Peri-procedural myocardial injury: 2005 update

Mechanical Support Strategies for High-Risk Procedures in the Invasive Cardiac Catheterization Laboratory: A State-of-the-Art Review

Thanks to advancements in percutaneous cardiac interventions, an expanding patient population now qualifies for treatment through percutaneous endovascular procedures. High-risk interventions far exceed coronary interventions and include transcatheter aortic valve replacement, endovascular management of acute pulmonary embolism and ventricular tachycardia ablation. Given the frequent impairment of ventricular function in these patients, frequently deteriorating during percutaneous interventions, it is hypothesized that mechanical ventricular support may improve periprocedural survival and subsequently patient outcome. In this narrative review, we aimed to provide the relevant evidence found for the clinical use of percutaneous mechanical circulatory support (pMCS). We searched the Pubmed database for articles related to pMCS and to pMCS and invasive cath lab procedures. The articles and their references were evaluated for relevance. We provide an overview of the clinically relevant evidence for intra-aortic balloon pump, Impella, TandemHeart and ECMO and their role as pMCS in high-risk percutaneous coronary intervention, transcatheter valvular procedures, ablations and high-risk pulmonary embolism. We found that the right choice of periprocedural pMCS could provide a solution for the hemodynamic challenges during these procedures. However, to enhance the understanding of the safety and effectiveness of pMCS devices in an often high-risk population, more randomized research is needed.

Interventions in chronic total occlusions with bifurcation lesions: incidence, treatment, and in-hospital outcome

INTRODUCTION AND OBJECTIVES

Coronary chronic total occlusions (CTO) involving bifurcation lesions are a challenging lesion subset that is understudied in the literature. This study analyzed the incidence, procedural strategy, in-hospital outcomes and complications of percutaneous coronary interventions (PCI) for bifurcation-CTO (BIF-CTO).

METHODS

We assessed data from 607 consecutive CTO patients treated at the Institut Cardiovasculaire Paris Sud (ICPS), Massy, France between January 2015 and February 2020. Procedural strategy, in-hospital outcomes and complication rates were compared between 2 patient subgroups: BIF-CTO (n=245=and non-BIF-CTO (n=362).

RESULTS

The mean patient age was 63.2±10.6 years; 79.6% were men. Bifurcation lesions were involved in 40.4% of the procedures. Overall lesion complexity was high (mean J-CTO score 2.30±1.16, mean PROGRESS-CTO score 1.37±0.94). The preferred bifurcation treatment strategy was a provisional approach (93.5%). BIF-CTO patients presented with higher lesion complexity, as assessed by J-CTO score (2.42±1.02 vs 2.21±1.23 in the non-BIF-CTO patients, P=.025) and PROGRESS-CTO score (1.60±0.95 vs 1.22±0.90 in the non-BIF-CTO patients, P<.001). Procedural success was 78.9% and was not affected by the presence of bifurcation lesions (80.4% in the BIF-CTO group, 77.8% in the non-BIF-CTO-CTO group, P=.447) or the bifurcation site (proximal BIF-CTO 76.9%, mid-BIF-CTO 83.8%, distal BIF-CTO 85%, P=.204). Complication rates were similar in BIF-CTO and non-BIF-CTO.

CONCLUSIONS

The incidence of bifurcation lesions is high in contemporary CTO PCI. Patients with BIF-CTO present with higher lesion complexity, with no impact on procedural success or complication rates when the predominant strategy is provisional stenting.

Abnormal release of cardiac biomarkers in the presence of myocardial oedema evaluated by cardiac magnetic resonance after uncomplicated revascularization procedures

AIMS

To analyse the association of myocardial oedema (ME), observed as high T2 signal intensity (HT2) in cardiac magnetic resonance imaging, with the release of cardiac biomarkers, ventricular ejection, and clinical outcomes after revascularization.

METHODS AND RESULTS

Patients with stable coronary artery disease with the indication for revascularization were included. Biomarker levels [troponin I (cTnI) and creatine kinase MB (CK-MB)] and T2-weighted and late gadolinium enhancement (LGE) images were obtained before and after the percutaneous or surgical revascularization procedures. The association of HT2 with the levels of biomarkers, with and without LGE, evolution of left ventricular ejection fraction (LVEF), and 5-year clinical outcomes were assessed. A total of 196 patients were divided into 2 groups: Group 1 (HT2, 40) and Group 2 (no HT2, 156). Both peak cTnI (8.9 and 1.6 ng/mL) and peak CK-MB values (44.7 and 12.1 ng/mL) were significantly higher in Group 1. Based on the presence of new LGE, patients were stratified into Groups A (no HT2/LGE, 149), B (HT2, 9), C (LGE, 7), and D (both HT2/LGE, 31). The peak cTnI and CK-MB values were 1.5 and 12.0, 5.4 and 44.7, 5.0 and 18.3, and 9.8 and 42.8 ng/mL in Groups A, B, C, and D, respectively, and were significantly different. The average LVEF decreased by 4.4% in Group 1 and increased by 2.2% in Group 2 (P = 0.057).

CONCLUSION

ME after revascularization procedures was associated with increased release of cardiac necrosis biomarkers, and a trend towards a difference in LVEF, indicating a role of ME in cardiac injury after interventions.

Prognostic Impact of Atrial Fibrillation in Patients with Heavily Calcified Coronary Artery Disease Receiving Rotational Atherectomy

Background and Objectives: Although both rotational atherectomy (RA) and atrial fibrillation (AF) have a high thrombotic risk, there have been no previous studies on the prognostic impact of AF in patients who undergo percutaneous coronary intervention (PCI) using RA. Thus, the aim of the present study was to determine the prognostic impact of AF in patients undergoing PCI using RA. Materials and Methods: A total of 540 patients who received PCI using RA were enrolled between January 2010 and October 2019. Patients were divided into AF and sinus rhythm groups according to the presence of AF. The primary endpoint was net adverse clinical events (NACEs) defined as a composite outcome of all-cause death, myocardial infarction, target vessel revascularization, cerebrovascular accident, or total bleeding. Results: Although in-hospital adverse events showed no difference between those with AF and those without AF (in-hospital events, 54 (11.0%) vs. 6 (12.2%), p = 0.791), AF was strongly associated with an increased risk of NACE at 3 years (NACE: hazard ratio, 1.880; 95% confidence interval, 1.096-3.227; p = 0.022). Conclusions: AF in patients who underwent PCI using RA was strongly associated with poor clinical outcomes. Thus, more attention should be paid to thrombotic and bleeding risks.

Activities of daily living predict periprocedural myocardial infarction and injury following percutaneous coronary intervention: a cross-sectional study

BACKGROUND

In recent years, there has been growing interest in exploring the relationship between activities of daily living (ADL) and cardiovascular diseases. This retrospective cross-sectional study aimed to investigate the association of ADL measured by Barthel index (BI) with periprocedural myocardial infarction (PMI) and injury following percutaneous coronary intervention (PCI).

METHODS

Enrolled patients were stratified into impaired and unimpaired ADL groups according to their BI scores. Logistic regressions were conducted to explore the association of ADL on admission with periprocedural myocardial injury and infarction. Restricted cubic spline (RCS) curve and subgroup analysis were also performed.

RESULTS

Totally, 16.4% of patients suffered from PMI; the mean age was 65.8 ± 10.4 years old. RCS analysis showed that the morbidity of periprocedural myocardial infarction and injury showed a downward tendency with increasing BI scores. Multivariable logistic regression analysis demonstrated that impaired ADL was an independent risk factor for periprocedural myocardial infarction (OR = 1.190, 95% CI [1.041, 1.360], P = 0.011) and injury (OR = 1.131, 95% CI [1.017, 1.257], P = 0.023). Subgroup analysis showed that the association between ADL and PMI was founded in several subgroups, while the association between ADL and periprocedural myocardial injury was founded only in BMI ≥ 24 kg/m2 subgroup.

CONCLUSION

Impaired ADL at hospital admission was an independent risk factor for periprocedural myocardial infarction and injury among patients following PCI.

Impact of coronary stenting on top of medical therapy and of inclusion of periprocedural infarctions on hard composite endpoints in patients with chronic coronary syndromes: a meta-analysis of randomized controlled trials

INTRODUCTION

Composite endpoints are pivotal when assessing rare outcomes over relatively short follow-ups. Most randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with stent implantation to optimal medical therapy (OMT) in chronic coronary syndromes (CCS) patients included both hard and soft outcomes in their primary endpoint, with periprocedural myocardial infarctions (MIs) systematically allocated to the PCI arm. We meta-analyzed the above RCTs for composite hard endpoints, with and without periprocedural MIs.

EVIDENCE ACQUISITION

This study is registered in PROSPERO CRD42020166754 and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Collaboration reporting. Patients had inducible ischemia, no left main disease nor severe left ventricular dysfunction.

EVIDENCE SYNTHESIS

Six RCTs involving 10,751 patients followed for a mean of 4.4 years were included. PCI+OMT versus OMT alone was associated with no difference in the two co-primary composite endpoints of all-cause death/MI/stroke and cardiovascular death/MI including all-MIs (IRR 0.99; 95% CI 0.90-1.08 and IRR 0.95; 95% CI 0.83-1.08 respectively). After inclusion of spontaneous rather than all-MIs (i.e., excluding periprocedural MIs), the odds showed benefit of PCI+OMT for both co-primary endpoints (IRR 0.88; 95% CI 0.80-0.97, P<0.01 and IRR 0.81; 95% CI 0.69-0.95, P=0.01 respectively) with numbers needed to treat of 42 in both cases.

