Procedural myocardial injury, infarction and mortality in patients undergoing elective PCI: a pooled analysis of patient-level data

Abstract

Aims The prognostic importance of cardiac procedural myocardial injury and myocardial infarction (MI) in chronic coronary syndrome (CCS) patients undergoing elective percutaneous coronary intervention (PCI) is still debated. Methods and results We analysed individual data of 9081 patients undergoing elective PCI with normal pre-PCI baseline cardiac troponin (cTn) levels. Multivariate models evaluated the association between post-PCI elevations in cTn and 1-year mortality, while an interval analysis evaluated the impact of the size of the myocardial injury on mortality. Our analysis was performed in the overall population and also according to the type of cTn used [52.0% had high-sensitivity cTn (hs-cTn)]. Procedural myocardial injury, as defined by the Fourth Universal Definition of MI (UDMI) [post-PCI cTn elevation ≥1 × 99th percentile upper reference limit (URL)], occurred in 52.8% of patients and was not associated with 1-year mortality [adj odds ratio (OR), 1.35, 95% confidence interval (CI) (0.84–1.77), P = 0.21]. The association between post-PCI cTn elevation and 1-year mortality was significant starting ≥3 × 99th percentile URL. Major myocardial injury defined by post-PCI ≥5 × 99th percentile URL occurred in 18.2% of patients and was associated with a two-fold increase in the adjusted odds of 1-year mortality [2.29, 95% CI (1.32–3.97), P = 0.004]. In the subset of patients for whom periprocedural evidence of ischaemia was collected (n = 2316), Type 4a MI defined by the Fourth UDMI occurred in 12.7% of patients and was strongly associated with 1-year mortality [adj OR 3.21, 95% CI (1.42–7.27), P = 0.005]. We also present our results according to the type of troponin used (hs-cTn or conventional troponin). Conclusion Our analysis has demonstrated that in CCS patients with normal baseline cTn levels, the post-PCI cTn elevation of ≥5 × 99th percentile URL used to define Type 4a MI is associated with 1-year mortality and could be used to detect ‘major’ procedural myocardial injury in the absence of procedural complications or evidence of new myocardial ischaemia.

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)

“…As expected the prognostic implications of type 4a MI are greater than major periprocedural myocardial injury following PCI, with the risk of 1-year all-cause mortality being higher in patients with type 4a MI (AdjOR 3.21) when compared with those patients with major periprocedural myocardial injury (AdjOR 2.29). 62 These findings confirm that the presence of new ischaemic changes on ECG or angiographic evidence of a flow-limiting complication, as required for type 4a MI, do provide additional prognostic information. In this Consensus Document, we define patients with post-PCI cTn elevations >1× but ≤5× 99th percentile URL as having ‘minor’ periprocedural myocardial injury.…”

“…The incidence of periprocedural myocardial injury (defined as post-PCI cTn elevation >1× 99th percentile URL by the 4th UDMI) in CCS patients with normal baseline cTn values was 52.8% (79.8% if the analysis was restricted to hs-cTn), but periprocedural myocardial injury was not associated with all-cause mortality at 1 year ( Supplementary material online, Table S3D ). 62 These findings suggest that the 4th UDMI definition of periprocedural myocardial injury might be too sensitive, as it is not an independent predictor of all-cause mortality at 1 year. However, the study by Silvain et al .…”

“…However, the study by Silvain et al . 62 did find that post-PCI cTn elevations >3× 99th percentile URL independently predicted all-cause mortality at 1 year in CCS patients undergoing PCI, suggesting that even relatively low post-PCI elevations of cTn are prognostically relevant ( Supplementary material online, Table S3D ). The analysis may have been underpowered to detect the prognostic relevance of even smaller changes in cTn values.…”

“…A variety of patient features, lesion characteristics, and periprocedural factors have been shown to be independent predictors of periprocedural myocardial injury, type 4a MI, and MACE, in CCS patients undergoing PCI ( Table 2 , Supplementary material online, Table S2A and B ). 3 , 23–28 , 34 , 35 , 62–68 Identification of these factors prior to the PCI procedure may help to identify patients at higher risk of experiencing these periprocedural complications and allow the implementation of preventive measures ( Table 3 ). 69–88 Accordingly, these factors should be adjusted for using multivariate logistic regression in studies evaluating the prognostic relevance of post-PCI elevations in cTn.…”

“…However, this study did not evaluate whether post-PCI cTn elevation as a continuous variable was predictive of all-cause mortality at 1 year. 23 Silvain et al 62 have recently performed a patient-level pooled analysis focused on post-PCI cTn elevations (analysing a different set of studies to that by Garcia-Garcia et al 23 ) comprising 9081 CCS patients undergoing PCI ( Supplementary material online, Table S3d ). In this study, care was taken to evaluate the baseline (pre-PCI) cTn value to ensure that the appropriate 99th percentile URL for the assay was used, and if it was not, the study was excluded.…”