Incidence, predictors, and clinical significance of troponin-I elevation without creatine kinase elevation following percutaneous coronary interventions

Routine Revascularization Versus Initial Medical Therapy for Stable Ischemic Heart Disease: A Systematic Review and Meta-Analysis of Randomized Trials

BACKGROUND

Revascularization is often performed in patients with stable ischemic heart disease. However, whether revascularization reduces death and other cardiovascular outcomes is uncertain.

METHODS

We conducted PUBMED/EMBASE/Cochrane Central Register of Controlled Trials searches for randomized trials comparing routine revascularization versus an initial conservative strategy in patients with stable ischemic heart disease. The primary outcome was death. Secondary outcomes were cardiovascular death, myocardial infarction (MI), heart failure, stroke, unstable angina, and freedom from angina. Trials were stratified by percent stent use and by percent statin use to evaluate outcomes in contemporary trials.

RESULTS

Fourteen randomized clinical trials that enrolled 14 877 patients followed up for a weighted mean of 4.5 years with 64 678 patient-years of follow-up fulfilled our inclusion criteria. Most trials enrolled patients with preserved left ventricular systolic function and low symptom burden, and excluded patients with left main disease. Revascularization compared with medical therapy alone was not associated with a reduced risk of death (relative risk [RR], 0.99 [95% CI, 0.90-1.09]). Trial sequential analysis showed that the cumulative z-curve crossed the futility boundary, indicating firm evidence for lack of a 10% or greater reduction in death. Revascularization was associated with a reduced nonprocedural MI (RR, 0.76 [95% CI, 0.67-0.85]) but also with increased procedural MI (RR, 2.48 [95% CI, 1.86-3.31]) with no difference in overall MI (RR, 0.93 [95% CI, 0.83-1.03]). A significant reduction in unstable angina (RR, 0.64 [95% CI, 0.45-0.92]) and increase in freedom from angina (RR, 1.10 [95% CI, 1.05-1.15]) was also observed with revascularization. There were no treatment-related differences in the risk of heart failure or stroke.

CONCLUSIONS

In patients with stable ischemic heart disease, routine revascularization was not associated with improved survival but was associated with a lower risk of nonprocedural MI and unstable angina with greater freedom from angina at the expense of higher rates of procedural MI. Longer-term follow-up of trials is needed to assess whether reduction in these nonfatal spontaneous events improves long-term survival.

Periprocedural elevated myocardial biomarkers and clinical outcomes following elective percutaneous coronary intervention: a comprehensive dose-response meta-analysis of 44,972 patients from 24 prospective studies

AIMS

The optimal cut-off value of isolated cardiac biomarker elevation for defining prognostically important percutaneous coronary intervention (PCI)-related myocardial injury is not known. We performed a meta-analysis to evaluate the dose-response relationship between isolated cardiac biomarker elevations and the risk of all-cause mortality following elective PCI.

METHODS AND RESULTS

Twenty-four prospective studies (44,972 patients) were included. Patients with an isolated elevation of cardiac biomarkers had an increased risk of all-cause mortality when compared to those with no elevations (cardiac troponin I: odds ratio [OR] 1.42, 95% confidence interval [CI]: 1.19-1.69; creatine kinase-MB isoenzyme [CK-MB]: OR 1.43, 95% CI: 1.19-1.70). For the dose-response analysis, elevations of cardiac troponin I >3x or CK-MB >1x the 99th percentile upper reference limit (URL) were associated with increased mortality (cardiac troponin I: OR 1.51, 95% CI: 1.05-2.17; CK-MB: OR 1.25, 95% CI: 1.05-1.48). The pooled OR of mortality for each 3xURL increment of cardiac troponin I or CK-MB was 1.33 (95% CI: 1.15-1.53) and 1.38 (95% CI: 1.30-1.47).

CONCLUSIONS

We found that a positive dose-response relationship between isolated cardiac troponin I and CK-MB with all-cause mortality and elevated cardiac troponin I >3x or CK-MB >1x the 99th percentile URL was associated with an increased risk of mortality.

Heart-type fatty acid-binding protein (H-FABP) and highly sensitive troponin T (hsTnT) as markers of myocardial injury and cardiovascular events in elective percutaneous coronary intervention (PCI)

BACKGROUND/INTRODUCTION

Type 4a myocardial infarction (MI) occurs when myocardial injury is combined with either symptoms suggestive of myocardial ischaemia, new left bundle branch block, angiographic loss of patency of a major artery or imaging suggestive of new loss of myocardium. Myocardial injury is defined as a rise of >5 x 99th upper reference limit (URL) of 14 ng/l (i.e. >70 ng/l) for highly sensitive troponin T (hsTnT) at 6 h if hsTnT was normal at baseline or >20% rise from 0 to 6 h if hsTnT was >14 ng/l at baseline.

AIM

To assess the prognostic value of biomarkers of myocardial injury following elective percutaneous coronary intervention (PCI).

DESIGN

A cohort of 209 patients were included of whom 144 (68.9%) were male, mean age was 68.8 years, 28 (13.4%) were smokers, 31 (14.8%) were diabetic, 199 (95.2%) had hypercholesterolaemia and 138 (66.0%) had hypertension.

METHODS

We evaluated hsTnT, heart-type fatty acid-binding protein (H-FABP), troponin I (TnI), creatine kinase MB type (CKMB), myoglobin, glycogen phosphorylase BB (GPBB) and carbonic anhydrase III (CA III) at 0, 4, 6 and 24 h following elective PCI. Patients were followed up at 1 year to assess for major adverse clinical events (MACE).

