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Reklou A, Doumas M, Imprialos K, Stavropoulos K, Patoulias D, Athyros VG. Reduction of Vascular Inflammation, LDL-C, or Both for the Protection from Cardiovascular Events? Open Cardiovasc Med J 2018; 12:29-40. [PMID: 29785212 PMCID: PMC5897979 DOI: 10.2174/1874192401812010029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 03/25/2018] [Accepted: 03/27/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Low density lipoprotein cholesterol (LDL-C) and low grade arterial inflammation are key pathogenic factors for atherosclerosis and its manifestation, cardiovascular disease (CVD). OBJECTIVE In this narrative review we assessed if decreasing LDL-C levels or inflammation or both is more effective in reducing CVD events. RESULTS In the Scandinavian Simvastatin Survival Study (4S), all statin trials of the 90s' and the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) the benefit came from the LDL-C reduction. In the GREak and Atorvastatin Coronary heart disease Evaluation (GREACE), the Treating to New Targets (TNT), and the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trials both mechanisms in combination produced significant benefits. In the Atorvastatin for Reduction of MYocardial Damage during Angioplasty (ARMYDA) trials and the Canakinumab Antiinflammatory Thrombosis Outcome Study (CANTOS) with a human antibody targeting IL-1β with no lipid lowering effect, the reduction in arterial inflammation played the only beneficial role because there was no change in lipids levels. CONCLUSION Both LDL-C and inflammation reduction are beneficial to the reduction of CVD risk. However, canakinumab is a very expensive drug that only induced a 15% reduction in CVD events, thus drastically reducing the possibility for it to be used in clinical practice. Besides, canakinumab is associated with increased infections, some fatal. A potent statin with anti-inflammatory effects is probably the best choice for the majority of those needing hypolipidaemic drug therapy.
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Affiliation(s)
- Andromachi Reklou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
- George Washington University, Washington, DC, USA
| | - Konstantinos Imprialos
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Konstantinos Stavropoulos
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Dimitris Patoulias
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Vasilios G. Athyros
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
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Göksülük H, Atmaca Y, Uludağ MG, Kaya CT, Yıldırım O, Akbulut M, Özyüncü N, Erol C. Prevention of minor myocardial injury after elective percutaneous coronary intervention: comparison of ticagrelor versus clopidogrel. Acta Cardiol 2018; 73:1-7. [PMID: 29357752 DOI: 10.1080/00015385.2018.1429193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/15/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Elective percutaneous coronary intervention (ePCI) may cause minor elevation of cardiac enzymes, so-called minor myocardial injury (MMI) which can be due to different pathophysiological mechanism (e.g. distal embolisation, side branch occlusion, increased platelet activation triggered by the intracoronary metallic stents). We aimed to compare the effectiveness of ticagrelor versus clopidogrel for the prevention of MMI and major adverse clinical events (MACEs) after ePCI. METHODS Study population consisted of two groups of patients based on the treatment: Group I, receiving clopidogrel (n = 104), Group II, receiving ticagrelor (n = 96). Cardiac troponin I (cTnI), CK-MB were studied before and 12 hours after the procedure. Elevation of cTnI greater than 0.06 ng/ml was considered as MMI. All patients were also evaluated for the MACEs (death, myocardial infarction, stroke and transient ischaemic attack). RESULTS Fifty-two of 200 patients (26%) had MMI after the procedure. The minor myocardial injury was significantly more prevalent in clopidogrel group than that of ticagrelor group (33% vs. 19%, p = .03). Myocardial infarction (MI) and MACEs were significantly higher in the clopidogrel group (15% vs. 6%, for MI, p = .04; 16% vs. 6%, for MACEs, p = .03, respectively). Multivariate analysis demonstrated antiplatelet treatment, saphenous graft intervention, type-C lesion as independent predictors of MMI. CONCLUSIONS Present study showed that the combination of ticagrelor and aspirin was more effective than combination of clopidogrel and aspirin in decreasing MMI and MACEs after elective stenting.
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Affiliation(s)
| | - Yusuf Atmaca
- a Cardiology Department , Ankara University , Ankara , Turkey
| | | | | | - Onur Yıldırım
- a Cardiology Department , Ankara University , Ankara , Turkey
| | - Müge Akbulut
- a Cardiology Department , Ankara University , Ankara , Turkey
| | - Nil Özyüncü
- a Cardiology Department , Ankara University , Ankara , Turkey
| | - Cetin Erol
- a Cardiology Department , Ankara University , Ankara , Turkey
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Pang Z, Zhao W, Yao Z. Cardioprotective Effects of Nicorandil on Coronary Heart Disease Patients Undergoing Elective Percutaneous Coronary Intervention. Med Sci Monit 2017; 23:2924-2930. [PMID: 28617765 PMCID: PMC5484606 DOI: 10.12659/msm.902324] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Nicorandil is a nicotinamide ester commonly prescribed for treatment of patients with coronary heart disease (CHD). In the present study, we aimed to explore the cardioprotective effects of nicorandil on CHD patients undergoing elective percutaneous coronary intervention (PCI). Material/Methods One hundred patients with CHD undergoing PCI were randomly divided into a control group (n=48) and a nicorandil group (n=52). Patients in the control group received traditional therapy, and while patients in the nicorandil group received nicorandil before PCI in addition to the traditional therapy. After PCI, all patients underwent coronary angiogram, and TIMI frame count (TFC) was calculated. Plasma levels of cardiac troponin I (cTnI), creatine kinase-MB (CK-MB), myeloperoxidase (MPO), and malondialdehyde (MDA) were determined before and at 6, 18, and 24 h after PCI. Moreover, systolic blood pressure (SBP), mean blood pressure (DBP), heart rate (HR), and left ventricular ejection fractions (LVEF) were recorded before and 3 months after PCI. Results There was a significant difference in the rate of no-reflow (P=0.036) between the 2 groups. The blood frames and levels of cTnI, CK-MB, MPO, and MDA in the nicorandil group were significantly decreased compared to the control group (all P<0.05). Moreover, administration of nicorandil markedly decreased SBP, MBP, and HR, but obviously increased LVEF at 3 months after PCI (P<0.05 or P<0.01). Conclusions Nicorandil exerts cardioprotective effects on CHD patients undergoing elective PCI by decreasing PCI-related myocardial injury and rate of no-reflow and improvement of LVEF.
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Affiliation(s)
- Zhihua Pang
- Department of Cardiology, Tianjin Union Medical Center, Tianjin, China (mainland)
| | - Wei Zhao
- Heyuan Community Health Service Centers of Hongqiao District, Tianjin, China (mainland)
| | - Zhuhua Yao
- Department of Cardiology, Tianjin Union Medical Center, Tianjin, China (mainland)
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Tadros GM, Broder K, Bachour F. Intracoronary Macrothrombus Formation During Percutaneous Coronary Intervention Despite Optimal Activated Clotting Time Using Bivalirudin. Angiology 2016; 56:761-5. [PMID: 16327953 DOI: 10.1177/000331970505600614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The occurrence of intracoronary thrombus during percutaneous coronary intervention (PCI) is a well-known complication. It has been estimated that it complicates approximately 6% of all coronary procedures. Patients at highest risk for this complication include those with acute ischemic syndromes or with angiographically apparent thrombus. Since the development of PCI, intravenous unfractionated heparin (UFH) has remained the primary antithrombotic therapy for the prevention of periprocedural ischemic complications. The availability of a rapid “point of care” test for dose individualization (the activated clotting time [ACT]) has facilitated this process. Other forms of antithrombotic therapies such as direct thrombin inhibitors or low-molecular-weight heparin have been proposed as more effective anticoagulants during PCI. Bivalirudin is a direct thrombin inhibitor proven to decrease post-PCI ischemic complication rate compared with UFH and have a lower vascular complication rate compared with glycoprotein IIb/IIIa receptor antagonists. We herein report a case of acute macrothrombus formation during PCI despite adequate ACT achieved with bivalirudin.
