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[Periprocedural myocardial damage: chronicle of a (cellular) death foretold]
Michele Galli1, Alberto Genovesi Ebert
1U.O. di Cardiologia Ospedali Riuniti Azienda USL 6 Area Livornese Viale Alfieri, 36 57100 Livorno. m.galli@nord.usl6.toscana.it
Insights
Monitoring cardiac markers after percutaneous coronary intervention (PCI) is crucial. Current debates question the clinical significance of minor myocardial enzyme elevations post-PCI, emphasizing the need for standardized measurement protocols.
Area of Science:
- Cardiology
- Biomarker analysis
- Interventional cardiology
Background:
- Cardiac marker monitoring is standard after percutaneous coronary intervention (PCI).
- Physicians debate the significance of asymptomatic creatine phosphokinase elevations post-PCI.
- Detecting periprocedural damage depends on enzyme and ECG measurement intensity.
Discussion:
- The definition of acute myocardial infarction has expanded to include minor, asymptomatic biomarker elevations.
- Debate exists on the clinical relevance of CK-MB elevations (1-3x upper limit of normal) post-PCI.
- Skepticism surrounds the impact of minor cardiac marker elevations on survival after uncomplicated PCI.
Key Insights:
- Pre- and postprocedural ECGs and serial cardiac marker measurements are essential.
- Routine CK-MB level tracking is mandatory, even in asymptomatic patients post-PCI.
- A consensus on myocardial damage assessment post-PCI is needed.
Outlook:
- Standardized protocols will improve understanding of minor periprocedural myocardial damage.
- Better understanding will refine strategies for preventing and treating myocardial damage.
- Further research is needed to clarify long-term prognostic implications.
Abstract:
Cardiac marker monitoring after percutaneous coronary intervention (PCI) is now widespread; thus, the recognition of just how frequently myocardial enzyme elevations result from even successful PCI has become increasingly important, despite some physician's interest in minimizing the significance of isolated asymptomatic creatine phosphokinase elevations without an angiographically apparent cause. The meaningfulness of elevated cardiac enzymes after revascularization procedures is one of the most controversial issues in interventional cardiology. The rate of periprocedural damage detection is highly dependent on the intensity of enzyme and ECG measurement. With the use of more sensitive and specific cardiac markers of myocardial necrosis, the traditional definition of "acute myocardial infarction" has been expanded to include even small and asymptomatic biomarker elevations. On the other hand, most debate has focused on the clinical relevance of an elevation in CK-MB levels to 1 to 3 times the upper limit of normal, and many cardiologists argue that the appropriate cut-off point after PCI is even higher. Doubts whether "small" cardiac marker elevations have per se any impact on survival after uncomplicated procedures, as well as the excess of fideism on the effectiveness of contemporary coronary stenting couple with the mistaken equation "excellent angiographic result = excellent clinical outcome". Pre and postprocedural ECG recording and serial cardiac marker measurement should be incorporated into clinical pathways, and routine CK-MB levels tracking is now mandatory even in asymptomatic subjects having successful PCI. A consensus about how to check myocardial damage after PCI (i.e. which and how serum markers should be measured and reported) is eagerly awaited. A broader agreement will contribute to a better understanding of pathophysiology and long-term prognostic implications of "minor" periprocedural myocardial damage, allowing to improve our strategies to prevent and treat it.