Cardiac troponin T and I and creatine kinase-MB as markers of myocardial injury and predictors of outcome following percutaneous coronary intervention

Evaluation of microcirculatory protection in percutaneous revascularisation: A stent implantation technique and device comparison

BACKGROUND

Coronary microvascular dysfunction (CMD) after percutaneous coronary intervention (PCI) is prognostically important and may also be a cause of persistent angina. The stent balloon inflation technique or material properties may influence the degree of CMD post-PCI.

METHODS

Thirty-six patients with stable angina attending for elective PCI were randomized to either slow drug eluting stent (DES) implantation technique (DES slow group): +2 atm. every 5 s., maintained for a further 30 s or a standard stent implantation technique (DES std group): rapid inflation and deflation. PressureWire X with thermodilution at rest and hyperemia and optical coherence tomography (OCT) were performed pre- and post-PCI. Combined primary endpoints were changes in index of microvascular resistance (delta IMR) and coronary flow reserve (delta CFR) following PCI. The secondary endpoints included differences in cardiac troponin I (delta cTnI) at 6 h post-PCI, Seattle angina questionnaire (SAQ) at 1, 3, 6, and 12 months and OCT measures of stent results immediately post-PCI and at 3 months.

RESULTS

Both groups were well matched, with similar baseline characteristics and OCT-defined plaque characteristics. Delta IMR was significantly better in the DES slow PCI arm with a median difference of -4.14 (95% CI -10.49, -0.39, p = 0.04). Delta CFR was also numerically higher with a median difference of 0.47 (95% CI -0.52, 1.31, p = 0.46). This did not translate to improved delta median cTnI (1.5 (34.8) vs. 0 (27.5) ng/L, p = 0.75) or median SAQ score at 3 months, (85 (20) vs. 95 (17.5), p = 0.47).

CONCLUSION

Slow stent implantation is associated with less CMD after elective PCI in patients with stable angina.

Frequency of periprocedural myocardial injury and infarction stratified by cardiac troponin I and cardiac troponin T

BACKGROUND

There are different definitions of periprocedural myocardial infarction (PPMI) both in terms of thresholds for cardiac biomarkers and the ancillary criteria for myocardial ischemia. Cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) are used interchangeably to diagnose PPMI.

OBJECTIVES

This study evaluated the frequency of periprocedural myocardial injury and infarction as defined by the Society of Cardiovascular Angiography & Interventions (SCAI), the Academic Research Consortium-2 (ARC-2), and the 4th Universal definition of MI (4UDMI) stratified using cTnT versus cTnI, among patients with chronic coronary syndrome (CCS) and unstable angina.

RESULTS

Among 830 patients, PPMI rates according to the SCAI, ARC2 and 4UDMI criteria were 4.34 %, 2.05 %, and 4.94 % respectively, with higher rates seen for all definitions when using cTnI versus cTnT (SCAI: 9.84 % vs. 1.91 %, p < 0.001; ARC 2: 3.15 % vs. 1.56 %, p = 0.136; and 4UDMI 5.91 % vs. 4.51 %, p = 0.391). Minor and major periprocedural myocardial injury was respectively observed in 58.31 % and 27.10 % of patients, with rates of both significantly higher when using cTnI versus cTnT (Minor: 69.29 % vs. 53.47 %, p < 0.001, Major: 49.21 % vs. 17.36 %, p < 0.001).

CONCLUSIONS

Among patients with CCS and unstable angina, PPMIs defined by SCAI occurred more frequently when using cTnI as opposed to cTnT, whereas the type of troponin had no impact on the incidence of PPMIs according to the ARC-2 and 4UDMI.

Effects of Remote Ischaemic Conditioning in Stable and Unstable Angina Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

AIM

Type 4a myocardial infarction (T4aMI), defined as myocardial injury associated with percutaneous coronary intervention (PCI), is associated with a poor prognosis and there is conflicting evidence regarding the effectiveness of remote ischaemic conditioning (RIC) in its prevention. This review aimed to determine the effect of RIC on stable and unstable angina patients.

METHOD

A systematic review was conducted in PubMed and Central database. Outcome measures were: changes in peak troponin, creatine kinase myocardial band (CKMB), C-reactive protein (CRP) level, incidence of T4aMI, and major adverse cardiovascular event (MACE). Data were meta-analysed and reported as standardised mean difference (SMD) and odds ratio (OR). Risk of bias was assessed with the Risk of Bias 2 (RoB2) tool.

RESULTS

Fifteen studies with no significant risk of bias were included. Peak troponin level was reduced in the RIC group, particularly after excluding a study with low statin use, while CKMB and CRP levels resulted in a non-significant SMD between the groups. The incidence of T4aMI was significantly lower in the intervention group (OR 0.714; p=0.026); this finding was also seen in subgroups of elective PCI, pre-conditioning, and high statin use. Incidence of MACE also only reached statistically significant protective effects with OR <1 in similar subgroups. No substantial heterogeneity was found and the funnel plot did not show publication bias.

CONCLUSION

Remote ischaemic conditioning in elective PCI patients has been proven to be potentially beneficial in reducing peak troponin levels and risk of T4aMI and MACE.

The value of serum Sema4D level in predicting the prognosis of patients with acute ST-segment elevation myocardial infarction and with high thrombus burden

BACKGROUND

Acute ST-segment elevation myocardial infarction (STEMI) is a serious cardiovascular disease. High thrombus burden is an independent risk factor for poor prognosis of acute myocardial infarction. However, there is no study on the correlation between soluble semaphorin 4D (sSema4D) level and high thrombus burden in patients with STEMI.

PURPOSE

This study aimed to investigate the relationship between sSema4D level and the thrombus burden of STEMI and further explore its effect on the main predictive value of the occurrence of major adverse cardiovascular events (MACE).

METHODS

From October 2020 to June 2021, 100 patients with STEMI diagnosed in our hospital's cardiology department were selected. According to the thrombolysis in myocardial infarction(TIMI)score, STEMI patients were divided into high thrombus burden groups (55 cases) and non-high thrombus burden groups (45 cases) 0.74 patients with stable coronary heart disease (CHD) were selected as stable CHD group, and 75 patients with negative coronary angiography (CAG) were selected as control group. Serum sSema4D levels were measured in 4 groups. The correlation between serum sSema4D and high-sensitivity C-reactive protein (hs-CRP) in patients with STEMI was analyzed. The relationship of serum sSema4D levels between the high and non-high thrombus burden group was evaluated. The effect of sSema4D levels on the occurrence of MACE was explored in one year after percutaneous coronary intervention.

