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Mortality, adverse events found higher in patients with elevated biomarkers after nonemergent PCI
Feldman D. Catheter Cardiovasc Interv. 2011;doi:10.1002/ccd.22962.
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Elevation of cardiac troponin I and troponin T among patients who underwent nonemergent percutaneous coronary intervention was predictive of long-term all-cause mortality and a composite of adverse events in a new study.
All patients (n=22,353) in the analysis were compiled from 22 studies published between 1998 and 2009 that reported on the prognostic effect of cardiac troponin I (cTnI) and troponin T (cTnT). All-cause mortality was defined as the study’s primary endpoint.
In all, post-PCI cTnT or cTnI was elevated in 32% of patients. During a mean follow-up of 17.7 months, the primary endpoint was noticeably higher for patients with cTnI or cTnT elevation after PCI compared with patients without cTnI or cTnT elevation (OR=1.45; 95% CI, 1.22–1.72). Similarly, the composite of adverse events of all-cause mortality and MI in patients with cTnI or cTnT elevation was also higher (OR=1.77; 95% CI, 1.48-2.11).
“Our meta-analysis supports the ACC/AHA recommendation to monitor cTn markers post-PCI as to assess long-term clinical outcomes and to identify patients with high-risk coronary artery features,” the researchers wrote. “Further studies are needed to determine if peri-procedural efforts to minimize cTn elevations and more intensive outpatient monitoring/treatment of patients with elevated cTn levels after nonemergent PCI will result in improved long-term outcomes.” – by Brian Ellis
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Meta-analyses can be very valuable but can also be misleading. One of the major problems with almost all of the studies in this area is that they use a baseline value that with rare exception is markedly above the recommended cut off value of the 99th percentile. When one does this one ignores the prognostic significance of the baseline value and also fails to understand that the values are most often rising. Thus, the results post procedure are substantially more elevated. Some would say most of the increase is due the natural rise of the elevated baseline value and most often not the procedure. If one uses the 99th percentile value as to define normality at baseline, it turns out that most if not all of the prognostic significance resides in the baseline value and there is modest or perhaps no additional contribution of the post-intervention values either short- or long- term. Lack of attention to this critical metric has confounded all of the meta-analyses and most of the studies. If one uses the 99th percentile value to define a normal baseline as in the Prasad study, there is no additional prognostic value in the post-PCI values. Unfortunately, that is the only study that uses that value at baseline. Thus, one needs to consider this meta-analysis with great caution.
– Allan S. Jaffe, MD
Cardiology
Today Editorial Board member
Disclosure: Dr. Jaffe has acted as consultant for numerous companies that develop and manufacture blood tests.
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