1. 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
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2. 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
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3. 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
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4. 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
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5. 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
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6. 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
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7. 30-Day Mortality According to Periprocedural cTnT Levels
Kaplan-Meier Estimates
Pre 0.01
P<0.001
2.3%
Independent predictor
HR 22.4 ( ); P=0.001
Mortality (%)
Independent predictor
HR 6.00 ( ); 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
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8. Pre-PCI Troponin and Long-Term Mortality
<0.01
>
>
>
>1.0
P<0.001
Death or MI (%)
Months from PCI
Prasad et al: Circ Cardiovasc Intervent 1:10, 2008
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9. Post-PCI Troponin and Long-Term Mortality
<0.01
>
>
>
>1.0
P<0.001
Mortality (%)
Months from PCI
Prasad et al: Circ Cardiovasc Intervent 1:10, 2008
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10. 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
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11. Multivariable Cox Model for Long-Term Risk of Death
95% hazard Variable 2 Hazard ratio ratio CL P
Pre-PCI cTnT elevation , 2.39 <0.001
Age * … <0.001
Congestive heart failure , 2.65 <0.001
Body mass index * … <0.001
Chronic renal failure , 3.16 <0.001
Diabetes , 1.97 <0.001
Ejection fraction * …
Cerebrovascular disease ,
Smoking ,
Isolated post-PCI cTnT elevation ,
Prasad et al: Circ Cardiovasc Intervent 1:10, 2008
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12. 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
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