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Affiliation(s)
- George M Tadros
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
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Martins KB, Mattos LA, Sousa AG, Sousa JM, Abzaid A, Feres F, de Ribamar JC, Staico R, Costa RA, Chaves AJ. A Randomized Trial of Creatine-kinase Leak After Rosuvastatin in Elective Percutaneous Coronary Intervention (CLEAR-PCI). J Interv Cardiol 2015; 28:339-47. [DOI: 10.1111/joic.12209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Kleber B.A. Martins
- Instituto Dante Pazzanese de Cardiologia; Interventional Cardiology; Sao Paulo Brazil
| | - Luiz A.P. Mattos
- Instituto Dante Pazzanese de Cardiologia; Interventional Cardiology; Sao Paulo Brazil
| | | | | | | | - Fausto Feres
- Instituto Dante Pazzanese de Cardiologia; Interventional Cardiology; Sao Paulo Brazil
| | | | - Rodolfo Staico
- Dante Pazzanese Institute of Cardiology; Sao Paulo Brazil
| | - Ricardo A. Costa
- Instituto Dante Pazzanese de Cardiologia; Interventional Cardiology; Sao Paulo Brazil
| | - Aurea J. Chaves
- Instituto Dante Pazzanese de Cardiologia; Interventional Cardiology; Sao Paulo Brazil
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Shehata M. Cardioprotective effects of oral nicorandil use in diabetic patients undergoing elective percutaneous coronary intervention. J Interv Cardiol 2014; 27:472-81. [PMID: 25174952 DOI: 10.1111/joic.12142] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE This study sought to evaluate the cardioprotective role of oral nicorandil (a hybrid between the nitrates and adenosine triphosphate [ATP] sensitive potassium channel activators) in diabetic patients undergoing elective percutaneous coronary intervention (PCI). BACKGROUND Myocardial injury commonly occurs during PCI. Several agents that mimic ischemic preconditioning could help minimize this phenomenon. METHODS One hundred diabetic patients with stable angina were prospectively enrolled, then randomly assigned to receive oral nicorandil: 20 mg once daily (group A, 50 patients) or placebo (group B, 50 patients) 1 week before and 6 months after PCI. Cardiac troponin I (cTnI) and creatine kinase-MB (CK-MB) levels were measured before and 6, 12, and 24 hours post-PCI. RESULTS Mean age of the study cohort was 59.8 ± 5.8 years (males = 68%). cTnI level was significantly lower in group A (6 hours: 7.3 ± 0.3 vs. 14.5 ± 0.4 pg/mL; 12 hours: 12.7 ± 0.7 vs. 25.3 ± 0.5 pg/mL; and 24 hours: 7.7 ± 0.5 vs. 15.0 ± 0.4 pg/mL, P < 0.001). After 6 months, the same group showed significantly higher left ventricle ejection fraction (LVEF%), that is, 63.5 ± 7.7% versus 56.5 ± 8.3% (P < 0.05), with a trend toward lower incidence of major adverse cardiac events (MACE). CONCLUSION In diabetic patients undergoing elective PCI, nicorandil intake was associated with decreased incidence of PCI-related myocardial injury and improvement of LVEF% after 6 months.
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Affiliation(s)
- Mohamed Shehata
- Department of Cardiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Lavi S, D'Alfonso S, Diamantouros P, Camuglia A, Garg P, Teefy P, Jablonsky G, Sridhar K, Lavi R. Remote ischemic postconditioning during percutaneous coronary interventions: remote ischemic postconditioning-percutaneous coronary intervention randomized trial. Circ Cardiovasc Interv 2014; 7:225-32. [PMID: 24692535 DOI: 10.1161/circinterventions.113.000948] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Remote ischemic preconditioning may result in reduction in infarct size during percutaneous coronary intervention (PCI). It is unclear whether remote ischemic postconditioning (RIPost) will reduce the incidence of myocardial injury after PCI, and whether ischemic conditioning of a larger remote organ (thigh versus arm) would provide further myocardial protection. METHODS AND RESULTS We randomized 360 patients presenting with stable or unstable angina (28% of patients) and negative Troponin T at baseline to 3 groups: 2 groups received RIPost (induced by ischemia to upper or lower limb), and a third was the control group. RIPost was applied during PCI immediately after stent deployment, by three 5-minute cycles of blood pressure cuff inflation to >200 mm Hg in the arm or thigh (20 mm Hg in the control) with 5-minute breaks between each cycle. The primary end-point was the proportion of patients with Troponin T levels >3×ULN postprocedure (at 6 or 18-24 hours), where ULN stands for upper limit of normal. A total of 120 patients were randomized to each group. There were no differences in baseline characteristics between the 3 groups. The primary outcome occurred in 30%, 35%, and 35% of the arm, thigh, and control groups, respectively (P=0.64). There were no differences in creatine kinase or high sensitivity C-reactive protein levels after PCI or in the incidence of acute kidney injury between the groups. CONCLUSIONS RIPost during PCI did not reduce the incidence of periprocedural myocardial injury. Similar effect was obtained when remote ischemia was induced to the upper or lower limb. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00970827.
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Affiliation(s)
- Shahar Lavi
- From the Western University (S.L., P.D., A.C., P.G., P.T., G.J., K.S., R.L.), London, Ontario, Canada; and London Health Sciences Centre (S.L., S.D., P.D., A.C., P.G., P.T., G.J., K.S., R.L.), London, Ontario, Canada
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He GX, Tan W. High-dose atorvastatin pretreatment could diminishes microvascular impairment in patients undergoing elective percutaneous coronary intervention. J Geriatr Cardiol 2013; 10:355-60. [PMID: 24454329 PMCID: PMC3888918 DOI: 10.3969/j.issn.1671-5411.2013.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 12/08/2013] [Accepted: 12/15/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES High-dose statins pretreatment is reasonable before percutaneous coronary intervention (PCI) to reduce the risk of periprocedural myocardial injury. However, the mechanism underlying this protective effect has not been elucidated. The aim of this study is to evaluate the effects of high-dose atorvastatin pretreatment on microvascular function and myocardial injury after elective PCI. METHODS Eighty four patients underwent elective PCI were randomly assigned to high-dose atorvastatin (40 mg/d) and low-dose atorvastatin (20 mg/d) treatment for 7 days before PCI. The index of microcirculatory resistance (IMR) was measured by an intracoronary ressure/temperature sensor-tipped guidewire at maximal hyperemia after PCI. Fractional flow reserve (FFR) was measured before and after procedure. Troponin I levels were obtained at baseline and 20-24 h after procedure. RESULTS IMR values were significantly lower in high-dose group when compared to low-dose group (16.5 ± 6.1 vs. 31.2 ± 16.0, P < 0.001). Pre-PCI troponin I levels between the two groups were similar (0.028 ± 0.05 vs. 0.022 ± 0.04, P = 0.55). However, post-PCI troponin I levels in high-dose group were significantly lower than low-dose group (0.11 ± 0.02 vs. 0.16 ± 0.09, P < 0.001). Multivariate analysis identified maximum inflation pressure > 20 atm as an independent predictor of IMR > 32 (Odds ratio (OR): 3.3, 95% confidence intervals (95%CI): 1.3-8.5, P = 0.02). High-dose atorvastatin was the only independent protective factor of IMR > 32 (OR: 0.29, 95%CI: 0.11-0.74, P = 0.01). CONCLUSIONS The present study confirmed that diminishing microvascular impairment is one of the mechanism underlying protecting effect of high-dose statins pretreatment from myocardial injury during PCI. These suggest that high-dose statin pretreatment is reasonable in patients undergoing elective PCI.
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Affiliation(s)
- Gui-Xin He
- Department of Cardiology, the First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Qingxiu District, Nanning 530023, Guangxi Province, China
| | - Wei Tan
- Department of Cardiology, the First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Qingxiu District, Nanning 530023, Guangxi Province, China
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Leoncini M, Toso A, Maioli M, Tropeano F, Bellandi F. Statin treatment before percutaneous cononary intervention. J Thorac Dis 2013; 5:335-42. [PMID: 23825770 DOI: 10.3978/j.issn.2072-1439.2013.05.09] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 05/13/2013] [Indexed: 12/31/2022]
Abstract
Treatment with 3-hydroxy-3-methyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) improves short-and-long term prognosis in high-risk patients with stable coronary artery disease and in those with acute coronary syndrome and their use is strongly recommended for secondary prevention. Moreover, recent data suggest that statin pre-treatment is associated with a better short- and long-term outcome in patients undergoing percutaneous coronary intervention. Current guidelines for coronary revascularization recommend the use of high-dose of statins before percutaneous coronary intervention to reduce the risk of periprocedural myocardial infarction in statin naïve patients (class IIa A) and in those on chronic statin therapy (class IIa B). However, the beneficial clinical effects elicited by statins in patients undergoing coronary angioplasty may arise not only from a cardiac protection against periprocedural myocardial injury but also from a renal protection against acute kidney injury caused by iodinated contrast media. Actually, statins exert multiple non-lipid lowering (pleiotropic) effects, including improved endothelial function, reduced inflammatory and immuno-modulatory processes, oxidative stress and platelet adhesion, that may contribute to both cardio- and nephro-protection even in the short-term.