RESULTS

Serum sSema4D level was positively correlated with hs-CRP level in STEMI patients (P < 0.05) with a correlation coefficient of 0.493. The sSema4D level was significantly higher in the high versus non-high thrombus burden group (22.54(20.82,24.17), P < 0.05). Moreover, MACE occurred in 19 cases in high thrombus burden group and 3 cases in non-high thrombus burden group. The results of Cox regression analysis showed that sSema4D was an independent predictor of MACE (OR = 1.497,95% CI: 1.213-1.847, P < 0.001).

CONCLUSION

The sSema4D level is associated with coronary thrombus burden and is an independent risk factor for MACE.

Cathepsin B/HSP70 complex induced by Ilexsaponin I suppresses NLRP3 inflammasome activation in myocardial ischemia/reperfusion injury

BACKGROUND

Myocardial ischemia/reperfusion injury (MI/RI) is a clinical issue in MI therapy that requires effective intervention. Cathepsin B (CTSB) plays an essential role in regulating cell death, inflammatory response and angiogenesis. Ilexsaponin I (ISI), a triterpenoid saponin obtained from Ilex pubescens Hook. et Arn, has anti-inflammatory and cardioprotective effects. However, the effect of ISI on MI/RI is unclear.

PURPOSE

The study aims to disclose the mechanism of ISI as a potent therapeutic agent for MI/RI.

METHODS

Left anterior descending (LAD) coronary artery ligation and oxygen-glucose deprivation and reperfusion (OGD/R) were used to establish MI/RI model in vivo and in vitro. ELISA, western blot and immunofluorescence were carried out to detect CTSB activity and NLRP3 inflammasome activation. Coimmunoprecipitation (Co-IP), molecular docking and surface plasmon resonance (SPR) analysis were used to detect the interaction of CTSB/HSP70 complex. Infarct area determination, echocardiography and hematoxylin and eosin (HE) staining were performed to assess the cardioprotection of ISI in vivo.

RESULTS

Plasma CTSB was elevated in patients after percutaneous coronary intervention (PCI), and was positively correlated with the level of cTnI in plasma, which was also found in MI/RI rat model. ISI significantly suppressed the overexpression and activity of CTSB after MI/RI or OGD/R. ISI remarkably suppressed CTSB triggered-NLRP3 inflammasome activation and reduced the maturation of IL-1β and IL-18. Importantly, we firstly found that ISI promoted CTSB/HSP70 complex formation to disrupt CTSB/NLRP3 complex, leading to NLRP3 inflammasome inactivation. ISI could also limit infarct size, improve cardiac function and reduce inflammatory infiltrates in vivo and protected H9c2 cells against OGD/R insult in vitro. Interrupting the HSP70 and CTSB interaction with HSP70 siRNA blocked the effect of ISI on CTSB, NLRP3 inflammasome activation and the cardioprotective effect.

CONCLUSION

ISI probably exerts cardioprotective effect against MI/RI by modulating HSP70 competitively bind to CTSB to suppress the activation of the NLRP3 inflammasome.

Evaluation of Melatonin Therapy in Patients with Myocardial Ischemia-Reperfusion Injury: A Systematic Review and Meta-Analysis

Objectives

We conducted a meta-analysis to quantitatively evaluate the effect of melatonin therapy on patients with myocardial ischemia-reperfusion injury (MIRI) and explore the influencing factors.

Background

Although preclinical studies have shown that melatonin can alleviate MIRI, its protective effect on MIRI in patients remains controversial.

Methods

We searched PubMed, the Cochrane Library, and Embase. The primary outcome was cardiac function (left ventricular ejection fraction [LVEF], left ventricular end-diastolic volume [LVEDV], and left ventricular end-systolic volume [LVESV]) and myocardial infarct parameters (total left ventricular mass and infarct size).

Results

We included nine randomized controlled clinical trials with 631 subjects. Our results showed that melatonin had no significant effects on the primary outcome, but subgroup analyses indicated that when melatonin was administered by intravenous and intracoronary injection at the early stage of myocardial ischemia, LVEF was improved (<3.5 h; standardized mean difference [SMD]:0.50; 95% CI: 0.06 to 0.94; P = 0.03) and the infarct size was reduced (<2.5 h, SMD: −0.86; 95% CI: −1.51 to −0.22; P = 0.01), whereas when melatonin was injected at the late stage of myocardial ischemia (≥3.5 h or 2.5 h), the results were the opposite. Furthermore, melatonin intervention reduced the level of cardiac injury markers, inflammatory cytokines, oxidation factors, and increased the level of antioxidant factors (P < 0.001).

Conclusions

The results indicated that the cardioprotective function of melatonin for MIRI was influenced by the route and timing regimen of melatonin administration; the mechanism of which may be associated with the production of inflammatory cytokines, the balance of oxidation, and antioxidant factors.

Significant decrease in lipid core burden index following balloon dilation was associated with the leakage of cholesterol crystals in a patient: a case report

BACKGROUND

Near-infrared spectroscopy (NIRS) has been used for analysis the composition of the atherosclerotic plaque in coronary arteries. However, meaning of significant decrease in max lipid core burden index at 4 mm (max LCBI_4mm) during percutaneous coronary intervention (PCI) is poorly understood.

CASE SUMMARY

A 64-year-old male with unstable angina underwent coronary angiography, which demonstrated a hazy tight culprit lesion in the mid-right coronary artery. Pre-intervention NIRS-intravascular ultrasound (NIRS-IVUS) and chemogram showed plaque with high lipid burden at the culprit lesion. Then, we used a distal protection device before PCI because of high max LCBI_4mm in the lesion. After pre-dilation with a scoring balloon, repeat NIRS-IVUS interrogation revealed an almost complete disappearance of the yellow signal and decrease in max LCBI_4mm (from 537 to 44) significantly, suggesting decrease in the lipid content of the plaque. Finally, a drug-eluting stent deployment followed by inflation of a non-compliant balloon led to an excellent result. After PCI, we detected trapped large amounts of debris on retrieval of the filter. Pathological diagnosis confirmed that trapped material was lipid-rich plaque including cholesterol crystals.