RESULTS

Myocardial injury was observed in 37 (17.7%) patients. Median hsTnT/H-FABP at 4 h were most predictive. MACE was noted in 6 (2.9%) patients, 3 had type 4a MI post PCI, P = 0.036.

DISCUSSION/CONCLUSIONS

Median 4 h hsTnT/H-FABP were most predictive of myocardial injury following PCI. H-FABP and hsTnT were predictive of MACE.

Remote Ischemic Conditioning in Elective PCI?

This review examines the rationale for using remote ischemic conditioning (RIC) in elective percutaneous coronary intervention (PCI) to prevent procedure-related ischemia-reperfusion injury and justifies the importance of periprocedural biomarker elevation following elective PCI as a valid target for RIC. We review the evidence for the use of RIC as a treatment in this setting and document the salutary rules that must be followed to successfully translate RIC for clinical benefit.

Type 4a myocardial infarction: Incidence, risk factors, and long-term outcomes

OBJECTIVES

To assess the incidence of and outcomes related to periprocedural (Type 4a) myocardial infarction (MI) in a cohort of patients undergoing percutaneous coronary intervention (PCI) for stable coronary disease or non ST-elevation acute coronary syndrome with stable or falling cardiac troponin levels.

BACKGROUND

The 2012 Third Universal Definition for Type 4a MI has not been prospectively studied in routine clinical practice.

METHODS

The study included 516 patients undergoing eligible PCI at a single institution. Data were extracted from the National Cardiovascular Data Registry, review of electronic medical records, and telephone interviews. Clinical outcomes assessed at one year included all-cause mortality, recurrent MI, or any repeat coronary revascularization.

RESULTS

Based on the Third Universal Definition of MI, 53 (10.3%) patients met criteria for Type 4a MI and 116 (22.5%) had myocardial injury. The Type 4a MI and myocardial injury groups each had significantly higher numbers of stents, longer stent lengths, and more use of rotational atherectomy than the control group. Type 4a MI was not associated with one-year mortality. The composite endpoint of death or recurrent MI at one year was similar between the Type 4a MI and myocardial injury groups (12 vs. 11%; P > 0.05), which were both higher compared with the control group (3%; P = 0.02, 0.03).

CONCLUSIONS

Type 4a MI and myocardial injury were frequent, and were associated with more complicated index PCI and more frequent death or recurrent MI at one year as compared with the control group. © 2016 Wiley Periodicals, Inc.

Predictors and Prognostic Significance of Troponin-I Release following Elective Coronary Angioplasty

The objective of this study was to investigate the predictors and prognostic significance of post-procedural cardiac troponin (cTn)-I elevations in a consecutive series of patients who underwent elective percutaneous coronary intervention (PCI). cTn-I was measured in 100 patients immediately before and within 24 h after the elective PCI. Post-procedural cTn-I elevation was observed in 27 of the 100 patients. In multivariate analysis, basal haemoglobin values and the number of repeated balloon dilatations were found to be independent predictors of cTn-I elevation. During the follow-up period of 12 ± 1.2 months, the cTn-I-positive group had more major adverse cardiovascular events than the cTn-I-negative group (33.3% versus 16.4%, respectively), but the difference was not significant. An increase in cTn-I levels following elective PCI procedures was frequent but did not predict a poor long-term outcome.

The prognostic role of troponin I elevation after elective percutaneous coronary intervention

OBJECTIVES

To assess the prognostic role of isolated troponin I (TnI) elevation after elective percutaneous coronary intervention (PCI) in patients with stable coronary artery disease.

BACKGROUND

The prognostic role of minor troponin elevation after PCI is controversial.

METHODS

A total of 1532 consecutive patients who underwent elective PCI were included. Follow-up data were obtained for 1432 of 1532 (93.4%) patients. The events taken into account in the follow-up included total mortality, cardiac death, hospitalization for acute myocardial infarction and/or unstable angina.

RESULTS

The following variables were identified as predictive of major adverse cardiac events (MACE) by univariate analysis: age 75 years at least (P = 0.012), ejection fraction less than 50% (P = 0.001), prior myocardial infarction (P = 0.031) and TnI 1.0 ng/ml at least after PCI (P = 0.04). The Cox-regression model identified the TnI elevation after PCI, the older age and the ejection fraction as independent predictors of MACE during follow-up (TnI: P = 0.042; older age: P = 0.001; ejection fraction: P = 0.003). In a subgroup of patients with preserved ejection fraction, the incidence of MACE was significantly higher in those with TnI of at least 1.0 ng/ml at least than in the ones with TnI less than 1.0 ng/ml, with the highest incidence among the older cohort. The multivariate analysis confirmed the TnI elevation 1.0 ng/ml at least after PCI and the older age as predictors of MACE.

CONCLUSION

This study documented that in clinically stable patients, minor TnI elevations after elective PCI are independent predictors of MACE during follow-up, as are older age and reduced ejection fraction. Additionally, TnI elevation was a predictor of MACE during follow-up in a subset of patients with preserved ejection fraction. The combination of TnI elevation and older age confers the highest risk of MACE.

Myocardial ischemia is a key factor in the management of stable coronary artery disease

Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decision-making for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis.

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.

Is periprocedural CK-MB a better indicator of prognosis after emergency and elective percutaneous coronary intervention compared with post-procedural cardiac troponins?