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Affiliation(s)
| | | | - Domenico Ferro
- From I Clinica Medica, Sapienza, University of Rome, Italy
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Sardella G, Conti G, Donahue M, Mancone M, Canali E, De Carlo C, Di Roma A, Calcagno S, Lucisano L, Fedele F. Rosuvastatin pretreatment in patients undergoing elective PCI to reduce the incidence of myocardial periprocedural necrosis: the ROMA trial. Catheter Cardiovasc Interv 2012; 81:E36-43. [PMID: 22517610 DOI: 10.1002/ccd.24403] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 01/22/2012] [Accepted: 03/02/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim of this study is to assess the efficacy of the high-dose rosuvastatin preadministration in reducing periprocedural myocardial necrosis and major adverse cardiovascular and cerebrovascular events (MACCE) in patients undergoing elective percutaneous coronary intervention (PCI). BACKGROUND Elective PCI may be complicated with an elevation of cardiac biomarkers. Several studies suggested that pretreatment with statins may be associated with a reduction in periprocedural myocardial necrosis. METHODS One hundred and sixty patients with stable angina who underwent elective PCI were randomly assigned to receive either a preprocedural loading dose (40 mg) of rosuvastatin group (RG, n = 80) or a standard treatment [control group (CG), n = 80].The primary endpoint was the incidence of periprocedural myocardial necrosis. The secondary endpoint was the assessment of MACCE [cardiac death, all-myocardial infarction (MI), stroke, and target vessel revascularization (TVR)] at a 30-day and 12-month follow-up, as well as the rate of periprocedural rise of Troponin T-serum levels >3× upper limit of normal. RESULTS Twelve and 24-hr post-PCI creatinine kinase MB isoform elevation >3× occurred more frequently in the CG than in the RG (22.7 vs. 7.1; P = 0.034 and 26.4 vs. 8.7; P = 0.003). At the 30-day and 12-month follow-up, the incidence of cumulative MACCE was higher in CG than in the RG (30.0% vs. 8.7%; P = 0.001 and 35.0% vs. 12.5%; P = 0.001).The difference between the groups was mainly due to the periprocedural MI incidence (26.4% vs. 8.7%; P = 0.003).The rate of cardiac death, spontaneous MI, TVR, and stroke were similar in the two groups. CONCLUSIONS High loading dose of rosuvastatin within 24 hr before elective PCI seems to decrease the incidence of periprocedural myocardial necrosis during a period of 12-months compared to the standard treatment.
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Affiliation(s)
- Gennaro Sardella
- Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences Department, Umberto I Hospital, Sapienza University of Rome, Italy.
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Balin M, Çelik A, Kobat MA, Baydas A. Circulating soluble lectin-like oxidized low-density lipoprotein receptor-1 levels predict percutaneous coronary intervention-related periprocedural myocardial infarction in stable patients undergoing elective native single-vessel PCI. J Thromb Thrombolysis 2012; 34:483-90. [DOI: 10.1007/s11239-012-0770-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Effect of myocardial protection of intracoronary adenosine and nicorandil injection in patients undergoing non-urgent percutaneous coronary intervention: A randomized controlled trial. Int J Cardiol 2012; 158:88-92. [DOI: 10.1016/j.ijcard.2011.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 12/27/2010] [Accepted: 01/04/2011] [Indexed: 11/18/2022]
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Chen ZW, Qian JY, Ma JY, Ge L, Ge JB. Risk factors of cardiac troponin T elevation in patients with stable coronary artery disease after elective coronary drug-eluting stent implantation. Clin Cardiol 2011; 34:768-73. [PMID: 22083940 DOI: 10.1002/clc.20973] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 08/17/2011] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Cardiac troponin T elevation after coronary intervention has been demonstrated to be associated with the prognosis of coronary artery disease (CAD). However, there were few studies about comprehensive risk factors analysis of troponin T elevation after elective drug-eluting stent (DES) implantation. HYPOTHESIS The prognosis of CAD after coronary interventions was associated with clinical and procedural risk factors of CAD, such as age, hypertension, severity extent of CAD and so on. METHODS From March to December in 2010, patients with stable CAD were admitted for elective coronary intervention in our hospital. They were divided into an elevated troponin T group and a normal troponin T group by postprocedural troponin T. Clinical factors, laboratory-test factors, and angiographic factors (such as gender, age, cholesterol, Gensini score, and others) were analyzed. RESULTS A total of 209 patients with an average age of 64.0 ± 9.9 years were enrolled in the study: 70 patients with elevated troponin T (≥0.03 ng/mL) after DES implantation and 139 patients with normal troponin T (<0.03 ng/mL). After univariate analysis, we found that age, hypertension, total cholesterol, low density lipoprotein-cholesterol (LDL-C), Gensini score, number of stenosed vessels, and total implanted stents were associated with postprocedural troponin T elevation. According to the results of multivariate analysis, we found that age, total cholesterol, number of stenosed vessels, and number of implanted stents were independent risk factors of postprocedural troponin T elevation. CONCLUSIONS Age, serum total cholesterol, number of stenosed vessels, and number of implanted stents could be independent risk factors of troponin T elevation after elective DES implantation.
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Affiliation(s)
- Zhang-Wei Chen
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, PR China
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Murakami D, Takano M, Yamamoto M, Inami T, Inami S, Okamatsu K, Ohba T, Seino Y, Mizuno K. Intense yellow culprit plaque coloration is closely associated with troponin-T elevation and flow complications following elective coronary stenting. J Atheroscler Thromb 2011; 18:906-13. [PMID: 21778655 DOI: 10.5551/jat.8128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM The elevation of troponin-T (TnT) and occurrence of transient slow-flow phenomena have been recognized as procedure-related myocardial injuries. Little is known about the characteristics of high-risk plaque resulting in myocardial injury after coronary stenting. METHODS The culprit plaques in 42 consecutive patients with stable angina undergoing elective coronary stenting were observed by angioscopy. The plaque color upon angioscopic examination was classified as either intense yellow or not yellow. Slow flow was defined as < TIMI grade 3 flow during the procedure. The TnT levels were measured 8, 16, and 24 hours after stenting, and myocardial injury was defined as TnT ≥ 0.03 ng/mL at any time point. RESULTS Twenty-four patients (57%) had intense yellow plaques and myocardial injury occurred in 22 patients (52%). The frequency of intense yellow plaque was significantly higher in the patients with myocardial injury than in those without myocardial injury (91% vs. 20%, p < 0.001). Transient slow flow occurred frequently in patients with myocardial injury than in those without myocardial injury (23% vs. 0%, p = 0.049). All patients with transient slow flow had intense yellow plaques at the culprit lesions. CONCLUSIONS Intense yellow culprit plaque coloration was closely associated with TnT elevation and flow complications following elective coronary stenting. Angioscopically-observed intense yellow coloration may therefore predict high-risk plaque for peri-procedural myocardial injury.
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Affiliation(s)
- Daisuke Murakami
- Cardiovascular Center, Chiba-Hokusoh Hospital, Nippon Medical School, Chiba, Japan
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Fujii K, Kawasaki D, Oka K, Akahori H, Iwasaku T, Fukunaga M, Eguchi A, Sawada H, Masutani M, Lee-Kawabata M, Tsujino T, Ohyanagi M, Masuyama T. The Impact of Pravastatin Pre-Treatment on Periprocedural Microcirculatory Damage in Patients Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2011; 4:513-20. [DOI: 10.1016/j.jcin.2011.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 01/10/2011] [Accepted: 02/18/2011] [Indexed: 10/18/2022]
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Patti G, Cannon CP, Murphy SA, Mega S, Pasceri V, Briguori C, Colombo A, Yun KH, Jeong MH, Kim JS, Choi D, Bozbas H, Kinoshita M, Fukuda K, Jia XW, Hara H, Cay S, Di Sciascio G. Clinical benefit of statin pretreatment in patients undergoing percutaneous coronary intervention: a collaborative patient-level meta-analysis of 13 randomized studies. Circulation 2011; 123:1622-32. [PMID: 21464051 DOI: 10.1161/circulationaha.110.002451] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous studies suggested that statin pretreatment reduces cardiac events in patients undergoing percutaneous coronary intervention. However, most data were observational, and single randomized trials included limited numbers of patients. METHODS AND RESULTS We performed a collaborative meta-analysis using individual patient data from 13 randomized studies in which 3341 patients received either high-dose statin (n=1692) or no statin/low-dose statin (n=1649) before percutaneous coronary intervention, with all patients receiving statin therapy after intervention. Occurrence of periprocedural myocardial infarction, defined as postintervention creatine kinase-MB increase ≥3 times the upper limit of normal, and 30-day major adverse cardiac events (death, myocardial infarction, target-vessel revascularization) was evaluated. Incidence of periprocedural myocardial infarction was 7.0% in the high-dose statin versus 11.9% in the control group, which corresponds to a 44% risk reduction in the active-treatment arm (odds ratio by fixed-effects model 0.56, 95% confidence interval, 0.44 to 0.71, P<0.00001). The rate of major adverse cardiac events at 30 days was significantly lower in the high-dose statin group (7.4% versus 12.6%, a 44% risk reduction; P<0.00001), and 1-month major adverse cardiac events, excluding periprocedural events, were also reduced (0.6% versus 1.4%; P=0.05). The benefit of high-dose statins was realized irrespective of clinical presentation (P for interaction=0.43) and was maintained across various subgroups but appeared greater in the subgroup with elevated baseline C-reactive protein levels (n=734; 68% risk reduction for periprocedural myocardial infarction versus 31% in those 1861 patients with normal CRP; P for quantitative interaction=0.025). CONCLUSIONS High-dose statin pretreatment leads to a significant reduction in periprocedural myocardial infarction and 30-day adverse events in patients undergoing percutaneous coronary intervention. This strategy should be considered in all patients with planned percutaneous coronary intervention.