CONCLUSIONS

Among CCS patients with inducible myocardial ischemia without severely reduced ejection fraction or left main disease, adding PCI to OMT reduces hard composite outcomes only after exclusion of periprocedural MIs. Continued efforts to define periprocedural MIs reproducibly, to assess their prognostic relevance and to prevent them are warranted.

Association of serum laboratory parameters with periprocedural myocardial infarction after a primary percutaneous coronary intervention

BACKGROUND

Periprocedural myocardial infarction (PMI) is one of the mortality-related complications of percutaneous coronary intervention (PCI) and significantly affects short- and long-term adverse outcomes and immediate cardiovascular events. Our present study aimed to evaluate the association of preprocedural serum laboratory parameters and PMI in patients who received primary PCI and attempted to provide detailed data on the predictors of PCI-related PMI.

METHODS

A total of 1184 consecutive coronary artery disease (CAD) patients who received primary and elective PCI between July 2015 and June 2017 were included and divided into control group and PMI group. The data of serum laboratory parameters were collected from the electronic database of Meizhou People's Hospital.

RESULTS

The results indicated that preprocedural fasting blood glucose were higher in PMI group compared with the control group (p < .001). Patients with prior hyperlipidemia were more likely to have experienced PCI-related PMI (p = .018) and the preprocedural level of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, apolipoprotein B (Apo B), and LDL-C/high density lipoprotein cholesterol (HDL-C) were significantly enhanced in PMI group (p < .001). Multivariate regression analysis revealed that preprocedural fasting blood glucose > 6.11 mmol/L (p < .001, OR = 1.949, 95% CI: 1.444-2.630) and LDL-C levels ≥130 mg/dL (p = .005, OR = 1.941, 95% CI: 1.217-3.098) independently predicted PCI-related PMI.

CONCLUSION

Our results indicated preprocedural fasting blood glucose >6.11 mmol/L and LDL-C levels ≥130 mg/dL may be useful predictors for PCI-related PMI. The study may provide a detailed data on the predictors of PCI-related PMI.

Association Between Contrast Volume-to-Creatinine Clearance Ratio and the Risk of Perioperative Myocardial Infarction After Elective Percutaneous Coronary Intervention

Although the use of iodinated contrast for percutaneous coronary intervention (PCI) has known toxicity issues, the association between the contrast volume-to-creatinine clearance (V/CrCl) ratio and perioperative myocardial infarction (PMI) is unclear. The present study is aimed to investigate the predictive value of V/CrCl ratio on the incidence of PMI, and to determine a relatively safe contrast media V/CrCl ratio cut-off value to prevent PMI undergoing elective PCI. The V/CrCl ratio were obtained from 5970 patients undergoing elective PCI for single-vessel lesions. Cardiac troponin I (cTnI) were measured at baseline, 8, 16, and 24 hours after PCI. PMI was defined as postprocedural > 5 × upper limit of normal. Receiver operating characteristic (ROC) curves were performed to identify the optimal sensitivity for the V/CrCl range. Multivariate regression model were used to assess the association between V/CrCl ratios and PMI. Eight hundred and ninety-seven patients (15.0%) developed PMI. There was a significant association between higher V/CrCl ratio and the development of PMI (P < 0.001 for the trend). ROC curve analysis indicated that V/CrCl ratio of 2.05 was a discriminator for PMI (area under the curve = 0.674). After adjusting for other potential risk factors, V/CrCl ratio > 2.05 remained significant associated with PMI (odds ratio, 1.921; 95% confidence interval, 1.311-2.815; P = 0.001). The finding of this study suggests the importance of minimizing the contrast media dose to avoid PMI development. Use of a contrast media dose based on renal function with a V/CrCl value < 2.05 might be valuable in preventing PMI.

Gensini score values for predicting periprocedural myocardial infarction: An observational study analysis

The Gensini score (GS) is a convenient, powerful tool for assessing the severity and complexity of coronary artery diseases. Our research investigated the relationship between the GS and periprocedural myocardial infarction (PMI). We recruited 4949 patients (3366 men, 1583 women; mean age 66.45 ± 10.09 years) with a single coronary artery revascularization. Based on the tertile of the GS 20 and 36, the population was divided into 3 groups: Low Group (0 < GS ≤ 20, N = 1809); Intermediate Group (20 < GS ≤ 36, N = 1579); High Group (GS > 36, N = 1561). PMI3 represented the endpoint for cTnI > 3-fold upper reference limit, while PMI5 represented the endpoint for cTnI > 5-fold upper reference limit. The incidence of PMI of High Group was statistically higher than that of Intermediate Group (P < .05), while that of Intermediate Group was statistically higher than Low Group (P < .05). With the adjustment of some general variables, GS was an independent significantly predictor for PMI3 (β = 0.006, P < .05) and PMI5 (β = 0.007, P < .05). Following receiver operating characteristic curve analysis, the optimal cut-off value to predict PMI are 22.5 for PMI3 and 27 for PMI5. The GS was an independent predictor of PMI in the single-coronary revascularization population. Additionally, the 22.5 of GS was the optimal cut-off value for determining the presence of PMI3, while the 27 of GS for PMI5.

Efficacy of Shexiang Tongxin Dropping Pills in a Swine Model of Coronary Slow Flow

Objective: Preliminary clinical studies have confirmed that Shexiang Tongxin dropping pills (STDPs) could improve angina pectoris and attenuate vascular endothelial dysfunction in patients with slow coronary flow, but the underlying mechanism is not fully unclear. We aimed to investigate the impact of STDP in a swine model of coronary slow flow (SF) and related mechanisms.

Methods: SF was induced by coronary injection of 40μm microspheres, and pigs were randomly divided into the SF group and SF plus STDP group. Pigs in the STDP group received sublingual STDP for 10 min, followed by 1 g STDP oral administration daily for 6 days. Coronary angiography was performed, the TIMI frame count (TFC) was determined, and hemodynamic measurements were performed before, at 30 min, and 7 days post-SF. Serum levels of total NO, NOS, ET-1, C-TNI, and BNP were measured. Myocardial expressions of TNF and IL-6, eNOS, VEGF, CD31, and α-SMA were analyzed by immunohistochemistry and Western blotting.

Results: Compared to the SF group, LVEF and TFC were significantly improved at 7 days post-SF in the STDP group. The serum ET-1 level was significantly reduced at 7 days, and NO and NOS levels were significantly higher in the STDP group. Seven days post-SF, myocardial TNF and IL-6 expressions were significantly downregulated, while the expressions of eNOS and VEGF, CD31, and ɑ-SMA were significantly upregulated in the STDP group.

Conclusion: Our results showed that STDP improved cardiac function and coronary flow, possibly through reducing inflammatory responses and upregulating myocardial eNOS and VEGF, CD31, and the ɑ-SMA expression.

Coenzyme Q10 Reduces Infarct Size in Animal Models of Myocardial Ischemia-Reperfusion Injury: A Meta-Analysis and Summary of Underlying Mechanisms

Objective

Effective interventions that might limit myocardial ischemia-reperfusion (I/R) injury are still lacking. Coenzyme Q₁₀ (CoQ₁₀) may exert cardioprotective actions that reduce myocardial I/R injury. We conducted this meta-analysis to assess the potential cardioprotective effect of CoQ₁₀ in animal models of myocardial I/R injury.

Methods

We searched PubMed and Embase databases from inception to February 2022 to identify animal studies that compared the effect of CoQ₁₀ with vehicle treatment or no treatment on myocardial infarct size in models of myocardial I/R injury. Means and standard deviations of the infarct size measurements were pooled as the weighted mean difference with 95% confidence interval (CI) using the random-effects model. Subgroup analyses were also conducted according to animals' species, models' type, and reperfusion time.

Results

Six animal studies (4 in vivo and 2 ex vivo) with 116 animals were included. Pooled analysis suggested that CoQ₁₀ significantly reduced myocardial infarct size by −11.36% (95% CI: −16.82, −5.90, p < 0.0001, I² = 94%) compared with the control group. The significance of the pooled effect estimate was maintained in rats, Hartley guinea pigs, and Yorkshire pigs. However, it became insignificant in the subgroup of rabbits −5.29% (95% CI: −27.83, 17.26; I² = 87%). Furthermore, CoQ₁₀ significantly reduced the myocardial infarct size regardless of model type (either in vivo or ex vivo) and reperfusion time (either ≤ 4 h or >4 h).

Conclusion

Coenzyme Q₁₀ significantly decreased myocardial infarct size by 11.36% compared with the control group in animal models of myocardial I/R injury. This beneficial action was retained regardless of model type and reperfusion time.

