Periprocedural Myocardial Injury and MI Associated With PCI
- Bulluck H, Paradies V, Barbato E, et al.
- Prognostically Relevant Periprocedural Myocardial Injury and Infarction Associated With Percutaneous Coronary Interventions: A Consensus Document of the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2021;May 31:[Epub ahead of print].
The following are key points to remember from this European consensus document on prognostically relevant periprocedural myocardial injury and infarction associated with percutaneous coronary interventions (PCIs):
- This consensus document aimed to establish the cut-off thresholds of cardiac troponin (cTn) to define prognostically relevant periprocedural myocardial injury and type 4a myocardial infarction (MI) (Universal Definition of MI) among patients with chronic coronary syndrome (CCS) undergoing PCI.
- Side-branch occlusion, distal embolization, coronary dissection, and endothelial dysfunction are potential mechanisms of post-PCI myocardial injury and type 4a MI.
- Several patient-related factors (advanced age, renal failure, diabetes mellitus), lesion characteristics (calcification, vein graft interventions), and procedural factors (multivessel PCI, long treated segments) are independently associated with post-PCI injury or type 4a MI.
- Optimum threshold for independently predicting all-cause mortality at 1-year post-PCI in CCS patients with normal baseline (pre-PCI) cTn values was >5x 99th percentile upper reference limit (URL).
- Post-PCI cTn should be measured 3-6 hours post-PCI and repeated at 12-24 hours if elevated.
- Main categorization includes PCI-related minor myocardial injury, PCI-related major myocardial injury, and PCI-related MI (Type 4a MI).
- Minor periprocedural myocardial injury is defined as cTn >1x and <5x 99th percentile URL. This is the most common type and is not an independent predictor of major adverse cardiac events (MACE) in CCS.
- Major periprocedural myocardial injury is defined as >5x 99th percentile URL increase of cTn values <48 hours after PCI in CCS patients with normal baseline cTn values without evidence of new myocardial ischemia by electrocardiography (ECG)/angiography or imaging. Overall incidence is <20% and is associated with increased risk of all-cause mortality at 1 year.
- Type 4a MI is present when there is >5x 99th percentile URL increase of cTn values <48 hours after PCI in CCS patients with normal baseline cTn values plus new evidence of ischemia either on ECG, imaging, angiography, or post-mortem examination. Although incidence is low (7-10%), it is associated with increased risk of MACE at 30 days and 1 year.
- Optimal pharmacotherapy strategies to reduce the risk of future cardiac events among patients with post-PCI major injury and type 4 MI remains to be determined.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Angiography, Coronary Artery Disease, Coronary Occlusion, Diabetes Mellitus, Diagnostic Imaging, Dissection, Electrocardiography, Embolization, Therapeutic, Myocardial Infarction, Myocardial Ischemia, Myocardium, Percutaneous Coronary Intervention, Renal Insufficiency, Secondary Prevention, Troponin
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