A best evidence topic in interventional cardiac surgery was written according to a structured protocol. The question we addressed related to the elevation of markers of cardiac damage associated with percutaneous coronary intervention (PCI). We explored and compared the clinical and prognostic relevance of the elevation of creatinine kinase-myocardial band (CK-MB) and cardiac troponin (cTn) levels during the periprocedural period and the post-procedural period, respectively, following an emergency or elective PCI. We found in excess of 390 papers after a systematic literature search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. From the best evidence available it appears that the monitoring of cardiac biomarkers following a PCI can provide important clinical information about the health of the myocardium, as well as prognostic information on short to mid-term outcomes of mortality up to 3 years. The narrow evidence base advocates the use of periprocedural CK-MB monitoring, recommending that an elevation in CK-MB is a significant predictor of adverse events. Troponins remain a precise and reliable marker of cardiac damage; however, current evidence argues that cTn holds little prognostic relevance until the degree of elevation is almost five times the upper limit of normal (ULN). Thus, the best evidence recommends the use of periprocedural CK-MB routinely during PCI to provide clinical and prognostic information about the degree of myocardial injury and risk of post-procedural morbidity and mortality.

PERIPROCEDURAL MYOCARDIAL DAMAGE

Percutaneous coronary intervention (PCI), as a method of myocardial revascularisation, is widely and effectively used for the treatment of coronary heart disease (CHD), with immediate success rates of >90%. Depending on the diagnostic criteria, 5–30% of these patients could develop the signs of periprocedural myocardial damage (PMD) or periprocedural myocardial infarction (PMI). PMD predictors, mechanisms of PMD development, and its specific clinical features play an important role in the PMI prevention. At present, there is no universal agreement on the definition and diagnostics of periprocedural myocardial necrosis and PMI, or on their impact on the clinical outcomes. According to the results of the recent studies, which are presented in this review, the current criteria of PMI might need to be modified, due to the increasingly high sensitivity of the modern threshold levels of troponin. 

Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Prevention of Spontaneous Myocardial Infarction in Subjects With Stable Ischemic Heart Disease

Background—

Contemporary studies have shown that spontaneous but not procedural myocardial infarction (MI) is related to subsequent mortality. Whether percutaneous coronary intervention (PCI) reduces spontaneous (nonprocedural) MI is unknown.

Methods and Results—

PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials until October 2012 comparing PCI with optimal medical therapy (OMT) for stable ischemic heart disease and reporting MI outcomes: spontaneous nonprocedural MI, procedural MI, and all MI, including procedure-related MI. Given the varying length of follow-up between trials, a mixed-effect Poisson regression meta-analysis was used. From 12 randomized clinical trials with 37 548 patient-years of follow-up, PCI compared with OMT alone was associated with a significantly lower incident rate ratio (IRR) for spontaneous nonprocedural MI (IRR=0.76; 95% confidence interval [CI], 0.58–0.99) at the risk of a higher rate of procedural MI (IRR=4.11; 95% CI, 2.53–6.88) without any difference in the risk of all MI (IRR=0.96; 95% CI, 0.74–1.21). The point estimate for PCI versus OMT for all-cause mortality (IRR=0.88; 95% CI, 0.75–1.03) and cardiovascular mortality (IRR=0.70; 95% CI, 0.44–1.09) paralleled that for spontaneous nonprocedural MI (but not procedural or all nonfatal MI), although these were not statistically significant.

Conclusions—

PCI compared with OMT reduced spontaneous MI at the risk of procedural MI without any difference in all MI. Consistent with prior studies showing that spontaneous MI but not procedural MI is related to subsequent mortality, in the present report the point estimate for reduced mortality with PCI compared with OMT paralleled the prevention of spontaneous MI with PCI. Further studies are needed to determine whether these associations are causal.

Risk factors and effects on long-term outcomes of cardiac troponin I elevation after drug-eluting stent implantation in patients with stable coronary artery disease

This study evaluated the risk factors of postprocedure cardiac troponin I (cTnI) increase and its effects on repeat revascularization and on overall clinical outcomes in patients with angina and normal preprocedural cTnI levels who underwent successful drug-eluting stent implantation. Postprocedure cTnI increase (≥0.5 ng/ml) was observed in 207 of 802 patients (25.8%). Patients with cTnI increase had more extensive coronary disease than patients without cTnI increase, which necessitated for the cTnI group more multilesion interventions and a longer total stent length. In multivariate analysis, total stent length (odds ratio 1.02, 1.01 to 1.03, p = 0.001) and use of glycoprotein IIb/IIIa inhibitors (3.07, 1.54 to 6.11, p <0.001) were identified as independent predictors of cTnI increase. During a median follow-up of 42 months, however, there were no significant between-group differences in Kaplan-Meier estimates of any repeat revascularization (24.8% vs 18.4%, hazard ratio 1.085, 0.723 to 1.627, p = 0.694) and major adverse cardiovascular events (27.0% vs 22.4%, 1.022, 0.703 to 1.485, p = 0.911). In conclusion, patients with postprocedure cTnI increase had more severe baseline coronary disease and received more complex interventional procedures. However, cTnI increase after successful drug-eluting stent implantation was not associated with an increased risk of repeat revascularization or of other adverse events.

Risks and complications of coronary angiography: a comprehensive review

Coronary angiography and heart catheterization are invaluable tests for the detection and quantification of coronary artery disease, identification of valvular and other structural abnormalities, and measurement of hemodynamic parameters. The risks and complications associated with these procedures relate to the patient’s concomitant conditions and to the skill and judgment of the operator. In this review, we examine in detail the major complications associated with invasive cardiac procedures and provide the reader with a comprehensive bibliography for advanced reading.

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.

