The myocardial injury occurring during revascularization interventions, such as coronary artery by-pass grafting (CABG) and percutaneous coronary intervention (PCI), is generally defined as periprocedural myocardial injury (PMI) and is identified by elevated cardiac biomarkers following the procedure.
In the sub-study of the EXCEL trial by Ben-Yehuda et al., PMI was defined as an increase in creatinine kinase-MB (CK-MB) within 72 hours after the procedure, and greater than 10 times the upper reference limit (URL) or greater than 5 times the URL together with angiographic artery occlusion, new pathological Q-waves or myocardial tissue loss on imaging. In 1858 patients with left main coronary disease, randomized to undergo CABG (n=923) or PCI with everolimus-eluting stent (n=935), the incidence of PMI and its association with 3-year prognosis were assessed.
PMI occurred more frequently in the CABG group (n=56) than in the PCI group (n=34) [OR: 0.61, 95% CI 0.40 to 0.93, p=0.02]. The presence of PMI was associated with an increased risk of cardiovascular death (aHR: 2.63, 95% CI 1.19 to 5.81, p=0.02) and all-cause death (aHR: 2.28, 95% CI 1.22 to 4.29, p=0.01) at 3 years, both after PCI and CABG, as compared to patients without PMI. However, only an elevation of CK-MB greater than 10 times the URL was prognostically significant in predicting 3-year mortality (aHR: 2.94, 95% CI 1.31 to 6.59, p=0.01).
Therefore, the assessment of cardiac biomarkers following left main revascularization procedures has an important prognostic value and could be routinely adopted in future investigations and clinical practice.
OR: odds ratio
aHR: adjusted hazard ratio (model adjusted for age, sex, hypertension, diabetes mellitus, chronic obstructive lung disease, left ventricular ejection fraction, SYNTAX score, baseline biomarker elevation, treatment)
Author: Lorena Casadonte, Cardiology Update