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Impact of Peri-Procedural Myocardial Infarction on Outcomes After Revascularization
Hironori Hara1, Patrick W Serruys2, Kuniaki Takahashi3
1Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.
Background:
Numerous definitions for peri-procedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG) surgery exist.
Objectives:
The purpose of this study was to investigate the PMI rates according to various definitions, their clinically relevant association with all-cause mortality at 10 years, and their impact on composite endpoints at 5 years in the SYNTAXES (Synergy between PCI with Taxus and Cardiac Surgery Extended Survival) trial.
Methods:
PMI was classified as a myocardial infarction occurring within 48 h of the procedure according to definitions of the SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries), ISCHEMIA (International Study Of Comparative Health Effectiveness With Medical And Invasive Approaches), and EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trials; the Fourth Universal Definition of MI; and the Society for Cardiovascular Angiography and Interventions (SCAI). Of the 1,800 patients enrolled, 1,652 with creatine kinase and/or creatine kinase-myocardial band (CK-MB) post-procedure were included. The association between PMI and mortality was analyzed by Cox regression.
Results:
PMI rates according to the SYNTAX and Fourth Universal Definition of MI, both of which required CK-MB elevation and electrocardiographic evidence of permanent myocardial damage, were 2.7% and 3.0%, respectively, in the PCI arm versus 2.4% and 2.1%, respectively, in the CABG arm. PMI rates according to the SCAI or EXCEL definition were higher in the PCI (5.7%) and CABG (16.5%) arms. PMIs according to the SYNTAX and Fourth Universal Definition of MI were more strongly associated with mortality than EXCEL and SCAI PMIs defined by isolated enzyme elevation when CK-MB was more than 10 times ULN. The impact of these "enzyme-driven events" on time-to-event curves and the composite endpoints was greater in the surgical cohort. PMIs after PCI were associated with 10-year mortality regardless of definition, whereas their impact on mortality after CABG was limited to 1 year.
Conclusions:
The rates of PMI are highly dependent on their definition, which affects time-to-event curves, composite endpoints, and their lethal prognostic relevance. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).
Insights
The definition of peri-procedural myocardial infarction (PMI) significantly impacts its rate and association with mortality after PCI and CABG. Strict definitions are more predictive of long-term outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Numerous definitions exist for peri-procedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG).
- Understanding PMI is crucial for assessing outcomes after revascularization procedures.
Purpose of the Study:
- To investigate PMI rates using various definitions.
- To assess the association of these definitions with 10-year all-cause mortality.
- To evaluate the impact of PMI on 5-year composite endpoints within the SYNTAXES trial.
Main Methods:
- PMI was defined based on criteria from SYNTAX, ISCHEMIA, EXCEL trials, the Fourth Universal Definition of MI, and SCAI.
- 1,652 patients with creatine kinase (CK) and/or creatine kinase-myocardial band (CK-MB) data were analyzed.
- Cox regression was used to analyze the association between PMI and mortality.
Main Results:
- PMI rates varied significantly by definition, with higher rates for SCAI or EXCEL definitions in both PCI and CABG arms.
- SYNTAX and Fourth Universal Definition of MI criteria (requiring CK-MB elevation and ECG changes) showed stronger association with mortality.
- PMI after PCI was linked to 10-year mortality, while impact on CABG mortality was mainly within 1 year.
Conclusions:
- The definition of PMI critically influences event rates, prognostic relevance, and composite endpoint analysis.
- Careful consideration of PMI definitions is essential for accurate outcome assessment in cardiovascular interventions.
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