Figure 1 Periprocedural myonecrosis and myocardial infarction after left main coronary artery revascularization with ... Figure 1 Periprocedural myonecrosis.

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Figure 1 Periprocedural myonecrosis and myocardial infarction after left main coronary artery revascularization with ... Figure 1 Periprocedural myonecrosis and myocardial infarction after left main coronary artery revascularization with percutaneous coronary intervention and coronary artery bypass grafting. (A) Cumulative frequency distribution curve for creatine kinase-MB elevation within 72 h after percutaneous coronary intervention and coronary artery bypass grafting normalized to the upper reference level. (B) Peak creatine kinase-MB elevations after percutaneous coronary intervention and coronary artery bypass grafting categorized in the pre-specified groups of <1× upper reference level, 1–3× upper reference level, 3–5× upper reference level, 5–10× upper reference level, and ≥10× upper reference level. Unless provided in the caption above, the following copyright applies to the content of this slide: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Eur Heart J, ehz113, https://doi.org/10.1093/eurheartj/ehz113 The content of this slide may be subject to copyright: please see the slide notes for details.

Figure 2 Kaplan–Meier time-to-event rates according to periprocedural myocardial infarction in patients undergoing ... Figure 2 Kaplan–Meier time-to-event rates according to periprocedural myocardial infarction in patients undergoing left main coronary artery intervention with percutaneous coronary intervention or coronary artery bypass grafting. (A) All-cause death; (B) cardiovascular death; and (C) non-cardiovascular death for patients with and without periprocedural myocardial infarction. CI, confidence interval; HR, hazard ratio. Unless provided in the caption above, the following copyright applies to the content of this slide: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Eur Heart J, ehz113, https://doi.org/10.1093/eurheartj/ehz113 The content of this slide may be subject to copyright: please see the slide notes for details.

Figure 3 Kaplan–Meier time-to-event rates in patients with vs Figure 3 Kaplan–Meier time-to-event rates in patients with vs. without periprocedural myocardial infarction according ... Figure 3 Kaplan–Meier time-to-event rates in patients with vs. without periprocedural myocardial infarction according to revascularization modality. (A) Cardiovascular death; (B) all-cause death. CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; P<sub>interaction</sub>, P-value for the interaction test comparing the effect of treatment (PCI vs. CABG) in patients with and without PMI; PMI, periprocedural myocardial infarction. Unless provided in the caption above, the following copyright applies to the content of this slide: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Eur Heart J, ehz113, https://doi.org/10.1093/eurheartj/ehz113 The content of this slide may be subject to copyright: please see the slide notes for details.

Figure 4 Kaplan–Meier time-to-event curves for cardiovascular death according to the peak post-procedure creatine ... Figure 4 Kaplan–Meier time-to-event curves for cardiovascular death according to the peak post-procedure creatine kinase-MB level. (A) All patients; (B) percutaneous coronary intervention-treated patients; (C) coronary artery bypass grafting-treated patients. Only creatine kinase-MB ≥10× the upper reference limit was prognostically significant in the overall population. CABG, coronary artery bypass grafting; CK-MB, creatine kinase-MB; PCI, percutaneous coronary intervention; URL, upper reference limit. Unless provided in the caption above, the following copyright applies to the content of this slide: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Eur Heart J, ehz113, https://doi.org/10.1093/eurheartj/ehz113 The content of this slide may be subject to copyright: please see the slide notes for details.

Take home figure Following percutaneous coronary intervention or coronary artery bypass grafting in patients with left main ... Take home figure Following percutaneous coronary intervention or coronary artery bypass grafting in patients with left main coronary artery disease, biomarkers should be drawn twice within 24 h to assess possible myocardial injury. In the EXCEL trial, creatine kinase-MB was used as the biomarker of choice given its strong association with subsequent mortality in prior studies.<sup>3</sup> In EXCEL, substantial myonecrosis defined as a peak creatine kinase-MB ≥10× the upper reference limit or ≥5× the upper reference limit plus either new pathological Q-waves or left bundle branch block, angiographically documented graft or native coronary artery occlusion or new severe stenosis with thrombosis and/or diminished epicardial flow, or imaging evidence of new loss of viable myocardium or new regional wall motion abnormality was strongly associated with all-cause and cardiovascular mortality within 3 years after both percutaneous coronary intervention and coronary artery bypass grafting, whereas lesser degrees of creatine kinase-MB elevation were not. If creatine kinase-MB is not available, cardiac troponin T or I may be substituted with a 7× higher threshold, and if the upper reference limit is unknown the upper limit of normal may be substituted. These data apply for patients with normal baseline biomarkers. If the biomarkers are elevated at baseline, other criteria may be used to diagnose a clinically relevant periprocedural myocardial infarction,<sup>3</sup> although these criteria were not evaluated in the EXCEL trial. Finally, while substantial myonecrosis after left main coronary artery disease revascularization has important prognosis implications, further studies are required to determine whether and how therapy might be adjusted in patients with periprocedural myocardial infarction so defined. Unless provided in the caption above, the following copyright applies to the content of this slide: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Eur Heart J, ehz113, https://doi.org/10.1093/eurheartj/ehz113 The content of this slide may be subject to copyright: please see the slide notes for details.