Frequency, risk factors, and effect on long-term survival of increased troponin I following uncomplicated elective percutaneous coronary intervention

BACKGROUND

The frequency, risk factors for, and effect on long-term survival of increased troponin I (cTnI) following elective, uncomplicated percutaneous coronary intervention (PCI) remains uncertain.

METHODS

We studied 907 patients undergoing elective PCI without recognized PCI complications and with at least 1 measurement of cTnI 12 or more h following the procedure. Patients with pre-PCI cTnI above 0.1 ng/ml or with myocardial infarction within the previous 48 h were excluded.

RESULTS

Maximal cTnI (TrMX) following PCI averaged 0.8 ng/ml, exceeded the upper normal of 0.1 ng/ml in 65.2% of patients and was 1.5 ng/ml or above in 13.7%. Of several demographic and procedural variables examined, the only significant predictor of TrMX was the number of stents deployed. (p < 0.0023 95% confidence interval [CI]: 0.10-0.46). Significant univariate predictors of survival (Kaplan-Meier) were older age (p < 0.0001), diabetes (p = 0.02), peripheral vascular disease (p < 0.0001), obstructive lung disease (p < 0.0001), congestive failure (p < 0.0001), renal impairment (p < 0.0001), and TrMX of 3.62 ng/ml or above (p = 0.0451). Independent predictors (Cox) were older age (p < 0.0001), obstructive lung disease (p < 0.0001), congestive failure (p < 0.0001), and TrMX (p = 0.0272).

CONCLUSIONS

Elevation of cTnI occurs in most patients undergoing elective, uncomplicated PCI. Deployment of multiple stents is associated with higher values of cTnI. Long-term survival is primarily influenced by age and pre-PCI comorbidities, however patients with the highest values of cTnI after PCI are also at increased risk of reduced survival. Significant independent predictors of reduced survival were older age, obstructive pulmonary disease, congestive failure (p < 0.0001 for each), and maximal post-PCI cTnI (p = 0.0272).

Troponin I and Creatine Kinase MB do not provide comparable information after PCI

OBJECTIVES

To compare cardiac troponin I (cTnI) and creatine kinase-MB (CK-MB) after PCI in cases with normal baseline levels of both biomarkers.

DESIGN

cTnI and CK-MB after PCI were stratified as multiples of the 99(th) percent upper reference limit (99%URL) and compared to each other in 489 patients. Post-PCI levels > three times 99%URL were classified as procedure-related infarctions. Results. After PCI, CK-MB was > 3x 99%URL in 58/486 patients (12%) and cTnI > 3x 99%URL in 292/487 patients (60%). cTnI was > 10x 99%URL in all cases with infarction according to CK-MB but CK-MB was often normal despite elevated cTnI. There was an only minimal overlap between two infarction populations, those with cTnI in the range from 1x to 10x 99%URL and those with CK-MB 1x to 10x 99%URL.

CONCLUSIONS

With the present quantification scales, infarction rate after PCI is > five-fold higher with cTnI than with CK-MB.

Subtle myocardial damage associated with diagnostic coronary angiography alone

AIMS

To evaluate the frequency, predictors and prognostic significance of elevation in cardiac troponin I (cTnI) after coronary angiography (CAG).

METHODS AND RESULTS

A series of 296 consecutive patients with normal pre-procedural cTnI levels and undergoing elective CAG at our centre were prospectively analysed. Positive cTnI elevation was defined as >0.06 ng/ml. Positive cTnI elevation was observed in 44 patients (14.8%), but CK-MB was elevated in only four patients (1.3%) after the procedure. The risk of cTnI elevation was independently associated with left ventricular hypertrophy (odds ratio [OR] 5.52; 95% confidence interval [CI], 2.54 to 12.02; P<0.001), inexperienced operator (OR 10.83; 95% CI, 2.47 to 47.43; P=0.002) and the amount of contrast agent (OR 1.12; 95% CI, 1.03 to 1.23; P=0.009 for each 10 ml increase), whereas it was not associated with the severity of coronary artery disease. At one year, however, postprocedural elevation of cTnI was not associated with an increased risk of death (2.3% vs. 0.8%, P=0.384) or myocardial infarction (2.3% vs. 2.0%, P=0.623).

CONCLUSIONS

A minor elevation of cTnI is observed commonly after CAG, which might be associated with left ventricular hypertrophy, operator's experience and the amount of contrast used; however, it does not influence 1-year events rates.

Prognostic Value of Isolated Troponin I Elevation After Percutaneous Coronary Intervention

Background—

Mild elevations of cardiac troponin are frequent after percutaneous coronary intervention (PCI). Their prognostic value is uncertain in the absence of changes in creatine kinase-MB (CK-MB).

Methods and Results—

We evaluated the relation between isolated elevations of cardiac troponin I (cTnI) and all-cause mortality. We studied 3494 consecutive patients who underwent PCI in 16 Italian tertiary cardiology centers. CK-MB and cTnI were analyzed in a central laboratory. Duration of follow-up was 2 years. The present analysis was restricted to 2362 patients with normal CK-MB and cTnI values at baseline and no CK-MB elevation after PCI. A rise in cTnI after PCI >0.15 ng/mL, the upper reference limit, was found in 932 patients (39.4%). A rise >0.45 ng/mL (>3×upper reference limit) was found in 467 patients (19.7%). Compared with patients with normal cTnI, those with cTnI elevation >0.15 ng/mL showed a slightly increased mortality (3.8% versus 2.6%; hazard ratio, 1.53; 95% confidence interval, 0.97 to 2.42; P =0.069). A cTnI elevation >0.45 ng/mL was associated with a higher risk of mortality (4.5% versus 2.7%; hazard ratio, 1.68; 95% confidence interval, 1.01 to 2.80; P =0.044), which, however, did not remain significant after adjustment for concomitant risk factors (hazard ratio, 1.45; 95% confidence interval, 0.86 to 2.46; P =0.162). Postprocedural cTnI elevation was associated with coronary and clinical features consistent with a worse risk profile.