Rosuvastatin Alleviates Coronary Microembolization-Induced Cardiac Injury by Suppressing Nox2-Induced ROS Overproduction and Myocardial Apoptosis

To explore the mechanism by which rosuvastatin prevents coronary microembolism (CME)-induced cardiac injury and cardiomyocyte apoptosis. Animal and cell models of CME were established and treated with different doses of rosuvastatin. Echocardiography and histological staining were applied to assess left ventricular function and cardiac injury. Masson trichrome staining was used to evaluate fibrin deposition in the myocardium. The activity of lactate dehydrogenase (LDH) in serum and cell culture supernatant was detected. TUNEL staining and flow cytometry were used to evaluate apoptosis in myocardium and cardiomyocytes, respectively. The activity of ROS was revealed by DHE staining. The expression levels of Nox2, cleaved caspase-3, cytochrome C, p53, Bax and Bcl-2 were also detected. Rosuvastatin pretreatment improved the left ventricular function of CME mice and reduced inflammatory cell infiltration and fibrin deposition in the myocardium. Rosuvastatin reduced the production of ROS by inhibiting the expression of Nox2. Rosuvastatin also downregulated pro-apoptotic proteins cleaved caspase-3, cytochrome C, p53 and Bax, and upregulated anti-apoptotic Bcl-2. Rosuvastatin mitigates CME-induced cardiac injury by inhibiting Nox2-induced ROS overproduction and alleviating p53/Bax/Bcl-2-dependent cardiomyocyte apoptosis.

Effects of bilirubin on perioperative myocardial infarction and its long-term prognosis in patients undergoing percutaneous coronary intervention

BACKGROUND

Although bilirubin is known to be an antioxidant, any relationship with coronary heart disease remains controversial. To the best of our knowledge, no previous study has investigated the association between bilirubin and perioperative myocardial infarction (PMI), including its long-term prognosis.

AIM

To investigate the impact of bilirubin levels on PMI in patients undergoing percutaneous coronary intervention (PCI), and long-term prognosis in post-PMI patients.

METHODS

Between January 2014 and September 2018, 10236 patients undergoing elective PCI were enrolled in the present study. Total bilirubin (TB) and cardiac troponin I (cTnI) levels were measured prior to PCI and cTnI at further time-points, 8, 16 and 24 h after PCI. Participants were stratified by pre-PCI TB levels and divided into three groups: < 10.2; 10.2-14.4 and > 14.4 μmol/L. PMI was defined as producing a post-procedural cTnI level of > 5 × upper limit of normal (ULN) with normal baseline cTnI. Major adverse cardiovascular events (MACEs) included cardiac death, MI, stroke and revascularization during a maximum 5-year follow-up.

RESULTS

PMI was detected in 526 (15.3%), 431 (12.7%) and 424 (12.5%) of patients with pre-PCI TB levels of < 10.2, 10.2-14.4 and > 14.4 μmol/L (P = 0.001), respectively. Multivariate logistical analysis indicated that patients with TB 10.2-14.4 and > 14.4 μmol/L had a lower incidence of PMI [TB 10.2-14.4 μmol/L: Odds ratio (OR): 0.854; 95% confidence interval (CI): 0.739-0.987; P = 0.032; TB > 14.4 μmol/L: OR: 0.846; 95%CI: 0.735-0.975; P = 0.021] compared with patients with TB < 10.2 μmol/L. Construction of a Kaplan-Meier curve demonstrated a higher MACE-free survival time for patients with higher TB than for those with lower TB (log-rank P = 0.022). After adjustment for cardiovascular risk factors and angiographic characteristics, multivariate Cox analysis showed that a TB level > 14.4 μmol/L was associated with a reduced risk of MACEs compared with a TB level < 10.2 μmol/L (hazard ratio 0. 667; 95%CI: 0.485-0.918; P = 0.013).

CONCLUSION

Bilirubin was a protective factor in PMI prediction. For post-PMI patients, elevated bilirubin levels were independently associated with a reduced risk of MACEs during long-term follow-up.

Predictors and clinical significance of periprocedural myocardial infarction following rotational atherectomy

OBJECTIVES

To investigate the potential predictors and clinical significance of periprocedural myocardial infarction (PMI), as defined by the latest Fourth Universal Definition of Myocardial Infarction (2018), following rotational atherectomy (RA).

BACKGROUND

PMI is not uncommon in patients undergoing RA, although the predictors and prognostic impact are unknown.

METHODS

Data from 229 consecutive patients who had undergone RA before drug-eluting stent (DES) implantation in a single center were analyzed. Patients' demographic information, clinical, angiographic, and procedural characteristics, and 1-year follow-up outcomes were collected retrospectively.

RESULTS

The overall incidence of PMI in patients undergoing RA was 48.5%. Age (adjusted odds ratio [OR]: 1.024, 95% confidence interval [CI]: 1.001-1.047, p = 0.043) and ejection fraction (adjusted OR: 0.977, 95% CI: 0.962-0.993, p = 0.004) were independent predictors of PMI in RA, although PMI was not associated with an increased risk of major adverse cardiovascular and cerebrovascular events (MACCEs) at the 1-year follow-up in patients undergoing RA.

CONCLUSION

Age and ejection fraction were independently associated with an elevated risk of PMI in patients undergoing RA. However, post-RA microinfarcts were not associated with an increased risk of MACCEs over the short-term follow-up period.

A fresh look at coronary microembolization

Mechanical stress from haemodynamic perturbations or interventional manipulation of epicardial coronary atherosclerotic plaques with inflammatory destabilization can release particulate debris, thrombotic material and soluble substances into the coronary circulation. The physical material obstructs the coronary microcirculation, whereas the soluble substances induce endothelial dysfunction and facilitate vasoconstriction. Coronary microvascular obstruction and dysfunction result in patchy microinfarcts accompanied by an inflammatory reaction, both of which contribute to progressive myocardial contractile dysfunction. In clinical studies, the benefit of protection devices to retrieve atherothrombotic debris during percutaneous coronary interventions has been modest, and the treatment of microembolization has mostly relied on antiplatelet and vasodilator agents. The past 25 years have witnessed a relative proportional increase in non-ST-segment elevation myocardial infarction in the presentation of acute coronary syndromes. An associated increase in the incidence of plaque erosion rather than rupture has also been recognized as a key mechanism in the past decade. We propose that coronary microembolization is a decisive link between plaque erosion at the culprit lesion and the manifestation of non-ST-segment elevation myocardial infarction. In this Review, we characterize the features and mechanisms of coronary microembolization and discuss the clinical trials of drugs and devices for prevention and treatment.

Association between the magnitude of periprocedural myocardial injury and prognosis in patients undergoing elective percutaneous coronary intervention

AIMS

This study aimed to investigate the prognostic implications of increased post-procedural cardiac troponin levels in patients undergoing elective percutaneous coronary intervention (PCI) and to define the threshold of prognostically relevant periprocedural myocardial injury (PMI).

METHODS AND RESULTS

A total of 3249 patients with normal baseline troponin levels referred for elective PCI were enrolled and followed up for a median period of 20 months. The primary endpoint was major adverse cardiovascular events (MACEs) comprising all-cause death, myocardial injury (MI), and ischaemic stroke. Post-PCI high-sensitivity cardiac troponin T (hs-cTnT) >99% upper reference limit (URL) occurred in 78.3% of the patients and did not increase the risk of MACEs [adjusted hazard ratio (adHR) 1.00, 95% confidence interval (CI) 0.58-1.74, P = 0.990], nor did 'major PMI', defined as post-PCI hs-cTnT >5× URL (adHR 1.30, 95% CI 0.76-2.23, P = 0.340). Post-PCI troponin >8× URL, with an incidence of 15.2%, started to show an association with a higher risk of MACEs (adHR 1.89, 95% CI 1.06-3.37, P = 0.032), mainly driven by myocardial infarction (adHR 2.38, 95% CI 1.05-5.38, P = 0.037) and ischaemic stroke (adHR 3.35, 95% CI 1.17-9.64, P = 0.025).

CONCLUSION

In patients with normal baseline troponin values undergoing elective PCI, PMI defined as hs-cTnT >8× URL after PCI was more appropriate for identifying patients with an increased risk of MACEs, which may help guide clinical practice in this population.

Utility of near-infrared spectroscopy to detect the extent of lipid core plaque leading to periprocedural myocardial infarction

OBJECTIVES

The aim of this study was to investigate whether lipid core plaque (LCP) in the entire stented segment detected by near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) could predict procedural myocardial infarction (PMI) in patients undergoing percutaneous coronary artery intervention (PCI).

BACKGROUND

NIRS-IVUS can identify LCP, described as high lipid core burden index (LCBI). Previously, the highest LCBI contained only in the 4-mm segment (maxLCBI_4mm ) was reported to predict PMI.

METHODS

Patients who underwent NIRS-IVUS examination during PCI for coronary artery disease at Chiba University Hospital were included. The extent of LCP in the stented segment derived from NIRS-IVUS analysis was presented as LCBI, maxLCBI_4mm , and LCP area index (LAI), reflecting the total amount of LCP in the entire stented segment calculated as LCBI×lesion length. PMI was defined as an elevation of creatine kinase MB > 3 times upper reference level (URL), and periprocedural myocardial injury (PMInj) was defined as an elevation of troponin I>5 times URL within 12 to 24 h after PCI.