DISCUSSION

This is the first report directly demonstrated that significant decrease in max LCBI_4mm at culprit lesion should be associated with the leakage of cholesterol crystals from lipid-rich plaque during PCI in the clinical patient.

lnc-3215 Suppression Leads to Calcium Overload in Selenium Deficiency-Induced Chicken Heart Lesion via the lnc-3215-miR-1594-TNN2 Pathway

Selenium deficiency has been proven to induce calcium disorders in the chicken heart. However, detailed regulatory mechanisms, e.g., the long noncoding RNA (lncRNA)-microRNA (miRNA)-mRNA regulatory axis, have not yet been described. Here, we point out lnc-2315, miR-1594, and Troponin T (TNNT2) based on the results of lncRNA and miRNA comparative genomics group analysis of Se-deficient chicken hearts compared with control hearts. We employed lnc-3215 and TNNT2 knockdown, miR-1594 knockdown, and overexpression models in the chicken embryos in vivo, and lnc-3215, miR-1594, and TNNT2 knockdown and overexpression models in cardiomyocytes in vitro. The dual-luciferase reporter assay and quantitative real-time PCR were used to confirm the relationships between miR-1594 and TNNT2, lnc-3215, and miR-1594 in cardiomyocytes. Our results revealed that TNNT2 suppression induced cardiac calcium overload in vivo and in vitro. miR-1594 activates cardiac calcium overload by targeting TNNT2. Moreover, we found that lnc-3215 regulates miR-1594, and thus influences the TNNT2 expression in vivo and in vitro; these conclusions were verified by gene knockdown in chicken embryos. Our present study revealed a novel regulatory model of a calcium program, which comprises lnc-3215, miR-1594, and TNNT2 in the chicken heart. Our conclusions may provide a feasible diagnostic tool for Se-deficient cardiomyocytes injury.

Effects of Curcuminoids on Myocardial Injury After Percutaneous Coronary Intervention

The rise of cardiac troponin post-percutaneous coronary intervention (PCI) is associated with a high risk of long-term cardiovascular events. Previous studies have shown that curcuminoids decreased myocardial injury post-coronary bypass graft surgery through anti-oxidant and anti-inflammatory effects. We sought to examine whether curcuminoids could prevent PCI-related myocardial injury. One-hundred enrolled patients receiving elective PCI were randomized to obtain curcuminoids or placebo 4 g/day at least 1 day before and after the scheduled PCI. Cardiac troponin-T and 12-lead electrocardiogram were evaluated before PCI and at 24 and 48 h post-PCI. The definitions of PCI-related myocardial injury and myocardial infarction were in line with the third universal definition of myocardial infarction. Baseline characteristics of patients and procedures did not differ between the curcuminoids and placebo groups. The mean age was 63.9 ± 10.8 years. The incidence of PCI-related myocardial injury was not different between curcuminoids and placebo groups (32% vs. 38%, P = .675). The peak high-sensitive cardiac troponin T levels after PCI were not different between the curcuminoids and placebo groups (201.0 ± 547.0 ng/L vs. 187.0 ± 703.9 ng/L respectively, P = .912). Further, the high-sensitive C-reactive protein levels post-PCI were similar in patients receiving curcuminoids and placebo (7.2 ± 18.8 mg/dL vs. 6.6 ± 17.5 mg/dL, respectively, P = .873). We found that short-term treatment with curcuminoids did not reduce the occurrence of PCI-related myocardial injury. We did not observe the role of anti-oxidative and anti-inflammatory effects of curcuminoids in the PCI-related myocardial injury.

Use of Multifactorial Treatments to Address the Challenge of Translating Experimental Myocardial Infarct Reduction Strategies

Myocardial tissue damage that occurs during an ischemic event leads to a spiraling deterioration of cardiac muscle structural and functional integrity. Reperfusion is the only known efficacious strategy and is the most commonly used treatment to reduce injury and prevent remodeling. However, timing is critical, and the procedure is not always feasible for a variety of reasons. The complex molecular basis for cardioprotection has been studied for decades but formulation of a viable therapeutic that can significantly attenuate myocardial injury remains elusive. In this review, we address barriers to the development of a fruitful approach that will substantially improve the prognosis of those suffering from this widespread and largely unmitigated disease. Furthermore, we proffer that ephrinA1, a candidate molecule that satisfies many of the important criteria discussed, possesses robust potential to overcome these hurdles and thus offers protection that surpasses the limitations currently observed.

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.

Level of Serum Enzymes and Electrocardiogram in Healthy Rabbits after Injection of ICD-85 as an Anticancer Agent

Background:

Our previous in vivo studies confirmed that ICD-85, as an anticancer agent, was able to prevent further growth of breast tumors and expand the life expectancy of mice with breast cancer.

Methods:

Blood collection was carried out before, 1, 3, and 6 hours after ICD-85 injection. Sera were used to determinate the cardio and hepatic enzymes levels, including ALT, AST, LDH, CPK, and Ck-MB. Coagulation factors such as PT and PTT were also assayed. ECGs of all rabbits were recorded during the experiment.

Results:

ECG results showed that the injection of 50 and 100 µg/kg ICD-85 into healthy rabbits has no significant effect on heart function while the injection of 150 to 200 µg/kg ICD-85 caused ECG wave changes and mild bradycardia without toxic effects on heart. After ICD-85 injection (concentrations below 100 µg/kg), no significant increase was observed in liver and cardiac enzymes (ALT, AST, LDH, CPK, and CK-MB). However, the concentration of 150 µg/kg and above caused a rise in the enzymes. Comparison of the PT and PTT before and after ICD-85 injection showed no significant clotting time at any concentrations below 200 µg/kg.

Conclusion:

Based on the results obtained in the present study as well as our previous reports, ICD-85 at concentrations below 100 µg/kg seems to have no significant effect on the serum enzymes as indicators of hepatotoxicity and cardiotoxicity in healthy rabbits. However, to confirm this conclusion, more detailed surveys on heart and liver is needed to be carried out.

