Predictors of periprocedural creatine kinase-myocardial band elevation complicating elective percutaneous coronary intervention

Current Challenges in Coronary Bifurcation Interventions

Coronary bifurcation lesions account for a significant proportion of all percutaneous coronary interventions (PCIs). Interventional treatment of coronary bifurcations is related to significant technical challenges, high complication rates, and worse angiographic and long-term clinical outcomes. This review covers the specific features and structure of coronary bifurcation and explores the main challenges in the interventional treatment of these lesions. This review evaluates various methodologies designed to address these lesions, considering factors such as plaque distribution and bifurcation geometry. It also emphasizes the limitations associated with current techniques. A novel combined optimization approach applied in the interventional treatment of coronary bifurcation may offer superior procedural and long-term outcomes. This combined technique could potentially address the drawbacks of each method, providing a more effective solution for optimizing stent placement in bifurcation lesions. Refining and evaluating these combined techniques is essential for improving clinical outcomes in patients with bifurcation lesions.

Usefulness of intracoronary administration of fasudil, a selective Rho-kinase inhibitor, for PCI-related refractory myocardial ischemia

BACKGROUND

Intra-procedural myocardial ischemia as an iatrogenic complication still remains a critical issue in contemporary interventional cardiology. The aim of this study was to examine the usefulness of fasudil, a selective Rho-kinase inhibitor, for percutaneous coronary intervention (PCI)-related myocardial ischemia.

METHODS

Among 448 PCI sessions performed between October 2015 and December 2017, we retrospectively examined 36 patients (69.0 ± 9.1 [SD] yrs., M/F 26/10) who underwent intracoronary administration of fasudil during a procedure to resolve myocardial ischemia that was resistant to intracoronary nitrate administration.

RESULTS

The refractory myocardial ischemia was caused by distal embolization (69%), enhanced vasoconstriction at distal site of chronic total occlusion (11%), coronary spasm (11%), and coronary dissection (8%), most of which occurred immediately after balloon or stent dilatation. Intracoronary fasudil significantly improved corrected TIMI frame count (from 37 [30-56] to 24 [12-36]) and TIMI flow grade (from 2 [1-2.5] to 3 [2-3]) (both P < 0.001). Finally, 86% of all subjects successfully obtained TIMI flow grade 3 at the end of the procedure. Intracoronary fasudil tended to be more effective in patients with an attenuated plaque detected by intravascular ultrasound. Importantly, among the 19 elective cases, fasudil successfully prevented 17 patients from developing post-procedure myocardial infarction. Although fasudil-induced transient hypotension requiring a vasopressor was noted in 22% of the subjects, no other adverse effects were noted.

CONCLUSIONS

These results indicate that fasudil is a useful and safe therapeutic option for PCI-related myocardial ischemia refractory intracoronary nitrate.

Clinical Predictors of Risk for Decreased Cardiac Tissue Perfusion After Percutaneous Coronary Intervention: A Retrospective Cohort Study

OBJECTIVE

To establish clinical predictors of risk for decreased cardiac tissue perfusion (DCTP) after percutaneous coronary intervention (PCI).

METHODS

Data on demographic, anthropometric, clinical, and procedural variables were collected as explanatory from a database of 1,542 adult patients undergoing PCI. A diagnosis of periprocedural myocardial infarction was used to confirm DCTP. A multivariate logistic regression determined the predictors of DCTP.

RESULTS

The independent predictors of risk for DCTP were age (OR = 1.02, CI 95% = 1.01-1.03, p = .008), multivessel disease (OR = 1.79, CI 95% = 1.30-2.46, p <.001) and intraprocedural lesion complications (OR = 4.56, CI 95% = 3.03-6.87, p <.001).

CONCLUSION AND IMPLICATIONS FOR NURSING PRACTICE

These results increase the level of evidence of risk for DCTP by refining its risk factors and can support nurses' clinical judgment.

Preprocedural N-terminal pro-B-type natriuretic peptide as a useful marker for predicting periprocedural myocardial injury following percutaneous coronary intervention in diabetic patients without cardiac dysfunction

BACKGROUND

Elevated preprocedural N-term pro-B-type natriuretic peptide (NT-pro-BNP) and postprocedural cardiac troponin I (cTnI) are related to a poor cardiac outcome in the non-diabetic population. We hypothesized that preprocedural NT-pro-BNP might be a useful marker in predicting periprocedural myocardial injury (PMI) following elective percutaneous coronary intervention (PCI) in type 2 diabetes (T2D).