RESULTS

Out of 141 enrolled patients, PMI occurred in 20 (14.2%) and PMInj occurred in 62 (44.0%) patients. Receiver-operating characteristic curve analysis revealed LAI was the strongest predictor for both PMI and PMInj (area under curve 0.771, p < 0.001, and 0.717, p < 0.001, respectively). Multiple logistic regression analysis determined high LAI value as the independent predictor of both PMI and PMInj.

CONCLUSIONS

Greater extent of LCP in the entire stented segment detected by NIRS-IVUS was significantly associated with PMI as well as PMInj in patients undergoing PCI.

Identification of important genes related to ferroptosis and hypoxia in acute myocardial infarction based on WGCNA

Acute myocardial infarction (AMI) tends to cause severe heart failure and the population suffering from AMI gradually become younger. This study aims to determine the key genes associated with AMI, ferroptosis and hypoxia that could serve as novel biomarkers for AMI. There were 522 up-regulated genes and 119 down-regulated genes in GSE4648. Based on the expression of ferroptosis-related genes (FRGs) and hypoxia-related genes, the ferroptosis Z-score and the hypoxia Z-score calculated by ssGSEA were significantly higher in the infarcted area of AMI mice than in the control group, and there was a positive correlation between ferroptosis and hypoxia Z-score. 6 modules were obtained by Weighted Gene Co-Expression Network Analysis (WGCNA), and 2 key modules and 66 key genes were screened out. Genes in the key modules were found mainly related to ERK1 and ERK2 cascade, TNF signaling pathway, and MAPK signaling pathway through Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. Protein-protein interaction (PPI) network analysis was performed on the key genes and 10 hub genes (Atf3, Ptgs2, Cxcl1, Socs3, Hspa1b, Selp, Cxcl2, Il1b, Myd88, and S100a8) were obtained using STRING and Cytohubba. The expression of 9 hub genes except Cxcl1 was consistent in GSE4648 and GSE775. The transcription factors (TFs)-hub genes interaction network was constructed and 48 TFs were obtained using TRRUST. Finally, it was verified through the animal experiment that these hub genes were up-regulated in AMI mice myocardial tissues. This study offers new ideas for the diagnosis and treatment of AMI.

Association of peri-procedural myocardial infarction with mortality after stenting true coronary bifurcation lesions: A pooled individual participant data analysis from four randomized controlled trials

BACKGROUND

Five definitions of peri-procedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) are used in clinical trials; their clinical relevance in coronary bifurcation stenting remains unclear.

OBJECTIVES

To understand the correlation between PMI and mortality in bifurcation lesions from the DKCRUSH studies.

METHODS

PMI was defined using serum creatine kinase-myocardial band (CK-MB) values within 48 h of PCI according to the SYNTAX, Fourth Universal Definition of MI (4th UDMI), ISCHEMIA, SCAI, and EXCEL definitions. Overall, 1300 patients with both CK and CK-MB measurements pre- and post-stenting were evaluated. The association of each PMI type and all-cause death or cardiac death at a median of 5.58 years of follow-up was analyzed using Cox regression.

RESULTS

In total, 56 (4.3%) patients had PMI. According to SYNTAX, 4th UDMI or ISCHEMIA, SCAI, and EXCEL definitions, PMI occurred in 21 (1.6%), 56 (4.3%), 29 (2.2%), and 32 (2.5%) patients, respectively. All definitions were significantly correlated with unadjusted mortality at the end of follow-up but not at 30 days or 1-year after stenting. PMI using SYNTAX, SCAI, and EXCEL definitions rather than 4th UDMI definition was strongly associated with adjusted all-cause death. By adjusted analysis, PMI according to 4th UDMI, SCAI, and EXCEL definitions but not SYNTAX definition was positively correlated with cardiac death at a median of 5.58 years of follow-up. CK-MB ≥ 5 x UNL strongly enhanced the correlation of CK-MB values with mortality.

CONCLUSIONS

PMI rate varies with the definition following stenting for bifurcation lesions. PMI defined by SCAI and EXCEL definitions is strongly correlates with adjusted all-cause and cardiac death.

Peripheral Artery Tonometry Reveals Impaired Endothelial Function before Percutaneous Coronary Intervention in Patients with Periprocedural Myocardial Injury

Background

Periprocedural myocardial injury (PMI) is a most common complication of percutaneous coronary intervention (PCI). Microembolization and inflammation underlying PMI could lead to coronary microvascular dysfunction (CMD) and vice versa. Reactive hyperemia index (RHI) assessed by peripheral artery tonometry (PAT) has been considered as a noninvasive method to assess endothelial function and CMD, which could be useful to predict PMI.

Methods

268 patients suspected with stable coronary artery disease (CAD) and scheduled for elective coronary angiography were enrolled. RHI was measured by using the Endo-PAT2000™ device before angiography. The association among RHI, PMI, and cardiovascular events was further assessed.

Results

In this cohort, 189 patients (70.5%) were diagnosed with CAD and 119 patients (44.4%) underwent drug-eluting stent (DES) implantation. Compared with patients without CAD, CAD patients had lower RHI (1.88 ± 0.55 vs. 2.02 ± 0.58, P < 0.05). Patients with PMI had a lower RHI before angiography (1.75 ± 0.37 vs. 1.95 ± 0.50, P < 0.05). Receiver operating characteristic curve analysis of RHI revealed an area under the curve (AUC) of 0.61, with a sensitivity of 62.7% and specificity of 50.0% to predict PMI. Moreover, we found that CAD patients with RHI ≤ 1.81 had a higher incidence of composite cardiac events after stenting (adjusted hazard ratio (HR) 3.31, 95% confidence interval (CI) 1.07–10.22, P < 0.05).

Conclusions

RHI assessment through PAT could be a promising method to predict PMI before the procedure. RHI is associated with increased risk of long-term adverse cardiac events after DES implantation.

High-dose statin pretreatment decreases periprocedural myocardial infarction and cardiovascular events in East Asian patients undergoing percutaneous coronary intervention: A meta-analysis of fifteen randomized controlled trials

BACKGROUND

Numerous studies have shown that high-dose statin pretreatment may reduce the risk of periprocedural myocardial infarction (PMI) and short-term major adverse cardiac events (MACE) in western people undergoing percutaneous coronary intervention (PCI). However, the effects in East Asian patients are still controversial. The objective was to evaluate the effects of short-term high-dose statin (all types) pretreatment compared with the control (low-dose or no statin) on the reduction of the rate of MACE and PMI in East Asian patients.

METHODS

PubMed/Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) in East Asian patients up to December 2019, in which short-term high-dose statin pretreatment was compared with control for patients undergoing PCI. The primary outcome measure was the incidence of MACE at 30 days. The secondary outcome measure was the incidence of PMI. The meta-analysis was performed with the fixed-effect model or random-effects model according to the heterogeneity. The meta-analysis was performed using RevMan 5.3 software (Cochrane Collaboration).

RESULTS

Fifteen RCTs that enrolled 4313 East Asian patients were identified. High-dose statin pretreatment was associated with a 54% relative reduction in 30-day MACE (OR, 0.46; 95% CI, 0.31-0.67; P < .001) and a 50% relative reduction in PMI (OR, 0.50; 95% CI, 0.34-0.76; P = .001).

CONCLUSIONS

High-dose statin pretreatment can significantly reduce 30-day MACE and PMI for East Asian patients undergoing PCI.

Inflammation during Percutaneous Coronary Intervention-Prognostic Value, Mechanisms and Therapeutic Targets

Periprocedural myocardial injury and myocardial infarction (MI) are not infrequent complications of percutaneous coronary intervention (PCI) and are associated with greater short- and long-term mortality. There is an abundance of preclinical and observational data demonstrating that high levels of pre-, intra- and post-procedural inflammation are associated with a higher incidence of periprocedural myonecrosis as well as future ischaemic events, heart failure hospitalisations and cardiac-related mortality. Beyond inflammation associated with the underlying coronary pathology, PCI itself elicits an acute inflammatory response. PCI-induced inflammation is driven by a combination of direct endothelial damage, liberation of intra-plaque proinflammatory debris and reperfusion injury. Therefore, anti-inflammatory medications, such as colchicine, may provide a novel means of improving PCI outcomes in both the short- and long-term. This review summarises periprocedural MI epidemiology and pathophysiology, evaluates the prognostic value of pre-, intra- and post-procedural inflammation, dissects the mechanisms involved in the acute inflammatory response to PCI and discusses the potential for periprocedural anti-inflammatory treatment.

Comparison of the incidence of periprocedural myocardial infarction between percutaneous coronary intervention with versus without rotational atherectomy using propensity score-matching

Complications such as slow flow are frequently observed in percutaneous coronary intervention (PCI) with rotational atherectomy (RA). However, it remains unclear whether the high incidence of slow flow results in the high incidence of periprocedural myocardial infarction (PMI), reflecting real myocardial damage. The aim of this study was to compare the incidence of PMI between PCI with versus without RA using propensity score-matching. We included 1350 elective PCI cases, which were divided into the RA group (n = 203) and the non-RA group (n = 1147). After propensity score matching, the matched RA group (n = 190) and the matched non-RA group (n = 190) were generated. The primary interest was to compare the incidence of PMI between the matched RA and non-RA groups. Before propensity score matching, the incidence of slow flow and PMI was greater in the RA group than in the non-RA group. After matching, the incidence of slow flow was still greater in the matched RA group than in the matched non-RA group (16.8% vs. 9.5%, p = 0.048). However, the incidence of PMI was similar between the matched RA and matched non-RA group (7.4% vs. 5.3%, p = 0.528, standardized difference: 0.086). In conclusion, although use of RA was associated with greater risk of slow flow, use of RA was not associated with PMI after a propensity score-matched analysis. The fact that RA did not increase the risk of myocardial damage in complex lesions would have an impact on revascularization strategy for severely calcified coronary lesions.