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Affiliation(s)
- Giuseppe Patti
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy.
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Lavi S, Lavi R. Conditioning of the heart: From pharmacological interventions to local and remote protection. Int J Cardiol 2011; 146:311-8. [DOI: 10.1016/j.ijcard.2010.08.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 07/14/2010] [Accepted: 08/07/2010] [Indexed: 01/08/2023]
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Ito H. The no-reflow phenomenon associated with percutaneous coronary intervention: its mechanisms and treatment. Cardiovasc Interv Ther 2010; 26:2-11. [DOI: 10.1007/s12928-010-0034-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Indexed: 11/28/2022]
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Uetani T, Amano T, Kunimura A, Kumagai S, Ando H, Yokoi K, Yoshida T, Kato B, Kato M, Marui N, Nanki M, Matsubara T, Ishii H, Izawa H, Murohara T. The Association Between Plaque Characterization by CT Angiography and Post-Procedural Myocardial Infarction in Patients With Elective Stent Implantation. JACC Cardiovasc Imaging 2010; 3:19-28. [DOI: 10.1016/j.jcmg.2009.09.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 08/28/2009] [Accepted: 09/08/2009] [Indexed: 01/30/2023]
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Klein LW. Cardiac enzyme elevations after apparently successful percutaneous interventions are a marker of extensive coronary artery disease and complex stenoses. Catheter Cardiovasc Interv 2009; 74:823-5. [PMID: 19902503 DOI: 10.1002/ccd.22314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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23
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Attali P, Aleil B, Petitpas G, DePoli F, Wiesel ML, Wuillermin A, Cazenave JP, Mossard JM. Sensitivity and long-term prognostic value of cardiac troponin-I increase shortly after percutaneous transluminal coronary angioplasty. Clin Cardiol 2009; 21:353-6. [PMID: 9595219 PMCID: PMC6655666 DOI: 10.1002/clc.4960210511] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND After successful coronary interventions, minor elevations of creatine kinase MB (CK-MB) identified a population with a worse long-term prognosis than that in patients without enzyme elevations. In that setting, cardiac troponin-I (cTn-I), a highly specific marker for myocardial injury, was considered for a small study; the results did not support the view that significant myocardial damage occurred during successful percutaneous transluminal coronary angioplasty (PTCA). HYPOTHESIS The present study was designed to assess the rate of elevated values of cTn-I after successful PTCA and to determine its prognostic value. METHODS CTn-I and CK-MB were measured in 44 patients before and daily for 3 days after PTCA. Two groups of patients were considered according to the presence or absence of elevated levels of cTn-I. The rate of free-event survival was estimated for the two groups using the Kaplan-Meier method and was compared with the log rank test. RESULTS Globally, 36% of patients had an increase in cTn-I (normal values 0.35 ng/ml) and 9% had an increase in CK-MB, p = 0.002. The mean time to maximal enzyme level was 1.8 days for cTn-I and 2.2 days for CK-MB. Over a follow-up of 1375 +/- 416 days, 18% of patients experienced adverse events, and cTn-I did not identify a population of worse long-term prognosis. CONCLUSION These results suggest that cTn-I is more sensitive than CK-MB in identifying minor myocardial damage after PTCA, but these elevated concentrations of cTn-I in the short-term aftermath of angioplasty do not seem to be a marker of worse long-term prognosis.
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Affiliation(s)
- P Attali
- Service de Cardiologie, Hôpitaux Universitaires de Strasbourg, France
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Uetani T, Amano T, Kumagai S, Ando H, Yokoi K, Yoshida T, Kato B, Kato M, Marui N, Nanki M, Matsubara T, Ishii H, Izawa H, Murohara T. Intracoronary Electrocardiogram Recording With a Bare-Wire System. JACC Cardiovasc Interv 2009; 2:127-35. [DOI: 10.1016/j.jcin.2008.07.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 07/16/2008] [Accepted: 07/30/2008] [Indexed: 11/30/2022]
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Brunetti ND, Quagliara D, Di Biase M. Troponin ratio and risk stratification in subjects with acute coronary syndrome undergoing percutaneous coronary intervention. Eur J Intern Med 2008; 19:435-42. [PMID: 18848177 DOI: 10.1016/j.ejim.2007.04.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 04/23/2007] [Accepted: 04/23/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cardiac enzyme release after percutaneous coronary intervention (PCI) seems to play a role in risk stratification. After PCI, CK-MB plasmatic concentrations three times above the upper level of normal (ULN) are currently the most used risk stratification parameters. We sought to assess whether peak cardiac troponin I (cTn-I) concentration/base concentration ratio (PBTR) may act as a predictor of major adverse cardiac events (MACEs) after PCI, regardless of cTn-I ULN. METHODS We evaluated 326 consecutive patients with acute coronary syndrome (ACS) who underwent PCI. Baseline and post-PCI cTn-I values were evaluated over serial blood samples every 6h for at least 72h. Patients were further divided into four groups according to their PBTR values (<1, 1-4, 4-10, >10). MACEs were recorded over a 6-month follow-up period. Patients with primary PCI or unsuccessful PCI were excluded from the study. RESULTS Higher values of PBTR significantly correlated with a worse prognosis at 6 months (<1, 16.30% of MACEs; 1-4, 19.42%; 4-10, 24.39%; >10, 35.63%; p<0.05), both in Q-wave myocardial infarction (MI) and unstable angina (UA) subgroups. The correlation remained statistically significant, even considering subjects with peak cTn-I less than three times the ULN (p < 0.05) and after correction for age, gender, risk factors, diagnosis (MI versus UA), and peak cTn-I levels in a multiple Cox' regression analysis (HR 1.62, p<0.05). CONCLUSIONS PBTR is an independent predictor of MACEs after PCI in a 6-month follow-up period. This risk stratification tool may be useful to predict adverse events in PCI patients, even in the case of apparently non-elevated peak cTn-I concentrations.
