Myonecrosis After Revascularization Procedures

Abstract

The detection of elevated cardiac enzyme levels and the occurrence of electrocardiographic (ECG) abnormalities after revascularization procedures have been the subject of recent controversy. This report represents an effort to achieve a consensus among a group of researchers with data on this subject. Creatine kinase (CK) or CK-MB isoenzyme (CK-MB) elevations occur in 5% to 30% of patients after a percutaneous intervention and commonly during coronary artery bypass graft surgery (CABG). Although Q wave formation is rare, other ECG changes are common. The rate of detection is highly dependent on the intensity of enzyme and ECG measurement. Because most events occur without the development of a Q wave, the ECG will not definitively diagnose them; even the ECG criteria for Q wave formation signifying an important clinical event have been variable. At least 10 studies evaluating > 10,000 patients undergoing percutaneous intervention have demonstrated that elevation of CK or CK-MB is associated not only with a higher mortality, but also with a higher risk of subsequent cardiac events and higher cost. Efforts to identify a specific cutoff value below which the prognosis is not impaired have not been successful. Rather, the risk of adverse outcomes increases with any elevation of CK or CK-MB and increases further in proportion to the level of intervention. This information complements similar previous data on CABG. Obtaining preprocedural and postprocedural ECGs and measurement of serial cardiac enzymes after revascularization are recommended. Patients with enzyme levels elevated more than threefold above the upper limit of normal or with ECG changes diagnostic for Q wave myocardial infarction (MI) should be treated as patients with an MI. Patients with more modest elevations should be observed carefully. Clinical trials should ensure systematic evaluation for myocardial necrosis, with attention paid to multivariable analysis of risk factors for poor long-term outcome, to determine the extent to which enzyme elevation is an independent risk factor after considering clinical history, coronary anatomy, left ventricular function and clinical evidence of ischemia. In addition, tracking of enzyme levels in clinical trials is needed to determine whether interventions that reduce periprocedural enzyme elevation also improve mortality.

Same-day transfer of patients with unstable angina and non-ST segment elevation myocardial infarction back to their referring hospital after angioplasty

“…The rate of PCI-related MI in our patients (4.8%) was consistent with the rate reported in the literature (6,7). However, no abrupt vessel closure was observed in the present study.…”

Avaliação comparativa do valor prognóstico de quatro marcadores bioquímicos de lesão miocárdica pós intervenções percutâneas utilizando stents coronarianos

“…In only one patient, that value was exceeded, characterizing periprocedure infarction. The percentage of elevations in CK-MB activity in our study are lower than those reported in the literature, usually occurring in 15 to 25% of the patients 2,6,7 . This may be attributed to the exclusion of patients more prone to enzyme release (patients with lesions in the saphenous vein graft and those with recent acute coronary syndrome) 8,9 , and also to the influence of the technical characteristics and controlled invasiveness strategy that characterized our interventions (total time of balloon inflation < 120 seconds in 87% of the patients, maximum pressure of stent deployment ≤ 16 atmospheres in 70%, direct implantation of the prosthesis in 45% of the patients).…”

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The systematic assessment of total creatine kinase (total CK) and its MB subfraction (CK-MB) after percutaneous coronary intervention shows that 5% to 40% of the patients successfully treated have an elevation in the serum level of those enzymes, which may represent a certain degree of myocardial necrosis [1][2][3] . Recently, the analysis of other very sensitive biochemical markers specific for identifying myocardial damage (CK-MB mass, troponins T and I) has intensified the detection of that phenomenon, which has been much more frequently observed with the implantation of coronary stents 4,5 .

This study aimed at establishing the clinical meaning of those alterations and their impact on the occurrence of adverse cardiac events.

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Temporal changes in circulating P-selectin, plasminogen activator inhibitor-1, magnesium, and creatine kinase after percutaneous coronary intervention

“…CK-MB is a sensitive marker of myonecrosis and has been detected in 5%-50% of patients after PCI (Abdelmeguid and Topol, 1996;Califf et al, 1998;Kanaparti and Brown, 2000). The levels of serum CK-MB were significantly elevated after PCI, but values were still within the normal range, indicating that PCI induced a low-grade injury but not necrosis of the myocardium.…”