Prognosis of spontaneous myocardial infarction and various definitions of periprocedural myocardial infarction in patients who underwent percutaneous coronary intervention

BACKGROUND

Debate exists on the prognostic significance of spontaneous myocardial infarction (SMI) and periprocedural myocardial infarction (PMI), which could be diagnosed by various definitions.

METHODS AND RESULTS

A total of 10,724 patients undergoing percutaneous coronary intervention (PCI) were consecutively enrolled and followed up for a median of 2.4 years. We evaluated outcomes of all-cause death, cardiac death, and major adverse cardiovascular events (MACE). Patients were stratified into three groups, including the No MI group, PMI group, and SMI group. PMI was defined based on different diagnostic criteria, including the third and fourth universal myocardial infarction (MI) definitions, the society for cardiovascular angiography and interventions (SCAI) definition, and the independent biomarker definition. Regardless of these definitions, the PMI groups were all associated with a significantly increased MACE risk at one year or 1000 days (all P < 0.05), but not all-cause or cardiac death. The SMI group was associated with a markedly elevated risk of death and MACE, but it showed no significant different risk of MACE to PMI using varying definitions.

CONCLUSIONS

According to various PMI definitions, PMI and SMI were associated with an increased risk of MACE, but not death for PMI. No significantly different risk of MACE was observed between PMI and SMI.

Efficacy of Trimetazidine in Limiting Periprocedural Myocardial Injury in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

We systematically searched the literature to assess the efficacy of trimetazidine in reducing periprocedural myocardial injury and improving postoperative left ventricular ejection fraction (LVEF) in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). An electronic search was conducted based on the PubMed, Ovid, Scopus, Springer, CENTRAL, and Google Scholar databases; 14 randomized controlled trials (RCTs) were included. Our meta-analysis showed a significant reduction in cardiac troponin I (cTnI) levels with trimetazidine compared with controls (P < .00001) but not in serum creatine kinase-myocardial band levels (P = .49). There were significantly reduced odds of ischemic ST-T segment changes with trimetazidine (P = .0.03) but lack of significant difference in the incidence of anginal attacks between the 2 groups (P = .10). Results also suggest significantly higher LVEF with trimetazidine compared with controls (P < .00001). Meta-regression analysis indicated no influence of duration of trimetazidine therapy on cTnI levels. The administration of preprocedure trimetazidine may have a role in reducing periprocedural myocardial injury in patients with CAD undergoing PCI. Evidence also suggests that postoperative trimetazidine may improve LVEF in the short term. Lack of high-quality trials and the heterogeneity of studies limit the ability of our analysis to draw strong conclusions. Further well-designed RCTs are required to supplement current evidence.

Prognostic Impact of Percutaneous Coronary Intervention of Chronic Total Occlusion in Acute and Periprocedural Myocardial Infarction

Coronary chronic total occlusion (CTO) has gained increasing clinical attention as the most advanced form of coronary artery disease. Prior studies already indicated a clear association of CTO with adverse clinical outcomes, especially in patients with acute myocardial infarction (AMI) and concomitant CTO of the non-infarct-related coronary artery (non-IRA). Nevertheless, the prognostic impact of percutaneous coronary intervention (PCI) of CTO in the acute setting during AMI is still controversial. Due to the complexity of the CTO lesion, CTO-PCI leads to an increased risk of complications compared to non-occlusive coronary lesions. Therefore, this review outlines the prognostic impact of CTO-PCI in patients with AMI. In addition, the prognostic impact of periprocedural myocardial infarction caused by CTO-PCI will be discussed.

Myocardial damage associated with elective percutaneous coronary intervention in Chinese patients: a retrospective study

Objective

To determine the prevalence of percutaneous coronary intervention (PCI) related myocardial damage (injury or myocardial infarction), investigate several cardiac biomarkers, explore possible risk factors and assess survival in patients undergoing elective PCI.

Methods

Patients >18 years of age who had undergone an elective PCI at Huashan hospital in Shanghai, China from October 2016 to June 2017 and had baseline and post-PCI results available for four cardiac biomarkers (cTnT, CK-MB mass, hs-CRP and NT-ProBNP) were eligible. Patients were separated into two groups according to whether or not they had PCI related myocardial damage.

Results

Of the 143 patients who were eligible for the study, 75 (52%) were classified as ‘controls,’ and 68 (48%) had PCI related myocardial damage. Of the 68 patients, 64 (45%) had PCI related myocardial injury and 4 (3%) had PCI related myocardial infarction. Elderly Chinese patients, with high systolic blood pressure on admission and who required multiple coronary segments for PCI had a high risk of myocardial damage. Relative cTnT or relative CK-MB mass may be useful cardiac biomarkers for monitoring PCI related myocardial damage, especially at 24h post-PCI. There was no significant difference in survival rates between controls and those with myocardial complications.

Conclusions

PCI related myocardial damage is common but appears to have no impact on prognosis. Senior age, high systolic blood pressure and multiple coronary segments for PCI are risk factors.

Impact of the Polymorphism rs5751876 of the Purinergic Receptor ADORA2A on Periprocedural Myocardial Infarction in Patients Undergoing Percutaneous Coronary Intervention

Aim: Periprocedural myocardial infarction (PMI), a severe complication of Percutaneous Coronary Intervention (PCI) procedures, has a negative prognostic effect, both at short and long-term follow-up. So far, adenosine's role in preventing PMI has shown contrasting results. A genetic variant of ADORA2A receptor, 1976 C > T, has been suggested as a potential determinant of the interindividual response to adenosine, thus conditioning its potential benefits on PMI. In our study, we investigated whether the ADORA2A 1976 C > T polymorphism is associated with PMI occurrence in patients undergoing coronary stenting.

Methods: The study included consecutive patients undergoing PCI at the Azienda Ospedaliera-Universitaria “Maggiore della Carità,” Novara, Italy, between January 2010 and January 2016. Their genetic status was assessed using polymerase chain reaction (PCR) and restriction-fragment-length-polymorphism technique. Myonecrosis biomarkers were measured at intervals from 6 to 48 hours. PMI was defined as CKMB increased 3 times over the Upper Limit of Normal (ULN), or 50% of pre-PCI value; periprocedural myonecrosis was defined as troponin I increased 3 times over the ULN or by 50% of the baseline value.

Results: We included 1,104 patients undergoing PCI, 863 (78.2%) of whom carried the ADORA2A T-allele. No difference was found for the main demographic, clinical features, or biochemistry parameters. However, C-carriers had lower statin therapy use (p = 0.008) and lower HDL-cholesterol levels (p = 0.01). Homozygous C/C patients had more frequent multivessel disease (p = 0.03), longer lesions (p = 0.01) and Type C lesions (p = 0.01), thus requiring more complex procedures. After correction for baseline confounding factors at multivariate analysis, there was no difference in myocardial necrosis according to the ADORA2A genotype (p = 0.40). In contrast, PMI tended to increase in the homozygous C/C population (p = 0.06), but this trend was attenuated at multivariate analysis after correction for baseline confounding factors (C/C: OR[95%CI]= 1.52 [0.88–2.6], p = 0.14).

Conclusions: Our study showed that the polymorphism rs5751876 of the ADORA2A receptor is associated with a higher prevalence of complex coronary lesions and multivessel disease. However, it does not significantly influence the occurrence of periprocedural MI or myonecrosis.

Determinants of Periprocedural Myocardial Infarction in Current Elective Percutaneous Coronary Interventions

Periprocedural myocardial infarction (PMI) is closely associated with long-term cardiovascular events. The factors associated with PMI are not fully understood. The purpose of this study was to investigate the determinants of PMI in contemporary elective percutaneous coronary intervention (PCI). Overall, 731 elective PCI was divided into the PMI (n = 27) and non-PMI (n = 704) groups. Univariate and multivariate logistic regression analysis was used to find factors associated with PMI. In the univariate analysis, PMI was associated with complex lesion characteristics, such as the lesion length, lesion angle, calcification, and Medina classification. In the multivariate logistic regression analysis, the lesion length (per 10-mm increase: odds ratio (OR), 1.477; 95% confidence interval (CI), 1.161‒1.879; P = 0.002), lesion angle ≥ 45° (versus lesion angle < 45°: OR, 4.244; 95% CI, 1.187‒15.171; P = 0.026), and Medina classification (0,1,1) / (1,1,1) (versus other lesions: OR, 14.843; 95% CI, 6.235‒35.334; P < 0.001) were significantly associated with PMI. Of the 24 lesions with lesion angle ≥ 45° in the PMI group, 14 had final TIMI flow grade ≤ 2 in side branches and 9 had transient slow flow in main branches/transient ST elevation during PCI. Of the 87 lesions with Medina classification (1,1,1) / (0,1,1), 19 had final TIMI grade ≤ 2 in side branches. In conclusion, the lesion length, lesion angle ≥ 45°, and Medina classification (0,1,1) / (1,1,1) were significantly associated with PMI in contemporary elective PCI. Preventing flow limitation in both side branches and main vessels in elective PCI for the diffuse long, angulated, or true bifurcation lesions is important.