Conclusions—

In the absence of a rise in CK-MB, elevated cTnI levels after PCI are associated with a modest increased risk of death. However, this is not independent of the concomitant adverse baseline clinical characteristics of these patients.

Relation of troponin I levels following nonemergent percutaneous coronary intervention to short- and long-term outcomes

Increases of creatine kinase (CK) and CK-MB cardiac enzymes after nonemergent percutaneous coronary intervention (PCI) have been associated with an increased risk of cardiovascular events during follow-up. However, there are limited data about the incidence and prognostic significance of an isolated increase of cardiac troponin I (cTnI) without an increase in CK-MB after PCI. The aim of this study was to evaluate the impact of an isolated cTnI increase on long-term survival in patients undergoing nonemergent PCI with normal CK-MB levels after PCI. Using the 2004/2005 Cornell Angioplasty Registry, we evaluated the clinical outcomes in 1,601 patients (undergoing elective or urgent PCI) with normal preprocedure cTnI and CK-MB and normal CK-MB levels after the procedure. Patients were divided into 2 groups based on the presence of cTnI increase after PCI. The mean follow-up period was 24.6 +/- 7.6 months. An increase in cTnI was observed in 831 patients (51.9%). Drug-eluting stents were used in 87% of patients and glycoprotein IIb/IIIa inhibitors were administered in 48% of patients. Incidence of in-hospital major adverse cardiovascular events was low, 0.1% versus 0% (p = 1.000), in patients with versus without cTnI increases, respectively. By 2 years of follow-up, Kaplan-Meier survival rates were 94.1% versus 96.4% (log-rank p = 0.020) in those with versus without cTnI increases, respectively. By multivariate Cox regression analysis, an increase in cTnI after PCI (hazard ratio 1.62, 95% confidence interval 1.01 to 2.59, p = 0.047) was an independent predictor of increased long-term mortality. In conclusion, an isolated increase in cTnI after nonemergent PCI is common, not associated with more frequent adverse in-hospital outcomes compared to patients with normal cTnI, and provides long-term prognostic information regarding mortality.

Myocardial infarction after percutaneous coronary intervention: a meta-analysis of troponin elevation applying the new universal definition

AIM

Elevation of Troponin after scheduled percutaneous coronary intervention (PCI) is a recognized consequence. We sought to evaluate the prognostic significance and impact of the newly published definition of PCI-related myocardial infarction (MI) according to which any troponin elevation >3 times the upper reference limit identify a peri-procedural MI.

METHODS

Search of BioMedCentral, CENTRAL, mRCT and PubMed (updated May 2008). Outcomes of interest were: MACE [the composite of all cause death, MI, repeat target vessel PCI (re-PCI) and coronary artery bypass grafting (CABG)]; single end points were also assessed.

RESULTS

Fifteen studies have been included totalling 7578 patients. Troponin elevation occurred in 28.7% of the procedures. The incidence of PCI-related MI according to the new definition was 14.5%. During the hospitalization, any level of raised troponin was associated with an increased risk of MACE [OR 11.29 (3.00-42.48), Number needed to harm (NNH) 5], death [OR 7.16 (1.95-26.27), NNH = 100], MI [OR 30.85 (6.05-157.38), NNH = 4] and re-PCI [OR 4.13 (1.23-13.88), NNH = 50]. Patients with PCI-related MI had an increased risk of death [OR 17.25 (2.71-109.96), NNH = 100] and re-PCI [OR 10.86 (3.2-36.94), NNH = 25]. At follow up of 18 months any troponin elevation was associated with an increased risk of MACE [OR 1.48 (1.12-1.96), NNH = 20], death [OR 2.19 (1.59-3.00), NNH = 50], MI [OR 3.29 (2.71-6.31), NNH = 33] and re-PCI [OR 1.47 (1.06-2.03), NNH = 25]. In patients with PCI-related MI the risk of MACE was further increased: OR 2.25 (1.26-4.00), NNH = 3. An increase of the troponin level below the cut-off was not associated with MACE.

CONCLUSION

A diagnosis of MI according to the new guidelines applies to 15% of patients undergoing PCI and these patients are at high risk of further adverse events both during the hospital stay and at 18 months.

Prognostic implications of C-reactive protein and troponin following percutaneous coronary intervention

BACKGROUND

C-reactive protein (CRP), a marker of inflammation, plays a role in the pathophysiology of atherosclerotic events. The relationship between CRP levels and myocardial necrosis assessed by troponin T (TnT) in patients undergoing percutaneous coronary intervention (PCI) has not been established. In addition, the long-term significance of TnT rise following PCI is not clear.

OBJECTIVES

To examine the relationship between CRP and the rise in TnT levels, and evaluate the long-term prognostic implications of TnT rise following PCI.

METHODS

A total of 1208 patients underwent successful nonemergent PCI. Baseline demographic characteristics, CRP and TnT levels were prospectively collected before and 12 h to 18 h following PCI. Long-term follow-up data over two years were available.