Comparison of Ticagrelor Versus Prasugrel to Prevent Periprocedural Myonecrosis in Acute Coronary Syndromes

Guidelines recommend a ticagrelor loading dose (LD) before PCI or a prasugrel LD at the time of percutaneous coronary intervention (PCI) in intermediate and high-risk non-ST-elevation acute coronary syndrome (NSTE-ACS). However, achieving an optimal PR inhibition at the time of PCI is critical to prevent adverse events and depends on the timing of LD intake in relation to PCI. We aimed to compare the rate of myonecrosis related to PCI in patients with NSTE-ACS receiving ticagrelor pretreatment versus prasugrel at the time of intervention. We prospectively randomized 213 patients with NSTE-ACS to a 180 mg of ticagrelor LD given as soon as possible after admission and before PCI or to a 60 mg LD of prasugrel given at the time of PCI. The primary end point was the rate of periprocedural myonecrosis as defined by an increase of >5 times the ninety-ninth percentiles in troponin-negative patients or a 20% increase in troponin-positive patients. The 2 groups were similar regarding baseline characteristics including clinical setting (p = 0.2). Procedural characteristics were also identical including the number of treated vessels and stenting procedures. Patients in the prasugrel group more often required emergent PCI (p = 0.001). Patients in the ticagrelor group had less periprocedural myonecrosis compared with those in the prasugrel group (19.8% vs 38.3%; p = 0.03). The rate of major adverse cardiovascular events and Bleeding Academic Research Consortium ≥2 at 1-month follow-up was low and similar between the 2 groups. In conclusion, a ticagrelor LD as soon as possible before PCI is superior to prasugrel at the time of PCI to prevent periprocedural myonecrosis in NSTE-ACS.

Serum corin is reduced and predicts adverse outcome in non-ST-elevation acute coronary syndrome

BACKGROUND AND OBJECTIVES

The aim of the current study was to describe the role of corin, an enzyme that cleaves pro-atrial natriuretic peptide and pro-brain natriuretic peptide into their active peptides, in patients with acute coronary syndrome (ACS).

METHODS

Serum corin level was studied in patients with non-ST-elevation ACS who underwent percutaneous coronary intervention (n=152) and in control volunteers (n=103).

RESULTS

The corin level was lower in acute coronary syndrome patients (798±288 pg/ml) than in the controls (1165±613 pg/ml, p<0.0001). Those acute coronary syndrome patients who developed major adverse cardiovascular events (MACE; 60.9%) within 3 years of discharge had lower corin levels than the patients who did not experience major adverse cardiovascular events (698.16±233.67 vs. 952.1±297.81 pg/ml, p<0.0001). Using a multiple logistic regression model, corin level was a significant predictor of post-ACS MACE: p=0.0004 for 50 pg/ml steps, AUC 0.791, while p<0.0001, and AUC 0.804 using corin and brain natriuretic peptide as predictors.

CONCLUSIONS

Patients with non-ST-elevation ACS have lower serum corin levels than controls. Corin levels are lower in ACS patients who later experience MACE and thus might be predictor for MACE. This new putative biomarker may be useful, either alone or in combination with other biomarkers, for cardiovascular risk stratification assessment and outcome prediction in ACS patients.

Cirrhotic cardiomyopathy: pathogenesis and clinical relevance

Cirrhosis is known to cause alterations in the systemic haemodynamic system. Cirrhotic cardiomyopathy designates a cardiac dysfunction that includes impaired cardiac contractility with systolic and diastolic dysfunction, as well as electromechanical abnormalities in the absence of other known causes of cardiac disease. This condition is primarily revealed by inducing physical or pharmacological stress, but echocardiography is excellent at revealing diastolic dysfunction and might also be used to detect systolic dysfunction at rest. Furthermore, measurement of circulating levels of cardiac biomarkers could improve the diagnostic assessm+ent. Cirrhotic cardiomyopathy contributes to various complications in cirrhosis, especially as an important factor in the development of hepatic nephropathy. Additionally, cirrhotic cardiomyopathy seems to be associated with the development of heart failure in relation to invasive procedures such as shunt insertion and liver transplantation. Current pharmacological treatment is nonspecific and directed towards left ventricular failure, and liver transplantation is currently the only proven treatment with specific effect on cirrhotic cardiomyopathy.

The Effect of Exogenous Creatine Phosphate on Myocardial Injury After Percutaneous Coronary Intervention

Objective:

To evaluate the effect of exogenous creatine phosphate (CP) on myocardial injury after percutaneous coronary intervention (PCI).

Method:

Four hundred patients were divided to receive conventional therapy (control group) or 3-day intravenous infusion of CP after PCI (CP group). Levels of creatine kinase MB (CK-MB) and troponin I (TnI) were measured before and on postprocedural day 3.

Results:

Postprocedural CK-MB and TnI in the CP group were significantly increased compared to the control group. In the CP group, 8.0% and 5.0% of patients had an increase in CK-MB 1 to 3 times and >3 times, respectively, which were significantly lower than that of the control group (19.0% and 9.0%, respectively); 12.0% and 10.0% of patients had an increase in TnI 1 to 3 times and >3 times, respectively, which were significantly lower than that of the control group (21.0% and 18.0%, respectively).

Conclusion:

Exogenous CP was helpful to reduce myocardial injury after PCI.

Effect of remote ischemic preconditioning on serum troponin T level following elective percutaneous coronary intervention

BACKGROUND

Elective percutaneous coronary intervention (PCI) is associated with myocardial necrosis, as evidenced by troponin release, in approximately one-third of cases. This is known to be linked with subsequent cardiovascular events. This study assessed the ability of remote ischemic preconditioning (RIPC) to attenuate cardiac troponin T (cTnT) release after elective PCI.

OBJECTIVE

Evaluation of effect of RIPC on myocardial markers following elective PCI.

METHODS

One hundred and forty nine consecutive patients undergoing elective PCI with undetectable preprocedural cTnT were recruited. Subjects were randomized to receive RIPC (induced by three 5-min inflations of a blood pressure cuff to 200 mm Hg around the upper arm, followed by 5-min intervals of reperfusion) or control (cuff deflated) immediately before arrival in the cardiac catheterization room. The primary outcome was cTnT level at approximately 16 hr after PCI. Secondary outcomes included occurrence of postprocedural myocardial infarction (MI), CKMB levels at 16 hr after PCI and assessment of the inflammatory response as measured by C-reactive protein (CRP) levels.

