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Periprocedural myocardial injury linked to long-term mortality risk in CTO PCI
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In patients who undergo successful PCI for chronic total occlusion, the occurrence of periprocedural myocardial injury is linked to higher long-term mortality risk, according to recent findings.
In the retrospective study, researchers analyzed data on 1,058 patients (1,076 lesions; 82.5% men) enrolled in the CTO registry database, which prospectively recruits consecutive patients undergoing attempted CTO PCI at the Asan Medical Center in Seoul, South Korea. The researchers included all patients treated successfully with PCI using a drug-eluting stent for a minimum of one CTO lesion between March 2003 and August 2014. Eligible patients also underwent testing of creatine kinase-myocardial band (CK-MB) values using sandwich immunoassay 1 to 3 hours before PCI and at 6 hours after PCI.
The researchers defined periprocedural myocardial injury as an increase of CK-MB more than three times the upper limit in cases where the baseline CK-MB was normal.
The primary endpoint was mortality during a median 4.4 years of follow-up. Deaths were considered cardiac in the absence of an unequivocal, noncardiac cause. Events were adjudicated by an independent group of physicians.
The researchers determined that 121 patients (11.4%) experienced periprocedural myocardial injury.
In a multivariable analysis, the researchers identified the following variables as being predictive of periprocedural myocardial injury: renal failure (OR = 4.25; 95% CI, 1.59-11.35); attempted retrograde approach (OR = 2.27; 95% CI, 1.34-3.84); simultaneous non-target lesion intervention (OR = 1.74; 95% CI, 1.17-2.59) and number of stents (OR = 1.38; 95% CI, 1.08-1.77). During follow-up, 89 (8.4%) patients died, and 59 of these patients died of a cardiac cause. Q-wave MI occurred in 13 patients and stroke occurred in eight patients.
Patients with periprocedural myocardial injury during CTO PCI had significantly higher unadjusted rates of mortality (HR =1.96; 95% CI, 1.17-3.28) and cardiac mortality (HR = 1.92; 95% CI, 1.02-3.63) vs. those who did not have periprocedural myocardial injury.
After adjusted analysis using a Cox proportional hazards model, the association between periprocedural myocardial injury and increased risk for mortality was maintained (adjusted HR = 1.86; 95% CI, 1.09-3.17). In an analysis using a higher CK-MB cutoff to define periprocedural myocardial injury, these findings persisted, according to the researchers.
Although a trend was revealed toward higher all-cause death with increasing peak CK-MB levels, multivariable analyses found this association to retain statistical significance only for peak CK-MB levels of more than 10 times the upper reference limit.
“In patients undergoing successful PCI for CTO, those with renal insufficiency and who require a greater number of stents, multiple lesion treatment and a retrograde approach entail a greater risk of [periprocedural myocardial injury], which is associated with an increased risk of long-term mortality,” the researchers wrote. “The mechanism linking [periprocedural myocardial injury] and patient mortality should be determined by further investigations. It will be also important to define optimal strategies to prevent [periprocedural myocardial injury] for those in whom complex procedures are expected.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.
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