A machine learning-based approach for the prediction of periprocedural myocardial infarction by using routine data

Background

Periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) is associated with the bad prognosis in patients. Current approaches to predict PMI fail to identify many people who would benefit from preventive treatment, and machine learning (ML) offers opportunity to improve the performance of ML models for PMI based on the big routine data.

Methods

By using electronic medical records, we retrospectively extracted all records of patients from 2007 to 2019 in our cardiovascular center. The main enrollment criterion was that inpatients with one single coronary stenosis with stents implantation this time. The primary outcome was PMI [PMI3: cTnI >3-fold upper reference limit (URL); PMI5: cTnI >5-fold URL]. Four different ML algorithms [Support Vector Machine (SVM), Logistic Regression (LR), Random Forest (RF), Artificial Neural Networks (ANN)] were evaluated and their diagnostic accuracy measures were compared.

Results

A total of (10,886) patients who were admitted in our hospital. PMI3 and PMI5 results were analyzed respectively. The incidence of PMI3 and PMI5 was 20.9% and 13.7%. In PMI3 Drop group, ANN (accuracy: 0.72; AUC: 0.77) showed the best power to predict the presence of PMI; In PMI3 Mean Group, RF (accuracy: 0.72; AUC: 0.77) showed the best power; In PMI5 Drop group, RF (accuracy: 0.67; AUC: 0.67) showed the best power; In PMI5 Mean group, RF (accuracy: 0.61; AUC: 0.67) showed the best power.

Conclusions

ML methods may provide accurate prediction of PMI in CAD patients, and could be used as a precise model in the preventive treatment of PMI.

The prognostic significance of periprocedural infarction in the era of potent antithrombotic therapy. The PRAGUE-18 substudy

BACKGROUND

The prognostic significance of periprocedural myocardial infarction (MI) remains controversial.

METHODS AND RESULTS

The study aims to investigate the incidence of periprocedural MI in the era of high sensitivity diagnostic markers and intense antithrombotics, and its impact on early outcomes of patients with acute MI treated with primary angioplasty (pPCI). Data from the PRAGUE-18 (prasugrel versus ticagrelor in pPCI) study were analyzed. The primary net-clinical endpoint (EP) included death, spontaneous MI, stroke, severe bleeding, and revascularization at day 7. The key secondary efficacy EP included cardiovascular death, spontaneous MI, and stroke within 30 days. The incidence of peri-pPCI MI was 2.3% (N = 28) in 1230 study patients. The net-clinical EP occurred in 10.7% of patients with, and in 3.6% of patients without, peri-pPCI MI (HR 2.92; 95% CI 0.91-9.38; P = 0.059). The key efficacy EP was 10.7% and 3.2%, respectively (HR 3.44; 95% CI 1.06-11.13; P = 0.028). Patients with periprocedural MI were at a higher risk of spontaneous MI (HR 6.19; 95% CI 1.41-27.24; P = 0.006) and stent thrombosis (HR 10.77; 95% CI 2.29-50.70; P = 0.003) within 30 days. Age, hyperlipidemia, multi-vessel disease, post-procedural TIMI <3, pPCI on circumflex coronary artery, and periprocedural GP IIb/IIIa inhibitor were independent predictors of peri-pPCI MI.

CONCLUSIONS

In the era of intense antithrombotic therapy, the occurrence of peri-pPCI MI is despite highly sensitive diagnostic markers a rare complication, and is associated with an increased risk of early reinfarction and stent thrombosis.

Alprostadil Injection Attenuates Coronary Microembolization-Induced Myocardial Injury Through GSK-3β/Nrf2/HO-1 Signaling-Mediated Apoptosis Inhibition

Objective

Coronary microembolization (CME) results in progressive contractile dysfunction associated with cardiomyocyte apoptosis. Alprostadil injection improves microcirculation, which is effective in treating various cardiovascular disorders. However, the therapeutic effects of alprostadil in CME-induced myocardia injury remain unknown. Therefore, we evaluated the effects of alprostadil injection on cardiac protection in a rat model of CME and explored the underlying mechanisms.

Methods

A rat model of CME was established by injecting polyethylene microspheres into the left ventricle. After injection of microspheres, rats in the alprostadil group received alprostadil via tail vein within 2 minutes. Cardiac function, histological alterations in myocardium, serum c-troponin I (cTnI) levels, myocardium adenosine triphosphate (ATP) concentrations, the activity of superoxide dismutase (SOD) and malondialdehyde (MDA) content in myocardium, and myocardial apoptosis-related proteins were detected 12 hours after CME modeling.

Results

Compared with the Sham group, ATP concentrations, SOD activity in the myocardium, and cardiac function were significantly decreased in a rat model of CME. In addition, serum cTnI levels, MDA content, expression levels of pro-apoptotic proteins, and the number of TUNEL-positive nuclei were remarkably higher in CME group than those in the Sham group. However, alprostadil treatment notably reduced serum cTnI levels and expression levels of pro-apoptotic proteins, while noticeably improved cardiac function, and accelerated SOD activity in the myocardium following CME. Additionally, it was unveiled that the protective effects of alprostadil injection inhibit CME-induced myocardial apoptosis in the myocardium potentially through regulation of the GSK-3β/Nrf2/HO-1 signaling pathway.

Conclusion

Alprostadil injection seems to significantly suppress oxidative stress, alleviate myocardial apoptosis in the myocardium, and improve cardiac systolic and diastolic functions following CME by regulating the GSK-3β/Nrf2/HO-1 signaling pathway.

Identification of patients at higher risk for myocardial injury following elective coronary artery intervention

OBJECTIVES

To evaluate myocardial injury and infarction (MI) following elective percutaneous coronary intervention (PCI).

BACKGROUND

The substantially higher analytical power of high-sensitivity troponin (hsTn) assays allows detection of minor cardiac troponin (cTn) levels, which may be useful in monitoring myocardial injury and guiding therapies.

METHODS

Serial hsTnT measurements were conducted in patients undergoing elective PCI and were related to the extent of coronary artery disease (CAD) as reflected by the SYNTAX score risk categories and American College of Cardiology/American Heart Association classification of coronary lesions. Myocardial injury and MI were diagnosed according to the second and third versions of universal MI definition.

RESULTS

The study population consisted of 530 patients, who were grouped into low (41.3%), intermediate (35.4%), and high (23.3%) SYNTAX risk categories. The treated coronary lesions were classified into A 7.8%, B1 24.1%, B2 21.1%, C1 24.6%, and C2 22.4%. Postprocedural hsTnT increases correlated significantly with the complexity of treated coronary lesions (p < .05) and CAD magnitude (p < .05). Rates of MI type 4a according to the second and third MI definition criteria were 98 (27.5%) and 15 (4.2%) cases in patients with normal baseline hsTnT values (N = 357, 67.4%), as well as 137 (79.2%) and 27 (15.6%) cases in those with elevated baseline hsTnT values (N = 173, 32.6%), respectively.

CONCLUSIONS

After elective PCI, cTn releases correlate significantly with lesion complexity and CAD extent. Use of hsTnT assay enables precise monitoring of PCI-related myocardial injury and may identify patients at higher risk for ischemic events, who may benefit from potent platelet inhibition, which needs to be investigated in randomized trials.

Relationship of lipoprotein-associated phospholipase A2(Lp-PLA2) and periprocedural myocardial injury in patients undergoing elective percutaneous coronary intervention

BACKGROUND

Percutaneous coronary intervention (PCI) is one of the dominant methods for revascularization in patients with coronary heart disease (CHD). However, periprocedural myocardial injury (PMI) is a frequent complication following PCI and is known to be a predictor of postprocedural cardiovascular morbidity and mortality. Although several studies try to identify serum markers to predict the PMI, there is a little information about the role of lipoprotein-associated phospholipase A2 (Lp-PLA2) as a predictor of PMI. Therefore, we aimed to investigate the relationship of Lp-PLA2 levels and PMI in patients undergoing elective PCI.

METHODS

This study included 265 consecutive patients with normal preprocedural cardiac troponin T(cTNT) who received elective PCI. The samples for cTNT were collected at 8, 16, and 24 h after PCI to assess perioperative myocardial injury. The Lp-PLA2 and other serum lipid parameters were measured after 12 fasting hours before PCI.

RESULTS

The data suggested that the patients with preprocedural high Lp-PLA2 were strongly and independently correlated with the risk of PMI. Pearson correlation analysis showed that preprocedural Lp-PLA2 was significantly positively correlated with postprocedural cTnT elevation (r = 0.694, p < 0.05). Binary logistic regression analysis was used to analyze the risk factors of PMI, we found that Lp-PLA2 was independent risk factor for postprocedural cTnT elevation. The area under Receiver Operating Characteristic curve of Lp-PLA2 was 0.757 (95%CI 0.692 ~ 0.821, p < 0.001), the best cut-off point was 185 ng/ml, sensitivity and specificity were 65.33% and 76.32%.

