Prognostic Impact of Periprocedural Myocardial Infarction in Patients Undergoing Elective Percutaneous Coronary Interventions.

BACKGROUND: The magnitude of prognostically relevant myocardial injury after percutaneous coronary interventions remains poorly defined. The Society for Cardiovascular Angiography and Interventions (SCAI) proposed marked biomarker elevations to define periprocedural myocardial infarction (PMI). These consensus-based thresholds have not been validated in the era of high-sensitivity cardiac troponins. We sought to assess the prognostic impact of SCAI-defined PMI and explore optimal prognostic thresholds of high-sensitivity cardiac troponin T (hs-cTnT) after elective percutaneous coronary interventions. METHODS AND RESULTS: We evaluated patients who underwent elective percutaneous coronary interventions at 2 tertiary care centers with serial hs-cTnT measurements. PMI was defined as peak postprocedural hs-cTnT >70× upper reference limit (URL) in patients with nonelevated (≤1× URL) baseline levels; or incremental increase >70× URL in patients with elevated baseline levels. The primary outcome was 1-year all-cause mortality. Of 8140 patients, 220 (2.7%) died within 1 year. In multivariable analyses, patients with SCAI-defined PMI (n=140; 1.7%) had a higher risk of 1-year mortality (12.9% versus 2.5%, adjusted hazard ratio 4.10, 95% CI 2.51-6.68; P<0.001) as well as cardiac mortality (11.4% versus 2.1%, adjusted hazard ratio 4.21, 95% CI 2.50-7.11; P<0.001). Based on receiver operating characteristics analysis, the optimal prognostic threshold of hs-cTnT was >10×URL, observed in 14.6% of patients. This threshold showed lower specificity (85.7% versus 98.4%) but higher sensitivity (25.4% versus 8.2%) and better overall performance for prediction of 1-year mortality compared with the SCAI-defined cutoff value of troponin. CONCLUSIONS: In patients undergoing elective percutaneous coronary interventions, SCAI-defined PMI emerged as an independent, highly specific, but insensitive predictor of 1-year mortality. Optimal trade-off between sensitivity and specificity was observed at a lower threshold of hs-cTnT (10× URL) in this cohort.

Comparison of Vascular Closure Devices Versus Manual Compression After Femoral Artery Puncture in Women.

BACKGROUND: The value of vascular closure devices (VCD) in women undergoing transfemoral catheterization has not been sufficiently investigated. METHODS AND RESULTS: This is a sex-specific analysis of 1395 women enrolled in a large-scale, randomized, multicenter trial, in which patients undergoing transfemoral diagnostic coronary angiography were randomly assigned in a 1:1:1 ratio to arteriotomy closure with an intravascular VCD, extravascular VCD, or manual compression (MC). Primary objective was to assess the safety and efficacy of 2 different VCD compared with MC regarding vascular access-site complications at 30 days. A secondary comparison was between 2 different types of contemporary VCD. Overall, women were at higher risk for vascular access-site complications compared with men (9.0% versus 6.4%; P=0.002). Vascular access-site complications were comparable in women assigned to VCD and MC (8.6% versus 9.8%; P=0.451). There was no interaction of treatment effect and sex ( Pinteraction=0.970). Time to hemostasis was significantly shortened with VCD compared with MC (1 [interquartile range, 0.5-2.0] minutes) versus 11 [interquartile range, 10-15] minutes; P<0.001); however, more women with VCD required repeat MC (2.4% versus 0.6%; P=0.018). The use of the intravascular compared with the extravascular VCD was associated with a numerical reduction in vascular access-site complications (6.6% versus 10.7%; P=0.027) and significant reductions in time to hemostasis and VCD failure. CONCLUSIONS: In women undergoing diagnostic coronary angiography via the common femoral artery, VCD and MC provided comparable safety, while time to hemostasis was reduced with VCD. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01389375.

Markers of Reperfusion and Long-Term (8-Year) Prognosis after Primary Percutaneous Coronary Intervention.

