Association of peri‐procedural myocardial infarction with mortality after stenting true coronary bifurcation lesions: A pooled individual participant data analysis from four randomized controlled trials

Abstract

Background: Five definitions of peri-procedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) are used in clinical trials; their clinical relevance in coronary bifurcation stenting remains unclear.Objectives: To understand the correlation between PMI and mortality in bifurcation lesions from the DKCRUSH studies.Methods: PMI was defined using serum creatine kinase-myocardial band (CK-MB) values within 48 h of PCI according to the SYNTAX, Fourth Universal Definition of MI (4th UDMI), ISCHEMIA, SCAI, and EXCEL definitions. Overall, 1300 patients with both CK and CK-MB measurements pre-and post-stenting were evaluated. The association of each PMI type and all-cause death or cardiac death at a median of 5.58 years of follow-up was analyzed using Cox regression.Results: In total, 56 (4.3%) patients had PMI. According to SYNTAX, 4th UDMI or ISCHEMIA, SCAI, and EXCEL definitions, PMI occurred in 21 (1.6%), 56 (4.3%), 29 (2.2%), and 32 (2.5%) patients, respectively. All definitions were significantly correlated with unadjusted mortality at the end of follow-up but not at 30 days or 1-year after stenting. PMI using SYNTAX, SCAI, and EXCEL definitions rather than 4th UDMI definition was strongly associated with adjusted all-cause death. By adjusted analysis, PMI according to 4th UDMI, SCAI, and EXCEL definitions but not SYNTAX definition was positively correlated with cardiac death at a median of 5.58 years of follow-up. CK-MB ≥ 5 x UNL strongly enhanced the correlation of CK-MB values with mortality.Conclusions: PMI rate varies with the definition following stenting for bifurcation lesions. PMI defined by SCAI and EXCEL definitions is strongly correlates with adjusted all-cause and cardiac death.Imad Sheiban, Zhen Ge, and Jing Kan contributed equally to manuscript.

Provisional stenting with side branch rescue stenting is associated with increased 3-year target lesion failure in patients with acute coronary syndrome and coronary bifurcation lesions

“…In fact, our result showed a prediction of SB pretreatment for PMI. More recently, Sheiban et al ( 12 ) reported that PMI was positively correlated with TLF at 1-year follow-up after stenting bifurcation lesions. Conclusively, the routine performance of SB pretreatment before the PS procedures was not recommended by the current consortium ( 24 ) and previous clinical trials ( 4 – 9 ).…”

“…Spontaneous MI (after 48 h) was defined as a clinical syndrome consistent with MI with a CK-MB or troponin > 1 × URL and new ST-segment elevation or depression or other findings as above. All MIs were considered TVMI unless there was clear evidence that they were attributable to a non-target vessel ( 4 , 12 ). Clinically driven TLR was defined as angina or ischemia referable to the target lesion requiring repeat PCI or coronary artery bypass graft.…”

Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations

“…63 Unfortunately, evidence regarding this is scarce; however, it has been shown that PMIs defined by the Society for Cardiovascular Angiography and Interventions (SCAI) criteria, as opposed to the 4th Universal Definition of Myocardial Infarction (UDMI) or the SYNTAX definition, have the best correlation to adverse outcomes after stenting true bifurcations. 64 Furthermore, there are still debates about the most accurate cardiac biomarker to use, although in recent times the cardiology community has seen the extinction of creatine kinase-myocardial band (CK-MB) in favor of high-sensitivity cardiac troponin (hs-cTn). Nevertheless, the correlation among the many available type I hs-cTn assays is unclear and leaves room for potential differences between studies or incorrect endpoint definitions.…”