METHODS

We prospectively enrolled 1194 consecutive diabetic patients with normal cardiac function and preprocedural cTnI who were successfully undergoing elective PCI. Preprocedural NT-pro-BNP levels were assessed at admission, and PMI was evaluated by analysis of cTnI within 24 hours. The relationship between preprocedural NT-pro-BNP levels and the peak values of cTnI after PCI was examined.

RESULTS

Patients with high baseline NT-pro-BNP levels had higher postprocedural cTnI levels (β = 0.123, p < 0.001). In the multivariable model, NT-pro-BNP was associated with higher risk of postprocedural cTnI elevation above 1 × upper limit of normal (ULN, OR, 3.13; 95% CI, 1.51-6.50; p = 0.002), 3 × ULN (OR, 2.44; 95% CI, 1.17-5.08; p = 0.018), 5 × ULN (OR, 3.18; 95% CI, 1.44-7.0; p = 0.004), respectively. Moreover, the incidence of cTnI elevation was higher in patients with the upper tertile of NT-pro-BNP levels than that in ones with the lower tertile of NT-pro-BNP levels (> 1 × ULN: 63.1% vs. 50.0%, p < 0.001; > 3 × ULN: 39.2% vs. 31.9%, p = 0.032; > 5 × ULN: 30.4% vs. 21.9%, p < 0.006; respectively).

CONCLUSIONS

Our data, for the first time, demonstrated that increased preprocedural NT-pro-BNP levels were strongly and independently associated with a higher risk of PMI, suggesting that baseline NT-pro-BNP level might be a useful marker for predicting PMI following PCI in diabetic patients without cardiac dysfunction.

Impact of Strut Width in Periprocedural Myocardial Infarction: A Propensity-Matched Comparison Between Bioresorbable Scaffolds and the First-Generation Sirolimus-Eluting Stent

OBJECTIVES

This study aimed to assess the clinical impact of strut width (evaluated by abluminal strut surface area [ASSA]) on periprocedural myocardial infarction (PMI) and clinical outcomes in patients treated with bioresorbable scaffolds (BRS) versus first-generation sirolimus-eluting stents (SES).

BACKGROUND

To date, there are no reports on the impact of ASSA on PMI and clinical outcomes.

METHODS

We compared the impact of ASSA on outcomes and PMI in propensity-matched patients treated with BRS and SES. The primary outcome was the incidence of major adverse cardiac events (MACE), defined as the combination of all-cause mortality, follow-up myocardial infarction, and target vessel revascularization, at 30-days and 1-year follow-ups. The secondary endpoint was the incidence of PMI.

RESULTS

After propensity-matched analysis, 499 patients (147 BRS patients vs. 352 SES patients) were evaluated. Mean ASSA was higher in patients treated with BRS versus SES (BRS: 132.3 ± 76.7 mm(2) vs. SES: 67.6 ± 48.4 mm(2), p < 0.001). MACE was not significantly different between groups (30-days MACE: BRS: 0% vs. SES: 1.4%, p = 0.16, and 1-year MACE: BRS: 15.7% vs. SES: 11.4%, p = 0.67). The incidence of PMI was significantly higher in the BRS group (BRS: 13.1% vs. SES: 7.5%, p = 0.05). Multivariable analyses indicated that treatment of left anterior descending artery and ASSA were independent predictors of PMI.

CONCLUSIONS

BRS implantation, compared with SES implantation, was associated with a higher incidence of PMI. MACE at 30 days and 1 year were not significantly different. Left anterior descending artery percutaneous coronary intervention and ASSA were independent predictors of PMI.

How bifurcation angle impacts the fate of side branch after main vessel stenting: a retrospective analysis of 1,200 consecutive bifurcation lesions in a single center

OBJECTIVES

We aimed to investigate the effect of bifurcation angle (BA) on side branch (SB) occlusion after main vessel (MV) stenting.

BACKGROUND

BA is thought to impact the risk of SB occlusion in coronary bifurcation patients undergoing percutaneous coronary intervention (PCI).