Thrombolysis in Myocardial Infarction (TIMI) flow, myocardial perfusion grade (MPG), and infarct size are established markers of reperfusion in patients with ST-segment elevation myocardial infarction. Whether these markers provide long-term prognostic information remains unknown. This study included 1,406 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention. Postreperfusion TIMI flow, MPG, and infarct size (evaluated by scintigraphy at 7 to 14 days) were measured. The primary outcome was 8-year mortality. Overall there were 190 deaths. The Kaplan-Meier estimates of mortality were 22.6% (37 deaths) and 16.8% (153 deaths) according to TIMI flow ≤2 and TIMI flow 3 (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.66 to 1.00, p = 0.058 for 1 grade increment), 21.6% (106 deaths) and 14.5% (84 deaths) according to MPG ≤2 and MPG 3 (adjusted HR 0.87 [0.77 to 0.98], p = 0.020 for 1 grade increment) and 21.7% (115 deaths) and 13.7% (75 deaths) according to infarct size >10% (median value) and infarct size ≤10% of the left ventricle (adjusted HR 1.08 [1.03 to 1.13], p = 0.001, for 5% of left ventricle increment in infarct size). The C statistic of the model for all-cause mortality was 0.810 (0.781 to 0.839) with baseline variables, 0.812 (0.783 to 0.841) after incorporation of TIMI flow (P for significance compared to the model with baseline variables = 0.140), 0.813 (0.784 to 0.841) after incorporation of MPG (p = 0.345) and 0.815 (0.786 to 0.842) after incorporation of infarct size (p = 0.08). In conclusion, markers of reperfusion independently predict long-term mortality after primary percutaneous coronary intervention but offer limited incremental prognostic value to that provided by evaluation of baseline cardiovascular risk factors and clinical data.

High-sensitivity cardiac troponin T and prognosis in patients with ST-segment elevation myocardial infarction.

BACKGROUND: Evidence on the use of high-sensitivity cardiac troponins (hs-cTn) to risk-stratify patients with ST-segment elevation myocardial infarction (STEMI) is limited. METHODS: We assessed the prognostic value of preprocedural (admission) and peak postprocedural hs-cTnT in 818 patients with STEMI treated with primary percutaneous coronary intervention (PPCI). Preprocedural and peak postprocedural hs-cTnT was measured. The primary outcome was 3-year all-cause mortality. RESULTS: The median values of preprocedural and peak postprocedural hs-cTnT were 153ng/L and 1980ng/L. Overall, 134 patients died during the follow-up. There were 85 deaths in patients with preprocedural hs-cTnT >median value and 49 deaths in patients with preprocedural hs-cTnT ≤median value [Kaplan-Meier estimates of mortality, 22.2% and 13.5%; unadjusted hazard ratio (HR)=1.88, 95% confidence interval (CI) 1.32-2.67, p<0.001]. According to peak postprocedural hs-cTnT, there were 84 deaths in patients with postprocedural hs-cTnT >median value and 50 deaths in patients with postprocedural hs-cTnT ≤median value [Kaplan-Meier estimates of mortality, 22.3% and 13.4%; unadjusted HR=1.82 (1.28-2.59), p<0.001]. After adjustment, preprocedural [adjusted HR=1.08 (1.03-1.12), p<0.001] and peak postprocedural hs-cTnT value [adjusted HR=1.06 (1.04-1.08), p<0.001] were independently associated with 3-year mortality (with risk estimates calculated per 70×99th upper reference limit of hs-cTnT). The C statistic of multivariable model increased from 0.868 (0.841-0.895) to 0.872 (0.845-0.898) after incorporation of preprocedural hs-cTnT (p=0.050) and to 0.874 (0.846-0.899) after incorporation of the postprocedural hs-cTnT into the model (p=0.035). CONCLUSIONS: In conclusion, admission or peak postprocedural hs-cTnT is independently associated with the risk for 3-year mortality in patients with STEMI undergoing PPCI.

Comparative prognostic value of postprocedural creatine kinase myocardial band and high-sensitivity troponin T in patients with non-ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention.

OBJECTIVES: We aimed to assess the prognostic value of postprocedural creatine kinase myocardial band (CK-MB) and cardiac troponin (cTn) in patients with non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND: Whether postprocedural CK-MB or cTn is a better biomarker to stratify the risk after percutaneous coronary intervention (PCI) remains unknown. METHODS: This study included 2,077 patients with NSTEMI undergoing early PCI. Peak postprocedural values of CK-MB and high-sensitivity cTn T (hs-cTnT) were analyzed. The primary outcome was 3-year mortality. RESULTS: The median values of peak postprocedural CK-MB and hs-cTnT were 18.3 U L-1 and 0.140 µg L-1 , respectively. Overall, 211 patients died during follow-up. There were 129 deaths in patients with CK-MB >the median value and 82 deaths in those with CK-MB ≤the median value (Kaplan-Meier estimates of 3-year mortality, 18.9% and 14.0%, respectively; hazard ratio [HR] = 1.52, 95% confidence interval [CI] 1.16-2.01; P < 0.001). There were 134 deaths in patients with hs-cTnT >the median value and 77 deaths in patients with hs-cTnT ≤the median value (Kaplan-Meier estimates of 3-year mortality, 19.9% and 13.2%, respectively; HR = 1.90 [1.44-2.52]; P < 0.001). After adjustment, peak postprocedural CK-MB (adjusted HR = 1.05 [1.02-1.07], P < 0.001 for each 24 U L-1 increment) and hs-cTnT (adjusted HR = 1.12 [1.01-1.25], P = 0.037 for each unit higher log hs-cTnT) remained independently associated with the risk of 3-year mortality. The C-statistic(s) of the model with CK-MB and hs-cTnT were 0.789 [0.757-0.817] and 0.793 [0.762-0.821], respectively (P = 0.585). CONCLUSION: In patients with NSTEMI undergoing early PCI, peak postprocedural CK-MB and hs-cTnT are independently associated with the risk of 3-year mortality. © 2017 Wiley Periodicals, Inc.