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Wang TY, Peterson ED, Dai D, Anderson HV, Rao SV, Brindis RG, Roe MT. Patterns of cardiac marker surveillance after elective percutaneous coronary intervention and implications for the use of periprocedural myocardial infarction as a quality metric: a report from the National Cardiovascular Data Registry (NCDR). J Am Coll Cardiol 2008; 51:2068-74. [PMID: 18498965 DOI: 10.1016/j.jacc.2008.01.054] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Accepted: 01/16/2008] [Indexed: 11/30/2022]
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Uetani T, Amano T, Ando H, Yokoi K, Arai K, Kato M, Marui N, Nanki M, Matsubara T, Ishii H, Izawa H, Murohara T. The correlation between lipid volume in the target lesion, measured by integrated backscatter intravascular ultrasound, and post-procedural myocardial infarction in patients with elective stent implantation. Eur Heart J 2008; 29:1714-1720. [DOI: 10.1093/eurheartj/ehn248] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Medina HM, Bhatt DL. Evolution of anticoagulant and antiplatelet therapy: benefits and risks of contemporary pharmacologic agents and their implications for myonecrosis and bleeding in percutaneous coronary intervention. Clin Cardiol 2008; 30:II4-15. [PMID: 18228647 DOI: 10.1002/clc.20237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Periprocedural myonecrosis, as evidenced by elevated creatine kinase-myocardial bound (CK-MB) levels, occurs in up to 25% of patients undergoing percutaneous coronary intervention (PCI) and has been linked with an increased risk of adverse short- and long-term clinical outcomes. Such myonecrosis arises from three main pathophysiological mechanisms: procedure-related complications, lesion-specific characteristics (e.g., large thrombus burden, plaque volume), and patient-specific characteristics (e.g., genetic predisposition, arterial inflammation). Periprocedural myonecrosis has not been definitively identified as the cause of postprocedural ischemic events, although agents that reduce or prevent thrombosis--including aspirin, thienopyridines, heparin, low-molecular-weight heparins, glycoprotein IIb/IIIa inhibitors, and direct thrombin inhibitors--have been shown to reduce the incidence of ischemic outcomes in this population, as have agents that reduce inflammation (aspirin, statins). At the same time, antithrombotic agents are known to increase the risk of bleeding and the use of transfusions, which have likewise been associated with worse outcomes in these patients. Thus, optimal management of patients undergoing PCI represents a balance between minimizing the risk of ischemic outcomes and simultaneously minimizing the risk of major bleeding. It may be that patients who have only minor, untreated postprocedural elevations in CK-MB level (with no clinical or angiographic signs of ischemia) might have a better prognosis than patients who have normal CK-MB levels but who suffer major bleeding complications.
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Affiliation(s)
- Hector M Medina
- Department of Cardiology, Baylor College of Medicine, Houston, Texas, USA
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Bozbas H, Yildirir A, Mermer S, Konas D, Atar I, Aydinalp A, Ozin B, Korkmaz ME, Muderrisoglu H. Does pravastatin therapy affect cardiac enzyme levels after percutaneous coronary intervention? Adv Ther 2007; 24:493-504. [PMID: 17660157 DOI: 10.1007/bf02848771] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Serum cardiac enzyme elevation after percutaneous coronary intervention (PCI), a relatively common complication, is a prognostic determinant of long-term outcome in patients who undergo these procedures. Statins are postulated to reduce such complications. This study investigated the short-term effects of pravastatin on serum creatine kinase myocardial isoform (CK-MB) and serum cardiac troponin I (cTpI) levels after elective PCI. Of 93 patients studied, 72 (77.4%) were men, and 21 (22.6%) were women (mean age, 58.9+/-11.0 y). Patients were randomly divided into 3 groups before they underwent elective PCI. Preoperatively, group 1 patients (n=30) received pravastatin 10 mg/d, and group 2 patients (n=29) received pravastatin 40 mg/d. Control group patients (n=34) received no lipid-lowering medication. Serum CK-MB and serum cTpI levels were measured preoperatively and then again at 6, 24, and 36 h postoperatively. Demographic features of patients and characteristics of the PCI procedure, including number of vessels/lesions and duration and number of inflations, did not differ among groups (P>.05). Mean serum CK-MB and serum cTpI levels were significantly increased after PCI in all patients (P<.001). When compared with control group patients, those given pravastatin did not experience significantly lowered postprocedural serum CK-MB or serum cTpI levels (P>.05). Preprocedural pravastatin therapy at dosages of 10 mg/d and 40 mg/d seems inadequate for preventing serum cardiac enzyme elevations during short-term follow-up after PCI. Additional research on this topic is recommended.
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Affiliation(s)
- Huseyin Bozbas
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey.
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Kinoshita M, Matsumura SI, Sueyoshi K, Ogawa S, Fukuda K. Randomized Trial of Statin Administration for Myocardial Injury. Circ J 2007; 71:1225-8. [PMID: 17652885 DOI: 10.1253/circj.71.1225] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Minor myocardial damage after percutaneous coronary intervention (PCI) is associated with cardiac risks, which statins seem to reduce. The aim of this study was to examine whether intensive lipid-lowering therapy is more effective in decreasing the risk of cardiac injury after PCI than moderate lipid-lowering therapy. METHODS AND RESULTS Subjects comprised 42 patients with stable angina without previous statin treatment, randomly assigned to either an intensive lipid-lowering group (Group A: target low-density lipoprotein-cholesterol (LDL-C)<70 mg/dl) or a moderate lipid-lowering group (Group B: target LDL-C<100 mg/dl) 2 weeks before PCI. All patients took statins to reach target LDL-C levels. Incidence of periprocedural myocardial injury was assessed by analyzing levels of creatine kinase myocardial isozyme (CK-MB) and cardiac troponin T (TnT) before and 6, 12 and 24 h after PCI. Minor myocardial damage was defined as TnT elevation to >0.01 ng/ml. Frequency of minor myocardial damage was 14.2% in Group A and 47.6% in Group B (p=0.043). CK-MB was above the upper limit of normal (ULN) in 19% of Group A and 33.3% of Group B (p=0.44), and CK-MB was >3x ULN in 9.5% of Group A and 19% of Group B (p=0.66). CONCLUSIONS Intensive lipid-lowering therapy before PCI reduces minor myocardial damage during PCI with stenting compared with moderate lipid-lowering therapy.
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Affiliation(s)
- Masayoshi Kinoshita
- Division of Cardiology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, and Division of Cardiology, The Shizuoka Municipal Shimizu Hospital, Japan.
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Blankenship JC, Islam MA, Wood GC, Iliadis EA. Angiographic adverse events during percutaneous coronary intervention fail to predict creatine kinase-MB elevation. Catheter Cardiovasc Interv 2006; 63:31-41. [PMID: 15343564 DOI: 10.1002/ccd.20065] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We attempted to determine if aggressive detection of angiographic adverse events during coronary intervention could predict subsequent creatine kinase (CK)-MB elevations. During coronary intervention, both fluoroscopy and cine angiography were used to detect angiographic adverse events. At least one angiographic adverse event occurred in 133/251 (53%) of procedures. CK-MB elevation occurred in 24% of procedures. Slow flow during the procedure (P=0.002) and chest discomfort at the end of the procedure (P=0.007) were the strongest predictors of CK-MB elevation. Among procedures with no angiographic adverse events, CK-MB elevation occurred in 15/121 (12%), accounting for 25% of CK-MB elevations. We conclude that CK-MB elevation occurs after angiographically uncomplicated coronary interventions even when angiographic adverse events are aggressively detected. Routine monitoring of cardiac enzymes is necessary to detect all patients who will experience myocardial injury after coronary intervention.
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Affiliation(s)
- James C Blankenship
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania 17822, USA.
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Ali OA, Bhindi R, McMahon AC, Brieger D, Kritharides L, Lowe HC. Distal protection in cardiovascular medicine: current status. Am Heart J 2006; 152:207-16. [PMID: 16875899 DOI: 10.1016/j.ahj.2005.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 12/06/2005] [Indexed: 10/24/2022]
Abstract
Iatrogenic and spontaneous downstream microembolization of atheromatous material is increasingly recognized as a source of cardiovascular morbidity and mortality. Devising ways of reducing this distal embolization using a variety of mechanical means--distal protection--is currently under intense and diverse investigation. This review therefore summarizes the present status of distal protection. It examines the problem of distal embolization, describes the available distal protection devices, reviews those areas of cardiovascular medicine where distal protection devices are being investigated, and discusses potential future developments.
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Affiliation(s)
- Onn Akbar Ali
- Cardiology Department, Concord Repatriation General Hospital and ANZAC Research Institute, University of Sydney, Concord, Sydney, NSW, Australia
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Blankenship JC, Haldis T, Feit F, Hu T, Kleiman NS, Topol EJ, Lincoff AM. Angiographic adverse events, creatine kinase-MB elevation, and ischemic end points complicating percutaneous coronary intervention (a REPLACE-2 substudy). Am J Cardiol 2006; 97:1591-6. [PMID: 16728220 DOI: 10.1016/j.amjcard.2005.12.050] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Revised: 12/20/2005] [Accepted: 12/20/2005] [Indexed: 11/17/2022]
Abstract
Several angiographic adverse events during coronary balloon angioplasty have been associated with increased creatine kinase-MB (CK-MB) enzymes and adverse clinical outcomes. The significance of angiographic adverse events in the stent era has not been widely studied. We analyzed 10 types of angiographic adverse events that were reported in the 6,010-patient Second Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE-2) trial to determine their relation to CK-MB elevation and clinical ischemic end points after percutaneous coronary intervention (PCI). Angiographic adverse events occurred in 9.1% of REPLACE-2 patients. Most (8 of 10) types of angiographic adverse events were associated with an increased risk of increased CK-MB (p <0.001 for each), and 47% of all patients with an angiographic adverse event developed increased CK-MB. Logistic regression analysis showed that the strongest predictor of death, myocardial infarction, or revascularization at 6 months was the occurrence of an angiographic adverse event during PCI (odds ratio 1.9, 95% confidence interval 1.6 to 2.4, p <0.001). Side branch closure, abrupt closure, any decreased flow during the procedure, angiographic distal embolization, and perforation or tamponade were individual predictors of the occurrence of the combined clinical ischemic end point at 6-month follow-up (p <0.005 for each). In conclusion, most angiographic adverse events during PCI are associated with increased CK-MB and are powerful predictors of adverse clinical events within 6 months.