METHODS

A total of 1,171 consecutive patients with 1,200 bifurcation lesions undergoing one stent or provisional two stent techniques were studied. The lesions were divided into low angle and high angle groups using the median BA (52°). Multivariate logistic regression analysis was performed to identify independent predictors of SB occlusion.

RESULTS

SB occlusion occurred in 88 (7.33%) of 1,200 bifurcation lesions treated with the one stent technique or MV stenting first strategy. The rate of SB occlusion was significantly higher in the high angle group (63/600, 10.5%) than the low angle group (25/600, 4.2%) (P < 0.001). The rate of SB occlusion increased significantly across quartiles of BA as follows: from 3.63% in the first quartile of BA, to 4.71% in quartile II, to 8.14% in quartile III to 12.97% in quartile IV (P < 0.001). Multivariable analysis showed that high angle was an independent predictor of SB occlusion (odds ratio: 1.026, 95% confidence intervals: 1.014-1.037, P < 0.001). Plaque distribution at the same side of SB, MV Thrombolysis in Myocardial Infarction flow grade before stenting, pre-procedural diameter stenosis of bifurcation core, diameter ratio between MV/SB and diameter stenosis of SB before MV stenting were also independent predictors of SB occlusion.

CONCLUSIONS

High BA was an independent predictor of SB occlusion after MV stenting. The occlusion risk of SB with a high BA should not be ignored.

Relationship of glycated hemoglobin levels with myocardial injury following elective percutaneous coronary intervention in patients with type 2 diabetes mellitus

Background

Glycated hemoglobin (HbA1c) predicts clinical cardiovascular disease or cardiovascular mortality. However, the relationship between HbA1c and myocardial injury following elective percutaneous coronary intervention (PCI) in patients with type 2 diabetes mellitus (DM) has not been investigated.

Objectives

The study sought to assess the relationship between HbA1c and myocardial injury following elective PCI in patients with type 2 DM.

Methods

We studied a cohort of consecutive 994 diabetic patients with coronary artery disease (CAD) undergoing elective PCI. Periprocedural myocardial injury was evaluated by analysis of troponin I (cTnI). The association between preprocedural HbA1c levels and the peak values of cTnI within 24 hours after PCI was evaluated.

Results

Peak postprocedural cTnI >1×upper limit of normal (ULN), >3×ULN and >5×ULN were detected in 543 (54.6%), 337 (33.9%) and 245 (24.6%) respectively. In the multivariate model, higher HbA1c levels were associated with less risk of postprocedural cTnI >1×ULN (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.76–0.95; P = 0.005). There was a trend that higher HbA1c levels were associated with less risk of postprocedural cTnI >3×ULN (OR, 0.90; 95% CI, 0.81–1.02; P = 0.088). HbA1c was not associated with the risk of postprocedural cTnI elevation above 5×ULN (OR, 0.95; 95% CI, 0.84–1.08; P = 0.411).

Conclusions

The present study provided the first line of evidence that higher preprocedural HbA1c levels were associated with less risk of myocardial injury following elective PCI in diabetic patients.

Incidence of periprocedural myocardial infarction and cardiac biomarker testing after percutaneous coronary intervention in Japan: results from a multicenter registry

Periprocedural myocardial infarction (pMI) is an important complication associated with percutaneous coronary intervention (PCI). However, data on the frequency of biomarker testing and the incidence of pMI remain unclear. Using the multicenter Japan Cardiovascular Database, we identified 2182 patients who underwent PCI without preprocedural cardiac biomarker elevation (silent ischemia, stable angina, or unstable angina without biomarker elevation) from September 2008 to August 2011. Of these, 550 patients (25.2 %) underwent cardiac biomarker testing within 6-24 h after PCI. The incidence of pMI was 2.7 % among all identified patients and 7.5 % among those who underwent cardiac marker testing. Of note, cardiac biomarker testing was performed more frequently than no testing in patients with a higher risk profile such as unstable angina (32.7 vs 24.7 %, P < 0.001), higher symptom scaling (28.2 vs 22.5 %, P = 0.008), urgent or emergent procedures (19.3 vs 15.0 %, P = 0.022 or 4.2 vs 1.0 %, P < 0.001, respectively), and type C lesion (31.3 vs 25.2 %, P = 0.006). Presentation with silent ischemia (odds ratio = 1.51, 95 % confidence interval (CI) 1.16-1.97) and nonemergent PCIs (odds ratio = 3.45, 95 % CI 1.79-6.67) were associated with no postprocedural cardiac biomarker testing. The real-world multicenter PCI registry in Japan revealed an incidence of 2.7 % for pMI; however, cardiac biomarkers were assessed in only 25.2 % of patients after PCI. The results suggest an underuse of postprocedural biomarker testing and room for procedural quality improvement, particularly in cases of silent ischemia and nonemergent cases.

