Significance of Periprocedural Myocardial Infarctions in Percutaneous Coronary Interventions A New Look at an Old Topic Abhiram Prasad, MD, FRCP, FESC, FACC Consultant, Cardiac Catheterization Laboratory, Associate Professor of Medicine Mayo Clinic CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-1

Periprocedural MI Background Incidence varies 5-45% Correlate with delayed enhancement on MRI Associated with increased morbidity and mortality Often considered equivalent to “spontaneous MI” in clinical trials CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-2

Limitations of Prior Studies Most PCI outcome studies have not included the baseline troponin levels as a covariant When measured and included in the analysis, low cut-off values have not been used CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-7

Periprocedural Myonecrosis Mayo Clinic Study – Aim Evaluate the relative impact of preprocedural and postprocedural cTnT levels on short- and long-term survival rate after PCI, with the 99th percentile value of 0.01 ng/mL used as the cutoff for normal Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-8

Periprocedural Myonecrosis Mayo Clinic Study 5,487 nonemergency PCI Pre, 8- and 16-hr post PCI troponin T 30-day and long-term outcomes Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-9

Periprocedural Myonecrosis Mayo Clinic Study 63% had normal pre-PCI cTnT Of these, 43% had an elevated post-PCI cTnT Patients with elevated baseline cTnT values had significantly more adverse clinical (older, congestive heart failure, MI within 7 days of PCI, etc) and angiographic (multivessel disease, type C lesions, etc) and procedural characteristics Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-10

30-Day Mortality According to Periprocedural cTnT Levels Kaplan-Meier Estimates Pre 0.01 P<0.001 2.3% Independent predictor HR 22.4 (5.4-92.1); P=0.001 Mortality (%) Independent predictor HR 6.00 (1.30-27.8); P=0.02 Pre <0.01, post >0.01 0.6% Pre <0.01, post <0.01 0.1% Days from PCI Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-11

Pre-PCI Troponin and Long-Term Mortality <0.01 0.01-0.03 >0.03-0.1 >0.1-0.5 >0.5-1.0 >1.0 P<0.001 Death or MI (%) Months from PCI Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-12

Post-PCI Troponin and Long-Term Mortality <0.01 0.01-0.03 >0.03-0.1 >0.1-0.5 >0.5-1.0 >1.0 P<0.001 Mortality (%) Months from PCI Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-13

Long-Term Mortality According to Periprocedural cTnT Levels Pre 0.01 Pre <0.01, post >0.01 P<0.001 Mortality (%) Pre <0.01, post <0.01 Months from PCI Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-14

Multivariable Cox Model for Long-Term Risk of Death 95% hazard Variable 2 Hazard ratio ratio CL P Pre-PCI cTnT elevation 15.9 1.79 1.35, 2.39 <0.001 Age 83.0 * … <0.001 Congestive heart failure 42.8 2.11 1.69, 2.65 <0.001 Body mass index 25.5 * … <0.001 Chronic renal failure 22.5 2.256 1.61, 3.16 <0.001 Diabetes 19.4 1.60 1.30, 1.97 <0.001 Ejection fraction 11.3 * … 0.010 Cerebrovascular disease 9.3 1.43 1.14, 1.80 0.002 Smoking 5.3 1.28 1.04, 1.60 0.021 Isolated post-PCI cTnT elevation 3.4 1.31 0.98, 1.75 0.065 Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-15

Conclusions Mayo Clinic Study A preprocedural cTnT level >0.01 is a powerful independent predictor of prognosis after PCI PCI-related myonecrosis occurs frequently and predicts short-term but not long-term risk of death Association between post-PCI myonecrosis and outcomes in prior studies is a reflection of the preprocedural risk that may be estimated by using baseline cTnT and clinical characteristics Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CPXXXXXXX XXXXX, X XX XX-XX-XXXX CP1331879-16