CONCLUSION

Our study demonstrated that preprocedural Lp-PLA2 was associated with postprocedural cTnT elevation and was the independent risk factor of PMI.

Association between serum angiopoietin-2 concentrations and periprocedural myocardial injury in patients undergoing elective percutaneous coronary intervention

Angiopoietin-2 (Ang-2) is a proangiogenic factor that mediates inflammation and atherosclerosis. We evaluated the predictive value of circulating Ang-2 levels for periprocedural myocardial injury (PMI) in 145 patients undergoing elective percutaneous coronary intervention (PCI), and investigated whether post-PCI Ang-2 levels are influenced by PMI. PMI was defined as a post-procedural troponin elevation above the 5×99^th percentile upper reference limit. Blood samples for Ang-2 analysis were collected at admission and on postoperative days 1 and 3. PMI occurred in 40 patients (28%). At baseline, there was no difference in Ang-2 levels between PMI and non-PMI patients (P=0.554). However, a significant interaction effect between PMI occurrence and time on Ang-2 levels was observed (interaction P=0.036). Although serum Ang-2 levels in non-PMI patients gradually decreased, Ang-2 levels in PMI patients did not change between different time-points. Multiple logistic regression analysis revealed that age, total stent length, and serum levels of N-terminal pro-brain natriuretic peptide were independent PMI predictors. These findings indicate that pre-procedural Ang-2 levels do not impact PMI occurrence after elective PCI. However, changes in Ang-2 levels after the procedure are closely related to PMI.

Periprocedural myocardial and renal injury in patients undergoing elective percutaneous coronary interventions - is there an association?

Periprocedural myocardial injury (PMI) and contrast-induced nephropathy (CIN) are frequent complications of percutaneous coronary intervention (PCI) associated with early and late major adverse cardiovascular events. Both conditions are associated with similar risk factors, which could imply their possible association. The aim of our study was to assess the correlation of PMI and early postprocedural creatinine shift (ECS) as a marker of renal injury.A total of 209 hospitalized patients with stable coronary artery disease (CAD) were enrolled, who underwent an elective PCI in a period of 12 months. All patients had their serum high-sensitivity troponin I (hsTnI) measured at baseline and 16 hours after the PCI. PMI was defined according to the elevation of postprocedural hsTnI using criteria provided by both the most recent consensus documents as well as evidence-based data. Renal injury was evaluated using the ECS concept. Serum creatinine (SCr) was also measured at baseline and at 16 hours. ECS was defined as SCr >5% at 16 hours compared to baseline.Although incidence of both PMI (77.5%) and ECS (44.5%) were high, no association of these 2 conditions could be found. Further analyses of our data showed that diabetes is associated with a higher incidence of ECS, while patients on beta-blocker therapy had a lower incidence of ECS.In our study, no association between PMI and ECS was found. Additional studies with a larger number of patients and longer patient observation are needed to assess the correlation between PMI and CIN as well as to validate the attractive, but controversial, concept of ECS as an early marker of CIN.

Pyrrolidine Dithiocarbamate Attenuates Cardiocyte Apoptosis and Ameliorates Heart Failure Following Coronary Microembolization in Rats

Background

Nuclear factor-kB is highly activated in cardiovascular disorders. However, few articles have targeted at the role of nuclear factor-kB inhibitor in heart failure.

Aims

To evaluate the effects of nuclear factor-kB inhibitor pyrrolidine dithiocarbamate on cardiocyte apoptosis and cardiac function in a rat heart failure model.

Study Design

Animal experiment.

Methods

A stable and reproducible rat heart failure model (n=64) was prepared by injecting homologous microthrombotic particles into the left ventricle of Sprague–Dawley rats while obstructing the ascending aorta to produce coronary microembolization. Rats with heart failure were randomized into untreated (HFu) and pyrrolidine dithiocarbamate-treated (HFp) groups; the latter received an intraperitoneal injection of pyrrolidine dithiocarbamate (100 mg/kg/day) 1 h prior to surgery as well as on postoperative days 1-7. The sham group comprised 32 Sprague–Dawley rats. Eight rats from each group were sacrificed on days 1, 3, 7, and 14 postoperatively. Masson’s trichrome staining was used to determine the micro-fibrotic area to indicate the severity of myocardial loss. Terminal transferase uridine triphosphate nick end labeling staining was used to detect apoptotic cardiomyocytes. Echocardiography and hemodynamics were performed to evaluate left ventricular function.

Results

Rats with heart failure exhibited pathological changes evidenced by patchy myocardial fibrosis, remarkably elevated severity of myocardial loss, and persistently reduced left ventricular function. At the end of the study, compared with the HFu group, myocardial infarct size was reduced by 28% (p=0.001), cardiocyte apoptosis was suppressed (7.17%±1.47% vs 2.83%±0.75%, p<0.001), cardiac function parameters such as left ventricular ejection fraction (80%±4% vs 61%±6%), left ventricular + dP/dt max (4828±289 vs 2918±76 mmHg.s−1), left ventricular - dP/dt max (4398±269 vs 2481±365 mmHg.s−1), and left ventricular systolic pressure (126±13 vs 100±10 mmHg) were significantly increased, and left ventricular end-diastolic pressure was reduced (18±2 vs 13±1 mmHg) (p<0.001, for all) in the HFu group.

Conclusion

Our rat model can adequately mimic heart failure via coronary vessel embolization. Moreover, pyrrolidine dithiocarbamate treatment can reduce cardiocyte apoptosis and improve cardiac function, which may be beneficial for patients with heart failure secondary to myocardial infarction.

Lipid-Core Plaque Assessed by Near-Infrared Spectroscopy and Procedure Related Microvascular Injury

Background and Objectives

Microvascular damage due to distal embolization during percutaneous coronary intervention (PCI) is an important cause of periprocedural myocardial infarction. We assessed the lipid-core plaque using near-infrared spectroscopy (NIRS) and microvascular dysfunction invasively with the index of microcirculatory resistance (IMR) and evaluated their relationship.

Methods

This study is pilot retrospective observational study. We analyzed 39 patients who performed NIRS before and after PCI, while fractional flow reserve, thermo-dilution coronary flow reserve (CFR) and IMR were measured after PCI. The maximum value of lipid core burden index (LCBI) for any of the 4-mm segments at the culprit lesion (culprit LCBI_4mm) was calculated at the culprit lesion. We divided the patients into 2 groups using a cutoff of culprit LCBI_4mm ≥500.

Results

Mean pre-PCI LCBI was 333±196 and mean post-PCI IMR was 20±14 U. Post-PCI IMR was higher (15.6±7.3 vs. 42.6±17.6 U, p<0.001) and post-PCI CFR was lower (3.7±2.2 vs. 2.1±1.0, p=0.029) in the high LCBI group. Pre-PCI LCBI was positively correlated with post-PCI IMR (ρ=0.358, p=0.025) and negatively correlated with post-PCI CFR (ρ=−0.494, p=0.001). The incidence of microvascular dysfunction (IMR ≥25 U) was higher in the high LCBI group (9.4% vs. 85.7%, p<0.001). However, there were no significant differences in the incidences of creatine Kinase-MB (9.4% vs. 14.3%, p=0.563) and troponin-I elevation (12.5% vs. 14.3%, p=1.000).

Conclusions

A large lipid-core plaque at the ‘culprit’ lesion is observed higher incidence of post-PCI microvascular dysfunction after PCI. Prospective study with adequate subject numbers will be needed.

Comparison of the effect of 80 vs 40 mg atorvastatin in patients with isolated coronary artery bypass graft surgery: A randomized clinical trial

OBJECTIVES

Atorvastatin can decrease cardiac injury after coronary artery bypass graft (CABG) surgery. We compared the effects of 80 and 40  mg of atorvastatin per day on the levels of cardiac troponin T (cTnT) and creatine kinase-MB (CK-MB) after an isolated CABG.

METHODS

This randomized single-blind parallel clinical trial enrolled 125 patients (mean age = 60.59 ± 8.37 years) who were candidates for elective isolated CABG at the Tehran Heart Center between May 2017 and December 2017. Patients were randomly allocated into two groups to receive either 80 mg (n = 62) or 40 mg of atorvastatin (n = 63) per day, 5 days before surgery. The levels of cTnT and CK-MB, used as myocardial injury markers, were measured at baseline and then at 8 and 24 hours after CABG.

RESULTS

The levels of CK-MB and cTnT at baseline and at 8 and 24 hours following CABG were not significantly different between the two groups. Our repeated measures analysis of variance showed that the levels of CK-MB and cTnT increased significantly over time (P <  .001). No significant interaction was observed between time and the atorvastatin dosage on the levels of either CK-MB (P =  .159) or cTnT (P =  .646). In addition, the between-group effects were not significant for CK-MB (P =  .632) and cTnT (P =  .126).

CONCLUSION

The higher dose of atorvastatin (80 mg) did not exert a more protective effect than the standard dose of atorvastatin (40 mg) after CABG surgery.