RESULTS

The mean cTnT at 16 hr after PCI was lower in the RIPC group compared with the control group. (0.020 vs. 0.047 ng/ml; P = 0.047) Occurrence of postprocedural MI, CKMB and CRP levels did not differ in both groups (P = 0.097, 0.537, and 0.481 respectively).

CONCLUSION

The use of RIPC immediately prior to PCI attenuates procedure-related cTnT release and does not affect occurrence of post procedural MI, CKMB, or CRP levels.

Early invasive strategy and outcomes of non-ST-elevation acute coronary syndrome patients: is time really the major determinant?

In non-ST-elevation acute coronary syndromes (ACS), an early invasive strategy is recommended for middle/high-risk patients; however, the optimal timing for coronary angiography is still debated. The aim of this study was to evaluate the prognostic implications of the time of angiography in ACS patients treated in accord with an early invasive strategy. We analyzed the relationship between the time of angiography and outcomes at follow-up in 517 ACS patients, of whom 482 were revascularized with percutaneous coronary intervention (PCI) (86.9%) or coronary artery by-pass graft (13.1%). We also evaluated the influence of clinical, biohumoral and angiographic variables on the patients' outcomes at follow-up. Among patients submitted to angiography at different time intervals from both hospital admission and symptom onset, significant differences neither in mortality nor in cardiac ischemic events at follow-up were observed. At univariate analysis, complete versus partial revascularization, longer hospital stay, higher TIMI risk score, diabetes mellitus, higher discharge creatinine and admission anemia were associated with mortality and cardiac ischemic events at follow-up; a lower left ventricular ejection fraction was associated with mortality; higher peak troponin I and previous PCI were associated with cardiac ischemic events at follow-up. At multivariate analysis longer hospital stay, higher discharge creatinine levels, and previous PCI were independent predictors of cardiac ischemic events at follow-up. Our evaluation in ACS patients treated with an early invasive strategy does not support the concept that angiography should be performed as soon as possible after symptom onset or hospital admission. Rather, an unfavorable long-term outcome is influenced principally by the clinical complexity of patients.

Suppression of Myocardial Injury Markers following Percutaneous Coronary Interventions by Pre-treatment with Carvedilol

BACKGROUND

Retrospective studies and clinical trials have indicated that β-receptor blockers have an influential role in improving survival and reducing risk of recurrent infarction in patients with myocardial infarction. However, there is still controversy regarding the effects of β-receptor blockers on the markers of myocardial infarction following percutaneous coronary interventions (PCI).

OBJECTIVE

The aim of this study was to evaluate the pre-treatment effect of Carvedilol on markers of myocardial injury in patients undergoing elective PCI.

METHOD AND MATERIALS

In this clinical trial patients undergoing elective PCI were categorized randomly in the Carvedilol group including 100 patients who received two doses of 12.5 mg, 6 and 12 hours prior to PCI, and the control group (105 patients). Blood samples were obtained to analyse cardiac biomarker, 12 and 24 hours after PCI.

RESULTS

The clinical features were not significantly different between the two groups. A increase in the level of Troponin I was observed in the control group 24 hours following PCI (P=0.042), whereas this rise in troponin I was slight and insignificant in the Carvedilol group (P>0.05). some difference was observed between the two groups in regard to the level of CPK-MB after PCI (P=0.041).

CONCLUSION

The findings of our study indicate that pre-treatment with Carvedilol confers cardio-protection by limiting the rise of markers of myocardial injury following PCI.

Effect of the composition of atherosclerotic plaques and rate of platelet aggregation on elevation of serum levels of cardiac troponin T after percutaneous coronary interventions

PURPOSE

Elevation of the levels of myocardial biomarkers after percutaneous coronary intervention (PCI) has prognostic value in patients with coronary heart disease. We explored the relationship between elevation of the serum level of cardiac troponin T (cTnT) after PCI and platelet aggregation rate and coronary plaque composition.

METHODS

Eighty patients with unstable angina pectoris underwent PCI and were divided into two groups according to serum cTnT level 24 hours after PCI: group I (cTnT ≥2 times the normal level) and group II (cTnT <2 times the normal level). Coronary plaque composition was measured with virtual histology-intravascular ultrasound. Platelet aggregation rate was detected immediately before and 24 hours after PCI.

RESULTS

Compared with the patients in group II, patients in group I showed more unstable plaques, a larger necrotic core area (20.88 ± 8.04% vs. 15.31 ± 5.48%, P < 0.05), higher platelet aggregation rate (51.47 ± 12.72% vs. 44.78 ± 13.29%, P < 0.05), and longer stents. The serum cTnT level 24 hours after PCI was positively correlated with the necrotic core area.

CONCLUSIONS

In patients with unstable angina pectoris, a large necrotic core, high rate of platelet aggregation, and stent length are predictors of cTnT elevation after PCI.

The outcome of bifurcation lesion stenting using a biolimus-eluting stent with a bio-degradable polymer compared to a sirolimus-eluting stent with a durable polymer

AIMS

This study investigated the differences in clinical outcomes between patients with bifurcation lesions (BL) treated with a biolimus-eluting stent (BES) with a biodegradable polymer, and a sirolimus-eluting stent (SES) with a durable polymer.

METHODS AND RESULTS

The clinical outcomes were assessed in the 497 patients (BES 258, SES 239) enrolled in the multicentre, randomised LEADERS trial who underwent treatment of ≥1 BL (total=534 BL). At 12-months follow-up there was no significant difference in the primary endpoint of MACE, a composite of cardiac death, myocardial infarction and clinically indicated target vessel revascularisation (BES 12.8% vs. SES 16.3%, p=0.31). Patients treated with BES had comparable rates of cardiac death (BES 2.7% vs. SES 2.9%, p=1.00), numerically higher rates of myocardial infarction (BES 8.9% vs. SES 5.4%, p=0.17), and significantly lower rates of clinically indicated target vessel revascularisation (4.3% vs. 11.3%, p=0.004) when compared to those treated with SES. The rate of stent thrombosis at 12-months was 4.3% and 3.8% for BES and SES, respectively (p=0.82).

CONCLUSIONS

In the treatment of BL the use of BES lead to superior efficacy and comparable safety compared to SES.

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).