Effect of tailored antiplatelet therapy on periprocedural myonecrosis in patients with diabetes mellitus (from the DM-Verify Now Trial)

We investigated whether additional platelet inhibition with a glycoprotein IIb/IIIa inhibitor would be beneficial in reducing the risk of periprocedural myocardial infarction (PMI) in diabetic patients with high residual platelet reactivity (HPR). Patients with diabetes mellitus were administered aspirin and clopidogrel at a 300-mg loading dose 1 day before the procedure, and the VerifyNow P2Y(12) assay was performed just before percutaneous coronary intervention. Patients with HPR, defined as a P2Y(12) reaction unit of ≥270 were randomly assigned to group A or control group C1. Patients without HPR were assigned to control group C2. Conventional anticoagulation with heparin was given to groups C1 and C2, and group A received additional abciximab treatment. Clinically relevant PMI was defined as any elevation in the biomarkers creatine kinase-MB isoenzyme and cardiac troponin I >3 times the upper normal limit measured 8, 16, or 24 hours after percutaneous coronary intervention. Of the patients, 47 and 51 were assigned to group A and C1; the clinical and procedural characteristics in the 2 groups were balanced. Of the 47 patients in group A and 51 patients in group C1, 9 (19%) and 9 (18%), respectively, experienced a PMI event according to the creatine kinase-MB cutoff (p = 1.00), and 27 in group A (57%) and 29 in group C1 (57%) experienced a PMI event according to the troponin I cutoff (p = 1.00). Five minor bleeding events, including small and localized hematomas, were observed immediately after the procedure (4 in group A and 1 in group C1). Only 1 major bleeding event, retroperitoneal hemorrhage, was observed in group A. The patients in group C2 had a PMI event rate (50% of 32 patients, p = 1.00) similar to that of group C1. In conclusion, additional platelet inhibition using a tailored approach and a point-of-care assay did not improve the periprocedural outcome in diabetic patients with HPR.

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.

Periprocedural (30-day) risk of myocardial infarction after drug-eluting coronary stent implantation: a meta-analysis comparing cobalt-chromium and stainless steel drug-eluting coronary stents

AIMS

Because of the reduction in the rate events related with in-stent restenosis, most events after drug-eluting stent implantation occur shortly after coronary stenting. Cobalt-chromium alloys allow to reduce strut thickness and improve flexibility and deliverability of coronary stent platforms, and thus could be associated with lower short-term events after stenting. The aim of this study was to test the hypothesis that drug-eluting coronary stents with a cobalt-chromium platform reduce the incidence of periprocedural (30-day) myocardial infarction in comparison with stainless steel drug-eluting coronary stents.

METHODS AND RESULTS

A meta-analysis from nine randomised trials comparing cobalt-chromium and stainless steel drug-eluting coronary stents that overall included 11,313 patients was performed. The incidence of myocardial infarction, stent thrombosis, and cardiac death at 30 days was compared between both types of stents. At 30 days, the incidence of acute myocardial infarction was significantly lower in patients allocated to cobalt-chromium drug-eluting stents (2.3% vs. 3.9%, respectively; p=0.006; odds ratio 0.72, 95% confidence interval 0.58-0.91), due to a significant reduction in the rate of non-Q-wave myocardial infarction (odds ratio 0.67, 95% confidence interval 0.51-0.88). The incidence of stent thrombosis was similar between both groups of patients, (0.5% vs. 0.5%, p=0.76; odds ratio 1.09, 95% confidence interval 0.63-1.89).

CONCLUSIONS

Drug-eluting coronary stents that use cobalt-chromium stent platforms have a better safety profile at 30 days in comparison with stainless steel drug-eluting stents, due to a significant reduction in the rate of myocardial infarction.