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Affiliation(s)
- James C Blankenship
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania, USA.
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Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Murakami M, Iwasaki K, Kusachi S, Hina K, Hirota M, Hirohata S, Kamikawa S, Sangawa M, Yamamoto K, Shiratori Y. Nicorandil reduces the incidence of minor cardiac marker elevation after coronary stenting. Int J Cardiol 2006; 107:48-53. [PMID: 16337497 DOI: 10.1016/j.ijcard.2005.02.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Revised: 02/14/2005] [Accepted: 02/19/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Minor cardiac marker elevation after percutaneous coronary intervention has long-term prognostic significance. We examined whether nicorandil, a nicotinamide-nitrate ester, reduces the incidence of minor cardiac marker elevation after coronary stenting. METHODS Patients (n=192) undergoing coronary stenting were randomly assigned to receive nicorandil (nicorandil group, n=91) or vehicle (control group, n=101). Nicorandil (2 mug/kg/min, intravenously) was administered immediately after the patients were transferred into the catheterization laboratory and continued for 6 h. We measured the serum concentrations of creatine kinase isoenzyme MB (CK-MB) before, immediately after, and 6, 12, and 24 h after the procedure, and those of cardiac troponin T (cTnT) 24 h after the procedure. RESULTS There was no significant difference in clinical background between the 2 groups. The nicorandil group showed a significantly lower incidence of CK-MB elevation (>1x upper limit of control range, 20 IU/l) than the control group (8.8% vs 21.8%, p<0.05). The levels of serum CK-MB in the nicorandil group were significantly lower than those in the control group (13.4+/-5.7 vs 16.5+/-9.7 IU/l, p<0.01). Similarly, the nicorandil group showed a significantly lower incidence of cTnT elevation [>1x (0.1 ng/ml) or >2x (0.2 ng/ml)] upper limit of control range than the control group (14.3% vs 26.7%, p<0.05, or 7.7% vs 17.8%, p<0.05). Serum cTnT levels were also significantly lower in the nicorandil group than in the control group (0.05+/-0.10 vs 0.15+/-0.36 ng/ml, p<0.05). CONCLUSIONS The results demonstrated that nicorandil reduces minor cardiac marker elevation after coronary stenting.
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Affiliation(s)
- Masaaki Murakami
- Department of Medicine and Medical Science, Okayama University Graduates School of Medicine and Dentistry, Okayama, Japan
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Gaze DC, Collinson PO. Cardiac troponins as biomarkers of drug- and toxin-induced cardiac toxicity and cardioprotection. Expert Opin Drug Metab Toxicol 2005; 1:715-25. [PMID: 16863435 DOI: 10.1517/17425255.1.4.715] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac troponin T and I (cTnT, cTnI) are sensitive biochemical markers of myocardial cell necrosis and have been adopted as the gold standard tests for acute myocardial infarction. Subtle elevations in cTn above the detection limits of the currently available commercial assays confers poor prognosis. These markers are superior to classical enzyme markers of necrosis due to their cardiospecificity. The diagnosis of drug-induced cardiac toxicity using the classical enzymes is problematic due to the high elevations of these markers in skeletal muscle necrosis. cTnT and cTnI are now being adopted as sensitive biomarkers of drug-induced cardiac toxicity.
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Affiliation(s)
- David C Gaze
- St George's Hospital, Chemical Pathology, Blackshaw Road, Tooting, London SW17 0QT, UK.
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Abstract
During the past three decades, percutaneous coronary intervention has become one of the cardinal treatment strategies for stenotic coronary artery disease. Technical advances, including the introduction of new devices such as stents, have expanded the interventional capabilities of balloon angioplasty. At the same time, there has been a decline in the rate of major adverse cardiac events, including Q-wave acute myocardial infarction, emergency coronary artery bypass grafting, and cardiac death. Despite these advances, the incidence of post-procedural cardiac marker elevation has not substantially decreased since the first serial assessment 20 years ago. As of now, these post-procedural cardiac marker elevations are considered to represent peri-procedural myocardial injury (PMI) with worse long-term outcome potential. Recent progress has been made for the identification of two main PMI patterns, one near the intervention site (proximal type, PMI type I) and one in the distal perfusion territory of the treated coronary artery (distal type, PMI type II) as well as for preventive strategies. Integrating these new developments into the wealth of clinical information on this topic, this review aims at giving a current perspective on the entity of PMI.
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Affiliation(s)
- Joerg Herrmann
- Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street S.W., Rochester, MN 55905, USA.
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Cutlip DE, Kuntz RE. Does creatinine kinase-MB elevation after percutaneous coronary intervention predict outcomes in 2005? Cardiac enzyme elevation after successful percutaneous coronary intervention is not an independent predictor of adverse outcomes. Circulation 2005. [PMID: 16092153 DOI: 10.1161/circulationaha.104.478347] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Donald E Cutlip
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Clinical Research Institute, Boston, MA, USA.
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40
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Kim JH, Jeong MH, Yun KH, Kim KH, Kang DK, Hong SN, Lim SY, Lee SH, Lee YS, Hong YJ, Park HW, Kim W, Ahn YK, Cho JG, Park JC, Kang JC. Myocardial protective effects of nicorandil during percutaneous coronary intervention in patients with unstable angina. Circ J 2005; 69:306-10. [PMID: 15731536 DOI: 10.1253/circj.69.306] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The purpose of the study was to prospectively evaluate the protective effect of nicorandil during percutaneous coronary intervention (PCI) in patients with unstable angina (UAP). METHODS AND RESULTS Two hundred patients (61+/-10 year-old, male 143) diagnosed with UAP at an emergency medical center were randomly assigned to 2 groups: intravenous isosorbide dinitrate, Group I (n=100), or intravenous nicorandil, Group II (n=100). PCI was performed 12-48 h after infusion of each agent. Serum concentrations of creatine kinase-MB (CK-MB), cardiac troponin T (cTnT), and I (cTnI) were measured before and 6, 12, 24 h after PCI. Patients with non-coronary chest pain, requiring emergency coronary angiogram, temporary pacemaker or glycoprotein IIb/IIIa receptor blocker were excluded. PCI was successfully performed in 96 patients (Group I=54, 61.7+/-8.2 years, 32 males; Group II=42, 60.4+/-11.7 years, 27 males). No significant differences in clinical or coronary angiographic characteristics were observed between the 2 groups. The concentration of CK-MB was elevated in 9 patients (17%) of Group I and 6 (14%) of Group II, cTnT in 16 (30%), 6 (14%) and cTnI in 25 (46%), 9 (21%) after PCI. Elevation of any troponin was less frequent in Group II [28/54 (52%) vs 10/42 (24%) patients, p=0.01]. Major adverse coronary events during the 6-month clinical follow-up occurred in 9 (17%) of Group I and 5 patients of Group II (12%, p=NS). Follow-up echocardiography revealed lower left ventricular ejection fraction in Group I than in Group II (65.4+/-7.2% vs 71.0+/-6.7%, p=0.03). CONCLUSION Nicorandil has a myocardial protective effect during PCI in patients with UAP.