Long-term prognostic value of CK-MB and the troponins after angioplasty in patients with stable angina

OBJECTIVES

The long-term prognostic value (> 5 years) of elevated cardiac biomarkers after elective coronary angioplasty is yet not clear. Most previous studies have included high risk, unstable patients and with conflicting results. The aim of this study was to determine the prognostic value of CK-MB mass vs. the cardiac troponins (values ≥ 3 times the reference) after elective angioplasty in low-risk patients with stable angina.

METHODS

A total of 202 consecutive patients were included in the final analysis. Patients with elevated values at baseline, and those suffering an acute coronary syndrome < 1 month before the time of inclusion, were excluded. Blood samples were drawn just before, 1-3 hours and 4-8 hours after the procedure and the next morning. Using a cutoff value of three times the reference, patients with high and low values (= controls) of CK-MB mass, cardiac troponin T (TnT) and troponin I (TnI) were compared. No patient developed new Q-waves on ECG. The median follow-up time was 82 months equalising 1600 patient years.

RESULTS

None of the patients died during the procedure or within the first 30 days after angioplasty, confirming a low risk cohort. There was an increasingly number of patients with levels ≥ 3 times the reference post procedure in TnT (10.4%) and TnI (16.8%) vs. CK-MB (6.9%). All cause mortality, readmission for acute coronary syndromes and target lesion revascularisation were more frequent in patients with high CK-MB, 42.9% vs. 22.3 %, p = 0.05 (log-rank test). Corresponding values for TnT were 33.3% vs. 22.7%, p = 0.22. In the TnI patients, there were more adverse events in controls vs. the high group, 25.0% vs. 17.6%, p = 0.34.

CONCLUSIONS

CK-MB mass values ≥ 3 times, contrary to the cardiac troponins, predicts worse long-term event-free survival after elective angioplasty in low-risk patients.

Intramyocardial administration of chimeric ephrinA1-Fc promotes tissue salvage following myocardial infarction in mice

The purpose of this study was to investigate the role of intramyocardial administration of chimeric ephrinA1-Fc in modulating the extent of injury and inflammation in non reperfused myocardial infarction (MI). Our results show that intramyocardial injection of 6 μg ephrinA1-Fc into the border zone immediately after permanent coronary artery ligation in B6129s mice resulted in 50% reduction of infarct size, 64% less necrosis, 35% less chamber dilatation and 32% less left ventricular free wall thinning at 4 days post-MI. In the infarct zone, Ly6G+ neutrophil density was 57% reduced and CD45+ leukocyte density was 21% reduced. Myocyte damage was also reduced in ephrinA1-Fc-treated hearts, as evidenced by 54% reduced serum cardiac troponin I. Further, we observed decreased cleaved PARP, increased BAG-1 protein expression, increased phosphorylated AKT/total AKT protein, and reduced NF-κB protein with ephrinA1-Fc administration, indicating improved cellular survival. Of the eight EphA receptors known to be expressed in mice (A1–A8), RT-PCR revealed that A1–A4, A6 and A7 were expressed in the uninjured adult myocardium. Expression of EphA1–A3 and EphA7 were significantly increased following MI while EphA6 expression decreased. Treatment with ephrinA1-Fc further increased EphA1 and EphA2 gene expression and resulted in a 2-fold increase in EphA4. Upregulation and combinatorial activation of these receptors may promote tissue survival. We have identified a novel, beneficial role for ephrinA1-Fc administration at the time of MI, and propose this as a promising new target for infarct salvage in non reperfused MI. More experiments are in progress to identify receptor-expressing cell types as well as the functional implications of receptor activation.

Usefulness of mean platelet volume as a biomarker for long-term outcomes after percutaneous coronary intervention

Larger size platelets have enhanced reactivity. The mean platelet volume (MPV) is a marker of platelet activation and is usually measured as part of blood testing. The aim of the present study was to investigate the utility of the MPV as a biomarker in prognosticating the long-term outcomes after percutaneous coronary intervention (PCI). The baseline MPV values from consecutive patients undergoing PCI were screened. Of the 1,432 patients, the composite primary end point of mortality or myocardial infarction at 1 year occurred in 80 (5.6%). The patients in the highest tertile (MPV >9.1 fL) had an increased frequency of the primary end point compared to those in the mid (8.1 to 9.1 fL) and lowest (<8.1 fL) tertiles (9.0%, 4.5%, and 3.5%, respectively; p <0.01). Logistic regression analysis demonstrated diabetes (odds ratio 2.44, 95% confidence interval 1.48 to 4.00) and highest tertile of MPV (odds ratio 2.42, 95% confidence interval 1.47 to 3.99) as the best predictors of adverse outcomes. In patients with acute coronary syndrome, the preprocedural MPV and troponin levels demonstrated a comparable predictive relation to the primary end point (receiver operator characteristics curve analysis, area under the curve 0.64, p = 0.01; and 0.63, p = 0.01, respectively). In conclusion, an elevated MPV was a strong independent predictor of long-term outcomes after PCI. The preprocedural MPV had prognostic value similar to that of troponin in patients with acute coronary syndrome. These findings could be of importance in the clinical evaluation of patients before PCI and the design of future studies assessing antiplatelet therapies.

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.

Effect of intracoronary nicardipine on cardiac enzymes after elective percutaneous coronary intervention

BACKGROUND

Elevation in cardiac enzymes after percutaneous coronary intervention (PCI) is common and is associated with adverse clinical outcomes.

HYPOTHESIS

Administration of intracoronary nicardipine--a calcium channel blocker will reduce cardiac enzyme levels in patients undergoing elective PCI.

METHODS

In a single center, prospective, double-blind placebo-controlled trial, 193 patients undergoing elective PCI (with or without stenting) for chronic stable angina and/or an abnormal stress test were randomized to receive 200 mcg of intracoronary nicardipine (n = 93) or saline solution (n = 100) prior to intervention. Cardiac enzyme levels were measured immediately and at 8 and 16 hours after the procedure. Major adverse clinical events (MACE) were assessed at 30 days and at 6 months.

RESULTS

Incidence of periprocedural myonecrosis defined as elevation of troponin I levels > 1x the upper limit of normal was similar in both groups (placebo 15.4% vs drug 10.6%; P = 0.47). There was no significant difference in peak troponin I levels after PCI between the 2 groups (placebo 0.58 ng/mL +/- 1.08 ng/mL vs drug 0.97 ng/mL +/- 3.6 ng/mL; P = 0.35). Major adverse clinical events at 6 months were infrequent and not statistically different in the 2 groups (placebo 3.4% vs drug 1.2%; P = 0.52). Multivariate analysis revealed that pretreatment with nicardipine was not associated with reduction in the incidence of troponin I elevation (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.18-1.6; P = 0.28).

