for predicting myocardial damage was 74%, and specificity was 95%, with positive and negative predictive values of 93% and 81%, respectively. On multivariate analysis, intracoronary ST-segment shift was the sole independent predictor of myocardial damage (odds ratio, 54.1; 95% confidence interval, 12.1 to 240; PϽ0.0001). At a median follow-up of 12Ϯ5 months, major coronary event-free survival was significantly worse in group A patients (log-rank test 2 ϭ4.0; PϽ0.05). Conclusions-After successful single-vessel PCI, intracoronary ST-segment shift allows the prompt and inexpensive identification of patients developing myocardial injury, who may require adjunctive therapy and longer in-hospital stay.

Prediction of troponin elevation by means of intracoronary electrocardiogram during percutaneous coronary intervention of coronary bifurcation lesions (from COronary SIde Branch Residual IschemiA and COllateralization Assessment Study; COSIBRIA & Co Study

“…The present method is more comprehensive, however, as it provides a base for demonstrating the exact zone location source of possible troponin rise after intervention. In the subgroup of our patients with undetectable baseline troponin values, as in the cited studies, we demonstrated higher sensitivity and better negative predictive value (100%) in comparison with previous studies, with a slightly lower specificity (91% in our study vs. 95% in the Balian et al [8] study and 92% in the study by Uetani et al [10]). Since a different distribution of icECG shifts exists in the MB, this may explain the different sensitivity and specificity detected in previous studies.…”

“…Our results are comparable with the results of previous studies performed in non-bifurcation coronary interventions. Balian et al [8], in group of 108 stable, low-risk, non-bifurcation coronary patient population, found 74% sensitivity, 95% specificity, and 93% and 81% PPV and NPV, respectively, for any troponin increase. Despite the lower risk patient cohort, the frequency of postprocedural enzyme increase was almost identical to our patient population, although no data were provided about sensitivity and specificity of method regarding > 5 × N troponin I increase.…”

“…Hence, setting a different threshold for ST segment shift can subsequently improve the sensitivity of the method. Our definition was based on previous studies with icECG recordings and our own patient studies for examination of predictors of periprocedural necrosis [6][7][8][9][10][11][12]. Moreover, some of our patients may not have had a sufficiently long bout of ischaemia to cause myonecrosis.…”

“…The unipolar intracoronary electrocardiogram (icECG) recording from angioplasty guidewire represents local epicardial ECG and has been shown to be more sensitive and more reliable in detecting regional myocardial ischaemia during balloon inflation than standard ECG [6][7][8][9][10]. The icECG detects earlier ischaemia and the changes are more prominent than surface ECG.…”

“…Moreover, the post-procedural myocardial injury after uncomplicated PCI is not uncommon [2-4] with a frequency of 5% to 30%. Although this is thought to have no clinical significance, clinical trials demonstrated an increased risk of adverse cardiac events in patients with periprocedural myonecrosis [5].The unipolar intracoronary electrocardiogram (icECG) recording from angioplasty guidewire represents local epicardial ECG and has been shown to be more sensitive and more reliable in detecting regional myocardial ischaemia during balloon inflation than standard ECG [6][7][8][9][10]. The icECG detects earlier ischaemia and the changes are more prominent than surface ECG.…”