TY - JOUR
T1 - Implications of Alternative Definitions of Peri-Procedural Myocardial Infarction After Coronary Revascularization
AU - Gregson, John
AU - Stone, Gregg W.
AU - Ben-Yehuda, Ori
AU - Redfors, Björn
AU - Kandzari, David E.
AU - Morice, Marie Claude
AU - Leon, Martin B.
AU - Kosmidou, Ioanna
AU - Lembo, Nicholas J.
AU - Brown, W. Morris
AU - Karmpaliotis, Dimitri
AU - Banning, Adrian P.
AU - Pomar, Jose
AU - Sabaté, Manel
AU - Simonton, Charles A.
AU - Dressler, Ovidiu
AU - Kappetein, Arie Pieter
AU - Sabik, Joseph F.
AU - Serruys, Patrick W.
AU - Pocock, Stuart J.
N1 - Publisher Copyright:
© 2020 American College of Cardiology Foundation
PY - 2020/10/6
Y1 - 2020/10/6
N2 - Background: Varying definitions of procedural myocardial infarction (PMI) are in widespread use. Objectives: This study sought to determine the rates and clinical relevance of PMI using different definitions in patients with left main coronary artery disease randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) surgery in the EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: The pre-specified protocol definition of PMI (PMIProt) required a large elevation of creatine kinase-MB (CK-MB), with identical threshold for both procedures. The Third Universal Definition of MI (types 4a and 5) (PMIUD) required lesser biomarker elevations but with supporting evidence of myocardial ischemia, different after PCI and CABG. For the PMIUD, troponins were used preferentially (available in 49.5% of patients), CK-MB otherwise. The multivariable relationship between each PMI type and 5-year mortality was determined. Results: PMIProt occurred in 34 of 935 (3.6%) patients after PCI and 56 of 923 (6.1%) patients after CABG (difference −2.4%; 95% confidence interval [CI]: −4.4% to −0.5%; p = 0.015). The corresponding rates of PMIUD were 37 (4.0%) and 20 (2.2%), respectively (difference 1.8%; 95% CI: 0.2% to 3.4%; p = 0.025). Both PMIProt and PMIUD were associated with 5-year cardiovascular mortality (adjusted hazard ratio [HR]: 2.18 [95% CI: 1.13 to 4.23] and 2.87 [95% CI: 1.44 to 5.73], respectively). PMIProt was associated with a consistent hazard of cardiovascular mortality after both PCI and CABG (pinteraction = 0.86). Conversely, PMIUD was strongly associated with cardiovascular mortality after CABG (adjusted HR: 11.94; 95% CI: 4.84 to 29.47) but not after PCI (adjusted HR: 1.14; 95% CI: 0.35 to 3.67) (pinteraction = 0.004). Results were similar for all-cause mortality and with varying PMIUD biomarker definitions. Only large biomarker elevations (CK-MB ≥10× upper reference limit and troponin ≥70× upper reference limit) were associated with mortality. Conclusions: The rates of PMI after PCI and CABG vary greatly with different definitions. In the EXCEL trial, the pre-specified PMIProt was associated with similar hazard after PCI and CABG, whereas PMIUD was strongly associated with mortality after CABG but not after PCI.
AB - Background: Varying definitions of procedural myocardial infarction (PMI) are in widespread use. Objectives: This study sought to determine the rates and clinical relevance of PMI using different definitions in patients with left main coronary artery disease randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) surgery in the EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. Methods: The pre-specified protocol definition of PMI (PMIProt) required a large elevation of creatine kinase-MB (CK-MB), with identical threshold for both procedures. The Third Universal Definition of MI (types 4a and 5) (PMIUD) required lesser biomarker elevations but with supporting evidence of myocardial ischemia, different after PCI and CABG. For the PMIUD, troponins were used preferentially (available in 49.5% of patients), CK-MB otherwise. The multivariable relationship between each PMI type and 5-year mortality was determined. Results: PMIProt occurred in 34 of 935 (3.6%) patients after PCI and 56 of 923 (6.1%) patients after CABG (difference −2.4%; 95% confidence interval [CI]: −4.4% to −0.5%; p = 0.015). The corresponding rates of PMIUD were 37 (4.0%) and 20 (2.2%), respectively (difference 1.8%; 95% CI: 0.2% to 3.4%; p = 0.025). Both PMIProt and PMIUD were associated with 5-year cardiovascular mortality (adjusted hazard ratio [HR]: 2.18 [95% CI: 1.13 to 4.23] and 2.87 [95% CI: 1.44 to 5.73], respectively). PMIProt was associated with a consistent hazard of cardiovascular mortality after both PCI and CABG (pinteraction = 0.86). Conversely, PMIUD was strongly associated with cardiovascular mortality after CABG (adjusted HR: 11.94; 95% CI: 4.84 to 29.47) but not after PCI (adjusted HR: 1.14; 95% CI: 0.35 to 3.67) (pinteraction = 0.004). Results were similar for all-cause mortality and with varying PMIUD biomarker definitions. Only large biomarker elevations (CK-MB ≥10× upper reference limit and troponin ≥70× upper reference limit) were associated with mortality. Conclusions: The rates of PMI after PCI and CABG vary greatly with different definitions. In the EXCEL trial, the pre-specified PMIProt was associated with similar hazard after PCI and CABG, whereas PMIUD was strongly associated with mortality after CABG but not after PCI.
KW - coronary artery bypass grafting surgery
KW - coronary artery disease
KW - left main disease
KW - myocardial infarction
KW - percutaneous coronary intervention
KW - prognosis
KW - revascularization
UR - https://www.scopus.com/pages/publications/85091246383
U2 - 10.1016/j.jacc.2020.08.016
DO - 10.1016/j.jacc.2020.08.016
M3 - Article
C2 - 33004126
AN - SCOPUS:85091246383
SN - 0735-1097
VL - 76
SP - 1609
EP - 1621
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 14
ER -
