Prognostic value of recurrent episodes of creatine kinase-MB elevation following repeated catheter-based coronary interventions

Clinical end point definitions after percutaneous coronary intervention and their relationship to late mortality: an assessment by attributable risk

OBJECTIVES

To explore the relative and absolute risks associated with various definitions for myocardial infarction, bleeding and revascularisation within the context of percutaneous coronary intervention (PCI).

METHODS

The REPLACE-2 (randomised evaluation of PCI linking Angiomax to reduced clinical events) database of patients undergoing PCI was used. Various definitions of myocardial infarction, bleeding and revascularisation were modelled by logistic regression assessing their relationship with 12-month mortality. Estimates from these models were used to calculate the "attributable fraction" for late mortality associated with each definition.

RESULTS

The most liberal definition of myocardial infarction was associated with an attributable risk of 13.7% (95% CI 3.4% to 23.0%). The most stringent definition was associated with an attributable risk of 4.6% (95% CI 0.6% to 8.6%). Restrictive definitions of bleeding such as TIMI (thrombolysis in myocardial infarction) major bleeding are associated with a high odds ratio of risk (6.1, 95% CI 2.1 to 17.7, p = 0.001) but low attributable fraction (3.5%, 95% CI 0.9% to 6.8%).

CONCLUSIONS

Stringent end point definitions may under-represent the clinical significance of adverse outcomes after PCI. Considering both the proportional and absolute risk associated with definitions may be a more useful method for evaluating clinical trial end points. This analysis supports the current definitions of ischaemic events but suggests that more liberal definitions of bleeding events may also be relevant to late mortality.

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.