Neutrophil count as the centerpiece in the joined association networks of inflammatory and cell damage markers, and neuroendocrine stress markers in patients with stable angina pectoris following stenting

Objective

The primary aim of this study was to examine whether markers of cell damage and of the psycho-neuroendocrino-inflammatory/immune (PNI) system could be associated in patients with stable coronary artery disease (CAD) on the next day following percutaneous coronary intervention (PCI).

Materials and methods

Blood samples of 23 patients (18 men and five women, mean age 62.9 ± 10.6 years), were collected immediately before (pre-PCI), immediately after (post-PCI), and on the day following PCI (1d-PCI). Lactoferrin, LL-37 and interleukin-6 (IL-6) were assayed in plasma, in addition to cortisol and chromogranin A (CgA), as well as CK, ASAT and ALAT. Total and differential leukocyte counts were also analysed.

Results

At all the three time points, the monocyte fractions, the monocyte-to-lymphocyte and the neutrophil-to-lymphocyte ratios and CgA levels were elevated. We detected significant peri-procedural changes in the plasma levels of our PNI markers: IL-6 (p<0.05), lactoferrin, LL-37 (both: p <0.0001), CgA, (p<0.05), and cortisol (p<0.01). On the first day after PCI, highly significant associations were found of ASAT with IL-6 and neutrophil count (both: r>0.75, p<0.0001), and of CgA with neutrophil count and monocyte count (both: r>0.79, p<0.0001); furthermore, cortisol was also associated with neutrophil count (r>0.7, p<0.0001).

Conclusions

The findings suggest that myocardial damage could correlate not only with an inflammatory reaction but, via neutrophil count, also with increased level of stress in stable CAD after PCI. Furthermore, 1d-PCI neutrophil count may serve as an easy-to-obtain integrative PNI measure in stable CAD.

Efficacy and safety of Shen-Yuan-Dan capsules for peri-procedural myocardial injury following percutaneous coronary intervention: study protocol for a randomized, double-blind, placebo-controlled trial

Background

Peri-procedural myocardial injury (PMI) during percutaneous coronary intervention (PCI) will result in an unfavorable clinical prognosis in patients, thus urgently necessitating effective drug treatment measures. Shen-Yuan-Dan (SYD) capsules are a traditional Chinese medicine (TCM) preparation that have been found to have potential myocardial protection effects during the peri-procedural phase of PCI in previous clinical and basic research; however, there is a lack of rigorous, randomized, and controlled studies. The aim of this study is to evaluate the efficacy and safety of SYD in decreasing PMI.

Methods

This is a randomized, double-blind, placebo-controlled clinical trial. A total of 284 patients with unstable angina will be randomized into test and control groups. The two groups will be given SYD or a placebo (three times each day, four capsules each time) 3 days before PCI on the basis of conventional treatment. Twelve hours before PCI, an additional 4 capsules will be given, and drug treatment is planned to be maintained for 1 month after surgery. Dynamic changes in the myocardial enzyme in four time-points (before PCI, and 4, 24, 48 hours after PCI) in both groups of patients that will be observed. The follow-up period will be 1 month. The primary observation markers are planned to evaluate the efficacy and safety of SYD in decreasing PMI. The secondary observation markers will be to evaluate the major adverse cardiovascular events (MACEs) status at day 30 after PCI, (all-cause mortality, non-fatal myocardial infarction, repeated revascularization of target blood vessel) and Seattle Angina Questionnaire scores. GRACE scores will be used for risk stratification, and the intervention efficacy of SYD on PMI patients with different risks will be retrospectively evaluated.

Discussion

This study will provide a rigorous clinical evidence to evaluate the efficacy and safety of SYD in decreasing PMI and the results are worth anticipating.

Trial registration

The design of this trial has been registered with the Chinese Clinical Trial Registry (No. ChiCTR-IPR-17011069).

Role of metabolic manipulator trimetazidine in limiting percutaneous coronary intervention-induced myocardial injury

BACKGROUND

Trimetazidine (TMZ) is a metabolic modulator that shifts substrate utilization from fatty acid to carbohydrates, thereby, increasing myocardial glucose oxidation and improving myocardial ischemia. We evaluated whether TMZ is effective in reducing myocardial injury after percutaneous coronary intervention (PCI).

METHODS

Patients with stable angina undergoing elective PCI were divided into two groups, one who received oral TMZ (35 mg BD) started 7 days before PCI (n = 48) and second who did not receive any TMZ (in addition to the standard therapy (n = 52)). Troponin-I (cTnI) and creatine kinase-MB (CK-MB) were measured before, 8, and 24 h after PCI. The primary end point was a difference in post-PCI cTnI and CK-MB levels (vs baseline). Frequency of cTnI release in the two groups, total amount of cTnI release, and difference in TIMI flow grade before and after the procedure were also assessed.

RESULTS

Baseline demographics in the groups were comparable. Despite similar baseline levels, post-procedural cTnI was lower at 8 h (0.13 vs 0.56 ng/ml, p = 0.03) and 24 h (0.2 vs 1.13 ng/ml, p = 0.004) in the TMZ group. Decline or no change in cTnI was significantly more common in the TMZ group (26% vs 2%, p < 0.01). Total cTnI released after PCI, as assessed by area under curve was significantly lower in the TMZ group (15.84 vs 3.32 ng h/ml, p = 0.005). Although CK-MB levels were also lower in the TMZ group, the difference was not statistically significant. Incidence of post-PCI TIMI 1 or 2 flow was significantly lesser in the TMZ group.

CONCLUSIONS

Oral TMZ started 7 days before PCI was effective in limiting PCI-induced myocardial injury with lower cTnI levels and higher prevalence of TIMI-3 flow.

Unprotected versus protected high-risk percutaneous coronary intervention with the Impella 2.5 in patients with multivessel disease and severely reduced left ventricular function

Selecting a revascularization strategy in patients with multivessel disease (MVD) and severely reduced left ventricular ejection fraction (LVEF) remains a challenge. PCI with Impella 2.5 may facilitate high-risk PCI, however long-term results comparing unprotected versus protected PCI are currently unknown. We sought to evaluate the outcome of patients undergoing protected compared to unprotected percutaneous coronary intervention (PCI) in the setting of MVD and severely reduced LVEF.We included patients with MVD and severely reduced LVEF (≤35%) in this retrospective, single-centre study. Patients that underwent unprotected PCI before the start of a dedicated protected PCI program with Impella 2.5 were compared to patients that were treated with protected PCI after the start of the program. The primary endpoint was defined as major adverse cardiac and cerebrovascular events (MACCE) during a 1-year follow-up. The secondary endpoints consisted of in-hospital MACCE and adverse events.A total of 61 patients (mean age 70.7 ± 10.9 years, 83.6% male) were included in our study, of which 28 (45.9%) underwent protected PCI. The primary endpoint was reached by 26.7% and did not differ between groups (P = .90). In-hospital MACCE (P = 1.00) and in-hospital adverse events (P = .12) also demonstrated no significant differences. Multivariate logistic regression identified procedural success defined as complete revascularization and absence of in-hospital major clinical complications as protective parameter for MACCE (OR 0.17, 95% CI 0.04-0.70, P = .02).Patients with MVD and severely depressed LVEF undergoing protected PCI with Impella 2.5 demonstrate similar in-hospital and one-year outcomes compared to unprotected PCI.

Association between changes in platelet reactivity during elective percutaneous coronary intervention and periprocedural myocardial infarction: A pilot study

BACKGROUND

High platelet reactivity before percutaneous coronary intervention (PCI) reportedly increases the risk of PCI-related myocardial infarction (PMI) following elective PCI. We conducted a pilot study to evaluate changes in platelet reactivity during PCI and their association with the incidence of PMI.

METHODS

In total, 133 consecutive patients undergoing elective PCI after pretreatment with dual antiplatelet therapy for at least 7 days were prospectively enrolled. Platelet reactivity was measured by the VerifyNow^® assay (International Technidyne Corporation, Edison, NJ, USA) immediately before and after PCI.

RESULTS

Platelet reactivity significantly increased from 177.3 ± 53.4 P2Y12 reaction units (PRU) before PCI to 203.4 ± 52.8 PRU immediately after PCI (p < 0.001). Absolute changes in platelet reactivity were significantly greater in patients with than without PMI (32.4 ± 29.0 vs. 21.2 ± 24.8 PRU, respectively; p = 0.021). In the multivariable logistic regression analysis, the absolute change in PRU was an independent predictor of the incidence of PMI. Receiver operating characteristic curve analysis of the change in PRU during PCI for discriminating PMI showed a sensitivity, specificity, and the cut-off value of 46%, 76%, and 37 PRU, respectively (area under the curve = 0.607, p = 0.0235). When the patients were divided into two groups, namely a greater (change in PRU ≥ 37) and smaller (change in PRU < 37) increase group, the incidence rate of PMI was significantly higher in the greater than smaller increase group (59.1% vs. 34.8%, respectively; p = 0.008). Additional exploratory analyses by intracoronary imaging demonstrated that the proximal reference lumen area in the greater increase group was significantly smaller than that in the smaller increase group (6.5 ± 2.4 vs. 7.7 ± 3.1 mm², respectively; p = 0.032).

CONCLUSION

An increase in platelet reactivity after elective PCI is possibly associated with PMI. This finding should be validated by a larger-scale study.