High-Sensitivity Troponin T and Mortality After Elective Percutaneous Coronary Intervention.

BACKGROUND: The prognostic value of high-sensitivity troponin T (hs-TnT) elevation after elective percutaneous coronary intervention (PCI) in patients with or without raised baseline hs-TnT levels is unclear. OBJECTIVES: The goal of this study was to assess whether the prognostic value of post-procedural hs-TnT level after elective PCI depends on the baseline hs-TnT level. METHODS: This study included 5,626 patients undergoing elective PCI who had baseline and peak post-procedural hs-TnT measurements available. The primary outcome was 3-year mortality (with risk estimates calculated per SD increase of the log hs-TnT scale). RESULTS: Patients were divided into 4 groups: nonelevated baseline and post-procedural hs-TnT levels (hs-TnT ≤0.014 µg/l; n = 742); nonelevated baseline but elevated post-procedural hs-TnT levels (peak post-procedural hs-TnT >0.014 µg/l; n = 2,721); elevated baseline hs-TnT levels (hs-TnT >0.014 µg/l) with no further rise post-procedure (n = 516); and elevated baseline hs-TnT levels with a further rise post-procedure (n = 1,647). A total of 265 deaths occurred: 6 (1.6%) in patients with nonelevated baseline and post-procedural hs-TnT levels; 54 (3.8%) in patients with nonelevated baseline but elevated post-procedural hs-TnT levels; 50 (16.0%) in patients with elevated baseline hs-TnT levels with no further rise post-procedure; and 155 (18.2%) in patients with elevated baseline hs-TnT levels with a further rise post-procedure (p < 0.001). After adjustment, baseline hs-TnT levels (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 1.09 to 1.38; p < 0.001) but not peak post-procedural hs-TnT levels (HR: 1.04; 95% CI: 0.85 to 1.28; p = 0.679) were associated with an increased risk of mortality. Peak post-procedural hs-TnT findings were not associated with mortality in patients with nonelevated (HR: 0.93; 95% CI: 0.69 to 1.25; p = 0.653) or elevated (HR: 1.24; 95% CI: 0.91 to 1.69; p = 0.165) baseline hs-TnT levels. CONCLUSIONS: In patients with coronary artery disease undergoing elective PCI, an increase in post-procedural hs-TnT level did not offer prognostic information beyond that provided by the baseline level of the biomarker.

Prognostic value of gamma-glutamyl transferase in patients with diabetes mellitus and coronary artery disease.

OBJECTIVES: The aim of the study was to investigate the association between gamma-glutamyl transferase (GGT) activity and mortality in patients with diabetes mellitus and coronary artery disease (CAD). DESIGN AND METHODS: The study included 1448 patients with diabetes and angiography-proven CAD who underwent percutaneous coronary intervention (PCI). Baseline GGT measurements were available in all patients. The primary outcome was 3-year mortality. RESULTS: Patients were divided into 3 groups: a group consisting of patients with a GGT activity in the 1st tertile (GGT≤29.4U/L; n=487), a group consisting of patients with a GGT activity in the 2nd tertile (GGT>29.4-52.5U/L; n=479) and a group consisting of patients with GGT in the 3rd tertile (GGT>52.5U/L; n=482). Overall, there were 179 deaths: 46 (11.9%), 49 (12.1%) and 84 deaths (21.4%) among patients of the 1st, 2nd and 3rd GGT tertiles, respectively (adjusted hazard ratio [HR]=1.25, 95% confidence interval [CI] 1.05-1.49, P=0.011). Cardiac death occurred in 101 patients: 22 (5.8%), 30 (7.2%) and 49 deaths (12.9%) among patients of the 1st, 2nd and 3rd GGT tertiles, respectively (adjusted HR=1.23 [0.96-1.58], P=0.104, with risk estimates calculated per standard deviation increase in the logarithmic scale of GGT). GGT improved the risk prediction of models of all-cause (P=0.020) but not cardiac (P=0.135) mortality (P values show the difference in C-statistics between the models without and with GGT). CONCLUSION: In patients with diabetes and CAD treated with PCI, elevated GGT was independently associated with the risk of 3-year all-cause mortality.