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Affiliation(s)
- Ju Han Kim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwnagju, Korea
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41
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Varani E, Balducelli M, Vecchi G, Gatti C, Lucchi GR, Maresta A. Occurrence of Non-Q wave Myocardial Infarction Following Percutaneous Coronary Intervention in the Stent Era: Systematic Monitoring of the Three Markers of Myocardial Necrosis. J Interv Cardiol 2005; 18:243-8. [PMID: 16115152 DOI: 10.1111/j.1540-8183.2005.00042.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To compare the elevation of the three markers total creatine kinase (CK), CK-MB mass, and troponin I (TnI) and their relationship with clinical and procedural characteristics following percutaneous coronary intervention (PCI). METHODS We prospectively evaluated 385 patients consecutively undergoing successful PCI. The three markers were systematically measured before and at 6, 12, and 24 hours after PCI. Any increase above the upper normal limit (UNL) of any marker has been considered abnormal when basal values were normal, while a further increase was needed when basal values were altered. Patients with ongoing acute myocardial infarction were excluded from the analysis. RESULTS TnI was above UNL in 183 patients (51%); in 138 (38.5%) it was the only marker altered. CK-MB mass was elevated in 12.8% patients, more than 3x UNL in 5.5% and more than 5x UNL in 2.8%. In over one half of these patients, CK-MB values peaked at 12 hours following PCI. Total CK was above UNL in 23 patients only (6.4%) and more than twice UNL in 5 (1.4%). Only 1 patient out of the 5 with CK-MB mass more than 10x UNL had total CK higher than twice UNL. In our population, post-PCI elevation of myocardial necrosis markers correlate with the occurrence of minor procedural complications (observed overall in 7.8% cases; TnI and/or CK-MB > 1xUNL 96% vs 47.5%, P < 0.001) and the presence of higher complexity clinical and/or procedural features, such as multivessel disease, multivessel or multilesion PCI, multiple stenting and use of glycoprotein IIb/IIIa inhibitors. CONCLUSIONS The elevation of at least one biochemical marker of myocardial necrosis is frequent following successful PCI with routine stent implantation. CK-MB mass is the most practical marker, having optimal kinetic and peaking with the first 12-18 hours post-PCI. Definitive data on the prognostic role and the applicability for the diagnosis of myocardial infarction of minor elevation of CK-MB mass or isolated increase of TnI are lacking.
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Affiliation(s)
- Elisabetta Varani
- Department of Cardiology, Ospedale S. Maria delle Croci, Ravenna, Italy
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42
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Ramírez-Moreno A, Cardenal R, Pera C, Pagola C, Guzmán M, Vázquez E, Fajardo A, Lozano C, Solís J, Gassó M. Predictors and prognostic value of myocardial injury following stent implantation. Int J Cardiol 2004; 97:193-8. [PMID: 15458683 DOI: 10.1016/j.ijcard.2003.07.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2003] [Revised: 07/04/2003] [Accepted: 07/25/2003] [Indexed: 11/16/2022]
Abstract
BACKGROUND Troponin I concentrations are frequently elevated following percutaneous coronary intervention (PCI) even in procedures without complications and are considered, by some, as predictive of long-term morbidity and mortality. We assessed whether post-PCI troponin I concentrations bore any relationship to clinical, angiographic and in-laboratory minor adverse events indicative of myocardial injury and evaluated, in follow-up, whether these levels are useful as a predictive markers of adverse events. METHODS Patients (n=147) who were scheduled for PCI for stent placement were prospectively studied. In-laboratory events recorded were protracted chest pain, electrocardiographic changes, slow flows, dissections and lateral branch affectation. Troponin I and creatinine kinase MB fraction (CK-MB) mass were measured at baseline and post-procedure. Mean clinical follow-up was for 10.4+/-3.6 months. RESULTS During PCI, at least one adverse event occurred in 34% of patients and, in 38% of them, there was an elevation of troponin I as compared to 5.1% of those patients without any adverse event (relative risk=7.4; P<0.001). Elevation of troponin I concentrations occurred in 16.3% of all patients, 79.2% associated with an AE. CK-MB was elevated in 15.6% of patients. On multivariate analysis, protracted chest pain, lateral branch involvement and slow flow remained statistically significant in relation to post-procedure elevations of troponin I concentrations. Clinical follow-up showed a poorer prognosis in patients who had had elevated troponin I concentrations. CONCLUSIONS In-laboratory adverse event predict elevated post-procedure troponin I concentrations which are associated with myocardial injury. These elevations, in turn, predict poorer medium-term clinical outcomes.
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Affiliation(s)
- Antonio Ramírez-Moreno
- Servicio de Cardiología, Complejo Hospitalario Ciudad de Jaén, Avda Ejercito Español 10, 23007 Jaén, Spain.
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43
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Topol EJ. Invisible showers. Catheter Cardiovasc Interv 2004; 63:42-3. [PMID: 15343565 DOI: 10.1002/ccd.20131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Eric J Topol
- Cleveland Clinic Lerner College of Medicine, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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44
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Pasceri V, Patti G, Nusca A, Pristipino C, Richichi G, Di Sciascio G. Randomized Trial of Atorvastatin for Reduction of Myocardial Damage During Coronary Intervention. Circulation 2004; 110:674-8. [PMID: 15277322 DOI: 10.1161/01.cir.0000137828.06205.87] [Citation(s) in RCA: 367] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Small myocardial infarctions after percutaneous coronary intervention have been associated with higher risk of cardiac events during follow-up. Observational studies have suggested that statins may lower the risk of procedural myocardial injury. The aim of our study was to confirm this hypothesis in a randomized study.
Methods and Results—
One hundred fifty-three patients with chronic stable angina without previous statin treatment were enrolled in the study. Patients scheduled for elective coronary intervention were randomized to atorvastatin (40 mg/d, n=76) or placebo (n=77) 7 days before the procedure. Creatine kinase-MB, troponin I, and myoglobin levels were measured at baseline and at 8 and 24 hours after the procedure. Detection of markers of myocardial injury above the upper normal limit was significantly lower in the statin group versus the placebo group: 12% versus 35% for creatine kinase-MB (
P
=0.001), 20% versus 48% for troponin I (
P
=0.0004), and 22% versus 51% for myoglobin (
P
=0.0005). Myocardial infarction by creatine kinase-MB determination was detected after coronary intervention in 5% of patients in the statin group and in 18% of those in the placebo group (
P
=0.025). Postprocedural peak levels of creatine kinase-MB (2.9±3 versus 7.5±18 ng/mL,
P
=0.007), troponin I (0.09±0.2 versus 0.47±1.3 ng/mL,
P
=0.0008), and myoglobin (58±36 versus 81±49 ng/mL,
P
=0.0002) were also significantly lower in the statin than in the placebo group.
Conclusions—
Pretreatment with atorvastatin 40 mg/d for 7 days significantly reduces procedural myocardial injury in elective coronary intervention. These results may influence practice patterns with regard to adjuvant pharmacological therapy before percutaneous revascularization.
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Affiliation(s)
- Vincenzo Pasceri
- Interventional Cardiology Unit, San Filippo Neri Hospital, Rome, Italy
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45
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Nageh T, Sherwood RA, Harris BM, Byrne JA, Thomas MR. Cardiac troponin T and I and creatine kinase-MB as markers of myocardial injury and predictors of outcome following percutaneous coronary intervention. Int J Cardiol 2003; 92:285-93. [PMID: 14659867 DOI: 10.1016/s0167-5273(03)00105-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIMS This study was performed to determine the most sensitive biochemical marker for the detection of cardiac myocyte damage potentially sustained during percutaneous coronary intervention (PCI) and to assess whether such a marker can be used to identify patients at increased risk of poor subsequent clinical outcome. METHODS AND RESULTS We studied 109 consecutive patients presenting with clinical stable and unstable angina and undergoing PCI at our institution. Blood was sampled for creatine kinase-MB (CK-MB), cardiac Troponin T (cTnT) and I (cTnI) immediately before and at 6, 14 and 24 h post-PCI. Five patients with raised cardiac markers pre-PCI were excluded from further analysis. The occurrence of major adverse cardiac events (MACE) was documented in-hospital, at 30 days and at long-term clinical follow up of up to 20 months. MACE occurred in 26/109 (24%) patients: death=1, QWMI=4, NQWMI=5, repeat PCI=16 (nine target vessel revascularisations and seven de-novo lesions), CABG=5. cTnI had the highest detection rate for myocardial damage, with 58 cTnI-positive patients, 38 cTnT-positive patients and 28 CK-MB-positive patients in the 24 h following PCI (Pearson's Chi square test, P<0.01). The type of interventional strategy per se was not significantly associated with post-procedural cardiac marker concentrations (Kruskal-Wallis ANOVA, P>0.05). There was a significant association between post-procedural cardiac marker concentrations of CK-MB, cTnT and cTnI and the occurrence of procedural angiographic complications (P=0.0003, 0.0002, 0.001, respectively). All three markers, at each sampling time point between 6 and 24 h post-PCI, showed a significant predictive relationship with MACE in-hospital and at long-term follow up (ROC curve AUC analysis, P<0.05). All three markers provided equally predictive information at each of the three post-procedural sampling time points between 6 and 24 h following PCI. All levels of cardiac marker elevation above the clinically discriminant cut-off values were significantly predictive of outcome at long-term follow up. CONCLUSIONS cTnI proved to be the most sensitive marker in detecting myocardial necrosis following PCI. CK-MB, cTnT and cTnI all provided similarly reliable prognostic information, with cTnT and cTnI being marginally superior in predicting MACE at follow up.