CONCLUSIONS

In low-risk patients undergoing elective PCI, intracoronary nicardipine administration did not produce a significant cardioprotective effect in reducing postprocedural cardiac enzymes leakage.

Biochemical diagnosis of myocardial infarction evolves towards ESC/ACC consensus: Experiences from the Nordic countries

OBJECTIVES

To investigate the diagnostic approach in Nordic hospitals receiving patients suspected of acute myocardial infarction (MI), especially focusing on implementation of the recently proposed criteria by the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) for the definition of MI.

DESIGN

A survey with questionnaires of the diagnostic approach was conducted among all relevant departments (220) in the Nordic countries.

RESULTS

Seventy-six percent (167) of hospitals responded. Troponins I and T (TnI and TnT) and creatinine kinase monobasic fraction (mass concentration) (CKMB(mass)) covered 93 and 65% of hospitals, respectively. Of troponin users, 34% indicated use of TnI vs 66% using TnT. Sporadic use of AST, CK, LD and myoglobin was reported. There was a tendency to lower cut-off levels in Sweden and Finland. Among troponin assays, there was considerable heterogeneity regarding cut-off levels.

CONCLUSIONS

The Nordic countries are approaching ESC/ACC consensus on cardiac markers. Compared with previous national surveys (1995-1999), there is a shift towards the use of troponins. However, differences in cut-off levels of troponin emphasize the need for harmonization of assays.

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 value of procedure-related myocardial infarction according to the universal definition of myocardial infarction in saphenous vein graft interventions

BACKGROUND

In the recently published universal definition of myocardial infarction (MI), a troponin elevation above 3x above the 99th percentile of normal after percutaneous coronary intervention (PCI) is a procedure-related (type 4a) MI. Although troponin rise is common after saphenous vein graft (SVG) PCI, its prognostic value remains undetermined. We aimed to investigate the prognostic value of the universal definition of PCI-related MI in SVG interventions.

METHODS

A cohort of 589 unselected consecutives patients with normal preprocedural troponin Ic undergoing isolated SVG PCI with drug-eluting stent implantation was included. Patients were divided into 2 groups according to the peak troponin value post PCI: those with MI defined as a peak troponin value above 3x the 99th percentile of normal post-PCI (MI group, n = 166) and those without (no MI group, n = 423). The primary end point was the rate of major adverse cardiac events including death, MI, and target vessel revascularization at 1-year follow-up.

RESULTS

Baseline characteristics were similar between the 2 groups. In the MI group, patients had more complex angiographic features (type C lesions: 44.7 vs 34.8%; P = .006). The rate of direct stenting and distal protection use were similar in the 2 groups (MI vs no MI: 29.2 vs 28.7%; P = .9 and 32 vs 37.5%; P = .24, respectively). Patients in the MI group had a worse inhospital course but a similar 1-year rate of major adverse cardiac events (22.3 vs 19.1%; P = .39).

CONCLUSION

Procedure-related MI after PCI, as defined by the universal definition, is associated with an adverse inhospital course but may not predict long-term outcome in SVG PCI.

Combination of C-reactive protein and cardiac troponin I for predicting adverse cardiac events after sirolimus-eluting stent implantation

AIMS

We assessed the predictive value of a combination of C-reactive protein (CRP) and cardiac troponin I (cTnI) in a 2-year prospective study in patients undergoing sirolimus-eluting stents (SES) implantation.

METHODS AND RESULTS

CRP and cTnI levels were examined 1 day before and after SES implantation in 322 patients. CRP level greater than 3.0 mg/l (defining the high serum CRP levels) and cTnI level greater than 1.0 microg/l (defining the high serum cTnI levels) were considered abnormal. Major adverse cardiac events were defined as nonfatal myocardial infarction (MI), target vessel revascularization (TVR), and cardiac death. After 2+/-0.2 years of follow-up, there were 11 MI, 19 TVR, and 11 cardiac deaths. After adjustment for relevant risk factors, the combination of high CRP and cTnI remained predictive of adverse cardiac events, with the presence of both elevated CRP and cTnI associated with the highest risks of MI [relative risk (RR): 4.0, 95% confidence interval (CI): 2.3-6.4], TVR (RR: 3.3, 95% CI: 2.8-5.3), and cardiac death (RR: 4.2, 95% CI: 2.6-6.0). The presence of either a high CRP or cTnI was associated with an intermediated risk of MI (RR: 1.7, 95% CI: 1.2-2.2), TVR (RR: 1.5, 95% CI: 1.2-2.7), and cardiac death (RR: 2.8, 95% CI: 2.2-3.6).

CONCLUSION

The combination of elevated CRP and cTnI increased the risk of adverse cardiac events, demonstrating the additive impacts of active inflammation and myocardial injury on prognosis after SES implantation.

Troponin is superior to electrocardiogram and creatinine kinase MB for predicting clinically significant myocardial injury after coronary artery bypass grafting

AIMS

Cardiac biomarkers are routinely elevated after uncomplicated cardiac surgery to levels considered diagnostic of myocardial infarction in ambulatory populations. We investigated the diagnostic power of electrocardiogram (ECG) and cardiac biomarker criteria to predict clinically relevant myocardial injury using benchmarks of mortality and increased hospital length of stay (HLOS) in patients undergoing coronary artery bypass graft (CABG) surgery.

METHODS AND RESULTS

Perioperative ECGs, creatinine kinase MB fraction, and cardiac troponin I (cTnI) were assessed in 545 primary CABG patients. None of the ECG criteria for myocardial injury predicted mortality or HLOS. However, post-operative day (POD) 1 cTnI levels independently predicted 5-year mortality (hazard ratio = 1.42; 95% CI 1.14-1.76 for each 10 microg/L increase; P = 0.009), while adjusting for baseline demographic characteristics and perioperative risk factors. Moreover, cTnI was the only biomarker that significantly improved the prediction of 5-year mortality estimated by the logistic Euroscore (P = 0.02). Furthermore, the predictive value of cTnI for 5-year mortality was replicated in a separately collected cohort of 1031 CABG patients using cardiac troponin T.