RESULTS

Among the patients studied (mean age 62 years), 64% presented with acute coronary syndrome. A PCI procedure was associated with a significant increase in TnT levels (higher than 0.1 microg/L) in 238 patients (20%). Multivariate logistic regression identified presentation with acute coronary syndrome or myocardial infarction, no statin use at the time of the procedure, increased CRP and increasing length of stent as independent predictors of TnT rise following PCI. Periprocedural TnT rise was not associated with adverse events in follow-up examinations (OR 1.09, 95% CI 0.73 to 1.65).

CONCLUSIONS

Myocardial necrosis commonly occurred in otherwise successful PCI and was particularly prevalent in the proinflammatory milieu of a recent myocardial infarction. This response was blunted with statin therapy. However, there was no long-term adverse sequelae of these troponin rises following otherwise uncomplicated PCI.

Prognostic significance of small troponin I rise after a successful elective percutaneous coronary intervention of a native artery

Cardiac troponin I is a sensitive marker of myonecrosis. Data regarding the prognostic value of troponin I increase after percutaneous coronary intervention (PCI) are conflicting. A recent American College of Cardiology/American Heart Association statement defined a troponin I increase >3 times the 99th percentile as periprocedural myocardial infarction (MI). We sought to evaluate whether or not, in patients with a successful elective PCI judged on angiographic and clinical criteria, the postprocedural increase of troponin I could predict 1-year outcomes. A cohort of 3,200 consecutive patients with successful elective PCI was studied. End points included death/MI and major adverse cardiac events at 1 year. A troponin I increase >97.5th percentile was observed in 1,402 patients (43.8%, mean 0.32 ng/ml, range 0.01 to 4.94). A total of 751 patients (23.4%) had a troponin I increase >3 x 99th percentile. Troponin I status was associated with more complex coronary disease (19.6% vs 16.4%, p <0.005) and multivessel PCI (2.1 vs 1.6, p <0.001). At 1 year, there was no difference in death/MI (2.8% vs 3.5%, p = 0.3) or in major adverse cardiac events (9.6% vs 10.4%, p = 0.5) according to the level of troponin I increase. The lack of association between troponin I increase after PCI and outcome was found when troponin I increase was used as a continuous or a categorical variable. Logistic regression models failed to find any threshold from which troponin I increase could affect outcome. In conclusion, a small troponin I increase after a successful elective PCI was not infrequent and did not affect outcome in our study. The definition of periprocedural MI may be too strict. Measurement of troponin I after a successful PCI is questionable.

Significance of Periprocedural Myonecrosis on Outcomes After Percutaneous Coronary Intervention

Background— Myonecrosis after percutaneous coronary intervention (PCI) has been correlated with a worse prognosis, but controversy exists about the clinical significance and potential mechanisms for the association. The aim of this study was to evaluate the relative impact of preprocedural and postprocedural cardiac troponin T (cTnT) levels on survival rate after PCI.

Methods and Results— We evaluated 5487 patients from the Mayo Clinic registry who required nonemergency PCI, and we examined the relationship between periprocedural cTnT levels, with the 99th percentile cutoff value used for normal (<0.01 ng/mL), and outcomes. The patients were divided into 3 groups: normal preprocedural and postprocedural cTnT levels (no myonecrosis), normal preprocedural but elevated postprocedural cTnT levels (PCI-related myonecrosis), and abnormal preprocedural cTnT. The 30-day death rates were 0.1%, 0.6%, and 2.3%, respectively, in the 3 groups. In a multivariable model, an abnormal pre-PCI cTnT level (hazard ratio 9.66 [2.30–40.57]; P =0.002), and PCI-related myonecrosis (4.71 [1.02–21.83]; P =0.048) were independent predictors of 30-day mortality. Over a median follow-up of 28 months, an abnormal pre-PCI cTnT level (hazard ratio 1.79 [1.35–2.39]; P <0.001) independently predicted death, but the occurrence of PCI-related myonecrosis did not. A postprocedural elevation in creatine kinase MB fraction was not an independent predictor of long-term risk of death (0.912 [0.70–1.19]; P =0.5).

Conclusions— A preprocedural cTnT level >0.01 is a powerful independent predictor of prognosis after PCI and is of greater prognostic significance than the postprocedural biomarker levels. PCI-related myonecrosis occurs frequently and predicts short-term but not long-term risk of death.

Prognostic value of troponin after elective percutaneous coronary intervention: A meta-analysis

BACKGROUND

Although the prognostic importance of troponin in patients with anacute coronary syndrome is clear, the significance of troponin elevation after elective percutaneous coronary intervention (PCI) is a subject of debate. However, most studies up to now had a small sample size and insufficient events during follow-up.

METHODS

Electronic and manual searches were performed of studies reporting on prognosis of troponin after elective PCI. A meta-analysis was done of all suitable studies, with death in follow-up as primary endpoint and the combination of death or nonfatal myocardial infarction in follow-up as secondary endpoint.

RESULTS

20 studies involving 15,581 patients were included. These studies were published between 1998 and 2007. Overall, troponin was elevated after elective PCI in 32.9% of patients. The follow-up period varied between 3 and 67 months (mean 16.3). Increased mortality was significantly associated with troponin elevation after PCI (4.4% vs. 3.3%, P = 0.001; OR 1.35). Furthermore, the combined endpoint of mortality or nonfatal myocardial infarction also occurred more often in patients with post-procedural troponin elevation (8.1% vs. 5.2%, P < 0.001; OR 1.59).

CONCLUSIONS

According to this meta-analysis, troponin elevation after elective PCI provides important prognostic information.

Prognostic importance of troponin T and creatine kinase after elective angioplasty

BACKGROUND

The prognostic importance of elevated cardiac enzymes after elective percutaneous coronary intervention has been debated. Therefore, we performed a prospective observational study to evaluate the prognostic value of postprocedural rise of troponin T and creatine kinase.