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Affiliation(s)
- Thuraia Nageh
- King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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46
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47
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Ghazzal Z, Ashfaq S, Morris DC, Douglas JS, Marshall JJ, King SB, Weintraub WS. Prognostic implication of creatine kinase release after elective percutaneous coronary intervention in the pre-IIb/IIIa antagonist era. Am Heart J 2003; 145:1006-12. [PMID: 12796756 DOI: 10.1016/s0002-8703(03)00095-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The significance of mild elevations in cardiac enzymes after an elective percutaneous coronary intervention (PCI) still remains controversial. We evaluated the significance of creatine phosphokinase level (CPK) elevations in a large cohort of patients who had undergone an elective PCI before the IIb/IIIa receptor antagonist era. METHODS All patients enrolled in the Emory databank from 1981 to 1996 who had an elective PCI were evaluated. We identified 15,637 patients who met our inclusion and exclusion criteria. Patients were divided into 4 groups on the basis of the magnitude of the CPK elevation noted in the post-PCI period: group I (CPK <250 mg/dL, n = 14,512); group II (CPK 250-500 mg/dL, n = 715); group III (CPK 500-750 mg/dL, n = 164); and group IV (CPK >750 mg/dL, n = 246). RESULTS CPK elevations were associated with a significant increase in the periprocedure angiographic complications. Angiographic complication rates were 14.6%, 30.5%, 40.2%, and 43.5% in groups I, II, III, and IV, respectively (P <.001). Long-term survival also correlated inversely with the magnitude of CPK elevations. The 10-year survival rates were 73%, 71%, 69%, and 55% in groups I, II, III, and IV, respectively (P <.0001). After multivariate analysis to correct for clinical factors, a CPK elevation of at least 3-times normal (group IV) was found to be an independent predictor of diminished 30-day and long-term survival (hazard ratio 1.84, 95% CI 1.41-2.41, P <.0001). Elevations in CPK <3-times normal (groups II and III) were not independently predictive of poor long-term survival. CONCLUSION A CPK level >3-times normal after an elective PCI is a strong independent predictor of poor long-term prognosis.
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Affiliation(s)
- Ziyad Ghazzal
- Andreas Gruentzig Cardiovascular Center of Emory University School of Medicine, Division of Cardiology, Atlanta, GA, USA.
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Islam MA, Blankenship JC, Balog C, Iliadis EA, Lincoff AM, Tcheng JE, Califf RM, Topol EJ. Effect of abciximab on angiographic complications during percutaneous coronary stenting in the Evaluation of Platelet IIb/IIIa Inhibition in Stenting Trial (EPISTENT). Am J Cardiol 2002; 90:916-21. [PMID: 12398954 DOI: 10.1016/s0002-9149(02)02653-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In the Evaluation of Platelet IIb/IIIa Inhibition in Stenting Trial (EPISTENT), abciximab reduced ischemic complications of stent implantation at 30 days and 6 months. The responsible mechanisms remain unclear. We sought to determine if abciximab decreases ischemic complications by decreasing the incidence of angiographic complications during coronary stenting. In EPISTENT, patients were randomized to stenting with abciximab (abciximab group), stenting with placebo (placebo group), or balloon angioplasty with abciximab. Angiographic complications (including major or minor dissection, distal embolization, thrombus postprocedure, side branch or other vessel occlusion, residual stenosis >50%, transient coronary occlusion, and Thrombolysis In Myocardial Infarction final flow <3) were recorded prospectively. Creatine kinase (CK)-MB enzyme levels after intervention were measured at 6-hour intervals. We analyzed angiographic complications and CK-MB elevations in the abciximab group (n = 784) and the placebo group (n = 803). Angiographic complications were 29% less frequent in the abciximab group compared with the placebo group (17.0% vs 23.8%; p = 0.001). In patients with angiographic complications, there was a nonsignificant reduction in the incidence of CK-MB elevation >3 times normal with abciximab therapy (19.7% vs 24.5% in placebo group; p = 0.314). Abciximab (compared with placebo) significantly reduced the incidence of CK-MB elevation >3 times normal in those without any angiographic complications (6.5% vs 10.7%; p = 0.007). In summary, abciximab (compared with placebo) significantly reduced angiographic complications during coronary stenting. Abciximab also prevented CK-MB elevations in patients without angiographic complications.
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49
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Herrmann J, Von Birgelen C, Haude M, Volbracht L, Malyar N, Eggebrecht H, Konorza TFM, Baumgart D, Erbel R. Prognostic implication of cardiac troponin T increase following stent implantation. Heart 2002; 87:549-53. [PMID: 12010937 PMCID: PMC1767127 DOI: 10.1136/heart.87.6.549] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To identify the incidence and clinical significance of myocardial injury following elective stent implantation. DESIGN Prospective clinical study with 278 consecutive patients undergoing stenting of de novo coronary or saphenous vein graft lesions. Incidence of periprocedural myocardial injury was assessed by analysis of 12 lead ECG, creatine kinase (CK; upper limit of normal (ULN) 70 IU/l for women, 80 IU/l for men), and cardiac troponin T (cTnT; point of care test; threshold 0.1 ng/ml) before and 6, 12, and 24 hours after the intervention. Major adverse cardiac events (MACE: acute myocardial infarction, bypass surgery, and cardiac death) were recorded during clinical follow up (mean (SD) 7.8 (5.3) months). RESULTS Following elective stenting, the rate of a positive cTnT status was 17.3%, the rate of CK increase of 1-3x ULN 14.7%, the rate of CK increase of > 3x ULN 1.4%, and the rate of Q wave myocardial infarction 0.4%. Cardiac mortality during follow up was higher in patients with postprocedurally increased CK (7.1% v 1.3%, p = 0.01, log rank) and cTnT (9.1% v 0.9%, p < 0.001, log rank). In addition, postprocedurally increased cTnT was associated with a higher overall incidence of MACE (13.1% v 4.0%, p < 0.01, log rank) and was identified as an independent factor for MACE during follow up (hazard ratio 3.27, 95% confidence interval 1.14 to 9.41, p = 0.028). CONCLUSIONS Following elective stent implantation, a positive cTnT status identified patients at risk of a worse long term outcome. Treatment strategies have to be developed that lead to prognostic improvement by reducing periprocedural myocardial injury.
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Affiliation(s)
- J Herrmann
- Department of Cardiology, University Hospital Essen, Essen, Germany
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50
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Costa MA, Carere RG, Lichtenstein SV, Foley DP, de Valk V, Lindenboom W, Roose PC, van Geldorp TR, Macaya C, Castanon JL, Fernandez-Avilèz F, Gonzáles JH, Heyer G, Unger F, Serruys PW. Incidence, predictors, and significance of abnormal cardiac enzyme rise in patients treated with bypass surgery in the arterial revascularization therapies study (ARTS). Circulation 2001; 104:2689-93. [PMID: 11723020 DOI: 10.1161/hc4701.099789] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although it has been suggested that elevation of CK-MB after percutaneous coronary intervention is associated with adverse clinical outcomes, limited data are available in the setting of coronary bypass grafting. The aim of the present study was to determine the incidence, predictors, and prognostic significance of CK-MB elevation following multivessel coronary bypass grafting (CABG). METHODS AND RESULTS The population comprises 496 patients with multivessel coronary disease assigned to CABG in the Arterial Revascularization Therapies Study (ARTS). CK-MB was prospectively measured at 6, 12, and 18 hours after the procedure. Thirty-day and 1-year clinical follow-up were performed. Abnormal CK-MB elevation occurred in 61.9% of the patients. Patients with increased cardiac-enzyme levels after CABG were at increased risk of both death and repeat myocardial infarction within the first 30 days (P=0.001). CK-MB elevation was also independently related to late adverse outcome (P=0.009, OR=0.64). CONCLUSIONS Increased concentrations of CK-MB, which are often dismissed as inconsequential in the setting of multivessel CABG, appear to occur very frequently and are associated with a significant increase in both repeat myocardial infarction and death beyond the immediate perioperative period.
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Affiliation(s)
- M A Costa
- University Hospital Dijkzigt, Thoraxcentrum, Rotterdam, the Netherlands
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