CONCLUSION

Electrocardiogram diagnosis of post-operative myocardial injury after CABG does not independently predict an increased risk of 5-year mortality or HLOS. Conversely, cTnI is independently associated with an increased risk of mortality and prolonged HLOS.

Incidence and determinants of myocardial infarction following percutaneous coronary interventions according to the revised Joint Task Force definition of troponin T elevation

BACKGROUND

Elevations in troponin T (TnT) occur frequently following percutaneous coronary intervention (PCI) and are associated with an adverse prognosis. The Joint ESC/ACC/AHA/WHF Task Force have released a proposal for a universal definition of myocardial infarction (MI), including diagnostic criteria for PCI associated MI. This is based on a TnT cut-point of more than three times the 99th percentile (0.03 ng/ml), which better reflects the precision of the assay. Our study investigated the incidence and predictive factors of a PCI associated MI, using the revised definition.

METHODS

325 patients were studied following PCI with stenting. TnT was collected at both 8 and 18 h following PCI in patients with either stable or unstable angina and normal baseline TnT levels. Comparison was made of both clinical and procedural characteristics of patients with and without a rise in TnT following intervention, using cut points of 0.01 and 0.03 ng/ml.

RESULTS

TnT was elevated > or = 0.03 ng/ml in 27% and > or = 0.01 ng/ml in 39% of patients following PCI. Troponin elevation was significantly more likely in those patients who experienced peri-procedural ischemic symptoms or EKG changes, or in whom abciximab was used. The variables associated with a troponin rise showed a greater difference between TnT positive and negative patients when using 0.03 ng/ml compared to 0.01 ng/ml, suggesting that this may be a better definition of PCI-related MI.

CONCLUSIONS

Approximately one-quarter of low risk patients experience a procedural MI according to the revised definition. Rises in troponin were significantly associated with peri-procedural ischemic symptoms and EKG changes, and abciximab use, consistent with this level of TnT reflecting true myocardial necrosis.

Lack of consensus in biomarker measurement to diagnose PCI-related myocardial infarction

OBJECTIVE

To evaluate if biomarker sampling in PCI has adhered to the 2 000 consensus document for the diagnosis of procedure-related myocardial infarction (MI).

DESIGN

Firstly, a review of relevant papers from 2000 to September 2007 was done. Secondly, in October 2007, a questionnaire addressing biomarker sampling in routine PCI was sent to Danish PCI centres.

RESULTS

Fourteen papers fulfilled the selection criteria. In six studies serial sampling according to the consensus document had been done. Biomarker measuring before PCI was not performed in four studies. All centres answered the questionnaire. In none of six centres the proposed 3-sample testing of biomarkers had been followed. A pre-PCI sample was taken in one centre. In approximately half of the centres biomarkers were only measured on clinical indication.

CONCLUSION

Biomarker sampling for procedure-related MI according to the 2 000 consensus document has not been universally adapted. In order to avoid hampering of epidemiologic data and the comparison of future clinical trials it is proposed that the 2007 MI re-definition consensus document will be rapidly and universally accepted.

Biomarkers and Bioassays for Cardiovascular Diseases: Present and Future

Stratification of cardiac patients arriving at the emergency department is now being made according to the levels of acute cardiac biomarkers (i.e. cardiac troponin (cTn) or creatine kinase myocardial band (CK-MB)). Ongoing efforts are undertaken in an attempt to identify and validate additional cardiac biomarkers, for example, interleukin-6, soluble CD40L, and C-reactive protein, in order to further risk stratify patients with acute coronary syndrome. Several studies have also now shown an association of platelet transcriptome and genomic single nucleotide polymorphisms with myocardial infarction by using advanced genomic tools. A number of markers, such as myeloid-related protein 14 (MRP-14), cyclooxygenase-1 (COX-1), 5-lipoxygenase activating protein (FLAP), leukotriene A4 hydrolase (LTA4H) and myocyte enhancing factor 2A (MEF2A), have been linked to acute coronary syndromes, including myocardial infarction. In the future, these novel markers may pave the way toward personalized disease-prevention programs based on a person's genomic, thrombotic and cardiovascular profiles. Current and future biomarkers and bioassays for identifying at-risk patients will be discussed in this review.

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.

Myocardial injury after off-pump coronary artery bypass grafting operation

OBJECTIVE

Perioperative myocardial ischemia is less pronounced in off-pump coronary artery bypass (OPCAB) compared to on-pump coronary artery bypass; however, the threshold over which the postoperative release of cardiac troponin I (cTnI) release and creatine kinase-MB (CK-MB) after OPCAB should be considered clinically relevant is unknown. The study was designated to evaluate if perioperative myocardial damage, measured by means of postoperative release of cTnI and CK-MB, has an influence on short- and mid-term outcome after OPCAB operations.

METHODS

Two hundred and sixty-one unselected patients undergoing OPCAB had cTnI and CK-MB measured preoperatively and nine times postoperatively. Postoperative peak values were evaluated and the 80th percentiles were used to segregate the population into two groups for each marker. The following cut-offs were used: 7.1 ng/dl for cTnI peak and 36.3 ng/dl for CK-MB peak.

RESULTS

Patients with cTnI>7.1 ng/ml (n=51) and CK-MB>36.3 ng/ml (n=48) had a longer mechanical ventilation and ICU length of stay. Nevertheless, hospital mortality did not differ between groups. Survival after 3 years was 92.8+/-2.3% and 81.8+/-6.2 for patients with postoperative cTnI peak<or=7.1 ng/ml and >7.1 ng/ml, respectively (p=0.003). It was 93+/-2.2% and 80+/-6.8% for patients with CK-MB<or=36.3 ng/ml and >36.3 ng/ml, respectively (p=0.005). Adjusted hazard ratios for mid-term mortality were HR 2.7 (CI 1-7.6), p=0.05 for cTnI>7.1 ng/dl and HR 3.1 (CI 1-9.1), p=0.04 for CK-MB>36.3 ng/ml.

CONCLUSION

Perioperative myocardial damage should not be considered an innocuous event following OPCAB operations since the survival rate over 3 years is significantly worse in patients with the highest postoperative peak release of cTnI and CK-MB.