METHODS

Troponin T (cut-off value 0.05 ng/ml) and creatine kinase (cut-off value 180 IU/l with muscle-brain fraction >4%) were measured 12 h after elective percutaneous coronary intervention in 713 consecutive patients without elevated troponin before the procedure. Primary endpoint was the combined incidence of death, myocardial infarction, stroke, repeat angiography or re-admission because of anginal symptoms during the follow-up period.

RESULTS

Troponin was elevated after the procedure in 150 patients (21%) and creatine kinase in 66 pts (9%), with a strong association between increased troponin and creatine kinase. After a mean follow-up of 10.9 months, mortality was low (1%) and not associated with increased troponin or creatine kinase. There was, however, a strong relation between postprocedural troponin and re-admission for angina (p=0.001) or myocardial infarction (p=0.001). Furthermore, troponin rise was significantly associated with an increased risk of the primary endpoint (relative risk 1.55 95% confidence interval 1.01-2.38). After multivariate analysis, troponin elevation but not increased creatine kinase was associated with an increased risk of the primary endpoint (relative risk 1.59 95% confidence interval 1.02-2.47 for troponin elevation versus 1.16 95% confidence interval 0.62-2.15 for increased creatine kinase).

CONCLUSION

Increase of troponin T after elective percutaneous coronary intervention has stronger prognostic implication when compared to increased creatine kinase.

The relationship of body mass index to outcomes after percutaneous coronary intervention

OBJECTIVES

To evaluate the effect of body mass index (BMI) on in-hospital outcomes in patients undergoing percutaneous coronary intervention (PCI) at a tertiary care hospital center in Ontario, Canada.

BACKGROUND

Obesity is present in a large population of patients undergoing revascularization with PCI.

METHODS

Retrospective analysis of 4,631 patients aged 62.0 +/- 12 years, stratified by BMI into five groups: nonobese (<25 kg/m2); overweight (25-29.9 kg/m2); class I obese (30-34.9 kg/m2); class II obese (35-39.9 kg/m2); and class III obese (> or =40 kg/m2).

RESULTS

A BMI >25 kg/m2 was present in 79% of patients, and 35% were obese (BMI > or =30 kg/m2). Obese patients, particularly the class III obese, were significantly younger and had higher prevalence of diabetes, hypertension, and dyslipidemia (P < 0.0001). After adjustment for several covariates, lower BMI was independently associated with higher risk of major bleeding requiring transfusion (adjusted odds ratio [OR]= 1.40, 95% confidence interval [CI] 1.04-1.88, P = 0.025), and femoral hematoma (adjusted OR = 1.14, 95% CI 1.05-1.25, P = 0.003) in lean (<20 kg/m2) and normal BMI (20-24.9 kg/m2) patients. Obesity was not associated with death, myocardial infarction, repeat PCI, coronary artery bypass grafting, or major adverse cardiac event.

CONCLUSIONS

Obesity is not associated with increased risk of adverse postprocedural in-hospital outcomes. These findings, however, do not discount the need for sustained efforts in secondary prevention of obesity and its consequences.

Troponin T elevation and prognosis after multivessel compared with single-vessel elective percutaneous coronary intervention

BACKGROUND.: Although techniques for percutaneous coronary intervention (PCI) have improved, patients with PCI of more vessels may still have an increased risk. We performed a prospective observational study evaluating the differences between multivessel and single-vessel procedures according to postprocedural troponin T (TnT) elevation and events during follow-up. METHODS.: The study included 713 patients without elevated TnT (<0.05 ng/ml) before PCI. Primary endpoint was the combined endpoint of death, myocardial infarction, stroke, repeat coronary angiography and readmission for anginal symptoms during the mean follow-up of 10.9 months. RESULTS.: TnT after PCI was elevated in 150 patients (21%) and was significantly associated with an increased incidence of the primary endpoint (RR 1.55, 95% CI 1.01 to 2.38). PCI of more than one vessel was performed in 146 patients (20%). These patients more often had increased TnT levels after the procedure (31.5 vs. 18.3%, p=0.001) and an increased incidence of the primary endpoint during follow-up (28 vs. 19%, p=0.01). After multivariable analysis, multivessel PCI was a statistically significant predictor of postprocedural TnT increase (OR 1.90, 95% CI 1.17 to 3.06). Multivessel PCI was also associated with an increased risk of the primary endpoint (OR 1.73, 95% CI 1.18 to 2.52), but after adjusting for multivessel disease this association was not statistically significant (OR 1.42, 95% CI 0.92 to 2.19). CONCLUSION.: Elective PCI of more vessels in one session is, in comparison with single-vessel PCI, more often associated with postprocedural troponin T rise and a (nonsignificantly) higher incidence of cardiac events during follow-up. Whether staged PCI is associated with less morbidity has to be assessed. (Neth Heart J 2007;15:178-83.).

A study comparing the incidence and predictors of creatine kinase MB and troponin T release after coronary angioplasty. Does Clopidogrel preloading reduce myocardial necrosis following elective percutaneous coronary intervention?

BACKGROUND

To investigate the incidence and associated factors for enzyme release following percutaneous coronary intervention comparing assessment with creatine kinase MB (CK-MB) and troponin T (TnT).

METHOD

TnT and CK-MB were measured post procedure in a consecutive series of 933 patients undergoing elective percutaneous coronary intervention between 1/4/2003 and 1/5/2004 at a single regional cardiac centre.

RESULTS

CK-MB level significantly correlated to TnT levels (R=0.747, p<0.001) and a CK-MB level of above 3 times the upper limit of the local reference range (>3 x ULN) was predicted with 95% sensitivity (48% specificity) at a TnT level of 0.11. Multivariate predictors of >3 x ULN CK-MB release for uncomplicated percutaneous coronary intervention (n=898) were multi-vessel angioplasty (OR=2.51, 95% CI=1.57 to 4.01; p<0.001), saphenous venous graft angioplasty (OR=5.5, 95% CI=1.94 to 13.00; p=0.005) and lack of Clopidogrel preloading (OR=2.02, 95% CI=1.30 to 4.38; p=0.027).

CONCLUSIONS

TnT was found to be a sensitive although not a highly specific marker of CK-MB release. In this study a TnT level above a threshold of 0.11 would identify 95% of the prognostically important 3-fold CK-MB releases. Replacing the >3 x ULN CK-MB threshold with a TnT level of 0.1 ng/l following percutaneous coronary intervention would increase the apparent rate of myocardial infarction from 11% to 20%. Lack of Clopidogrel preloading was independently associated with a >3 x ULN CK-MB release following uncomplicated elective percutaneous coronary intervention.

Isolated Elevation in Troponin T After Percutaneous Coronary Intervention Is Associated With Higher Long-Term Mortality

OBJECTIVES

The aim of this study was to evaluate whether, in patients with normal post-procedure CK-MB, an isolated elevation in cardiac troponin T (cTnT) predicts long-term survival.

BACKGROUND

Cardiac troponin T is a sensitive and specific marker of myonecrosis. There is little known about the incidence and prognostic significance of an isolated elevation of cTnT without a rise in creatine kinase (CK)-MB following PCI.

METHODS

We evaluated the outcomes of 1,949 patients from the Mayo Clinic registry who had normal pre-procedure cTnT and CK-MB, required nonemergency percutaneous coronary intervention (PCI), and had normal CK-MB after the procedure.

RESULTS

An elevation in cTnT (cTnT+) was observed in 383 patients (19.6%) (median 0.04 ng/ml, interquartile range 0.03 to 0.06 ng/ml). The TnT+ status was associated with adverse clinical and angiographic characteristics, and multivessel PCI. Over the median follow-up duration of 26 months, mortality (p < 0.001) and the combined rate of death and myocardial infarction (p = 0.004) were significantly higher in cTnT+ patients. Estimated 3-year survival for those with and without cTnT elevation was 86.9% and 93.2%, respectively. By multivariate analysis, an elevation in cTnT after PCI was an independent predictor of increased long-term mortality. A doubling in the post-PCI cTnT was associated with a partial hazard ratio of 1.20 (95% confidence interval 1.02 to 1.40; p = 0.023).

CONCLUSIONS

An isolated minor elevation in cTnT after PCI provides long-term prognostic information regarding mortality and myocardial infarction.

Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study

BACKGROUND

The optimal stenting strategy in coronary artery bifurcation lesions is unknown. In the present study, a strategy of stenting both the main vessel and the side branch (MV+SB) was compared with a strategy of stenting the main vessel only, with optional stenting of the side branch (MV), with sirolimus-eluting stents.

METHODS AND RESULTS

A total of 413 patients with a bifurcation lesion were randomized. The primary end point was a major adverse cardiac event: cardiac death, myocardial infarction, target-vessel revascularization, or stent thrombosis after 6 months. At 6 months, there were no significant differences in rates of major adverse cardiac events between the groups (MV+SB 3.4%, MV 2.9%; P=NS). In the MV+SB group, there were significantly longer procedure and fluoroscopy times, higher contrast volumes, and higher rates of procedure-related increases in biomarkers of myocardial injury. A total of 307 patients had a quantitative coronary assessment at the index procedure and after 8 months. The combined angiographic end point of diameter stenosis >50% of main vessel and occlusion of the side branch after 8 months was found in 5.3% in the MV group and 5.1% in the MV+SB group (P=NS).

CONCLUSIONS

Independent of stenting strategy, excellent clinical and angiographic results were obtained with percutaneous treatment of de novo coronary artery bifurcation lesions with sirolimus-eluting stents. The simple stenting strategy used in the MV group was associated with reduced procedure and fluoroscopy times and lower rates of procedure-related biomarker elevation. Therefore, this strategy can be recommended as the routine bifurcation stenting technique.

Effects of metoprolol therapy on cardiac troponin-I levels after elective percutaneous coronary interventions

AIMS

Beta-blockers (BBs) have been shown to improve survival and reduce the risk of re-infarction in patients following myocardial infarction. There are conflicting data about the effects of BB therapy on cardiac biomarkers after percutaneous coronary interventions (PCIs). The aim of the study was to investigate the effects of BB use on cardiac troponin-I (cTnI) levels in patients who had undergone elective PCI.

METHODS AND RESULTS

In this prospective study, 287 patients with coronary artery disease were included. Patients were randomized either to BB or control groups prior to the intervention. Blood samples for cTnI were obtained before and at 6, 24, and 36 h after the procedure. Of the 287 patients included, 143 received metoprolol succinate 100 mg/day, and 144 received no BB and served as the control group. Baseline clinical characteristics of both groups, except for history of coronary artery bypass graft surgery, were similar. We observed no significant difference in the elevation of cTnI levels between the two groups after PCI (BB group, 17 patients, 11.9%; control group, 10 patients, 6.9%; P=0.2).

CONCLUSION

Metoprolol succinate therapy seems to have no cardioprotective effect in limiting troponin-I rise after PCI.