Myonecrosis after revascularization procedures

Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA. calif001@mc.duke.edu

The detection of elevated cardiac enzyme levels and the occurrence of electrocardiographic (ECG) abnormalities after revascularization procedures have been the subject of recent controversy. This report represents an effort to achieve a consensus among a group of researchers with data on this subject. Creatine kinase (CK) or CK-MB isoenzyme (CK-MB) elevations occur in 5% to 30% of patients after a percutaneous intervention and commonly during coronary artery bypass graft surgery (CABG). Although Q wave formation is rare, other ECG changes are common. The rate of detection is highly dependent on the intensity of enzyme and ECG measurement. Because most events occur without the development of a Q wave, the ECG will not definitively diagnose them; even the ECG criteria for Q wave formation signifying an important clinical event have been variable. At least 10 studies evaluating > 10,000 patients undergoing percutaneous intervention have demonstrated that elevation of CK or CK-MB is associated not only with a higher mortality, but also with a higher risk of subsequent cardiac events and higher cost. Efforts to identify a specific cutoff value below which the prognosis is not impaired have not been successful. Rather, the risk of adverse outcomes increases with any elevation of CK or CK-MB and increases further in proportion to the level of intervention. This information complements similar previous data on CABG. Obtaining preprocedural and postprocedural ECGs and measurement of serial cardiac enzymes after revascularization are recommended. Patients with enzyme levels elevated more than threefold above the upper limit of normal or with ECG changes diagnostic for Q wave myocardial infarction (MI) should be treated as patients with an MI. Patients with more modest elevations should be observed carefully. Clinical trials should ensure systematic evaluation for myocardial necrosis, with attention paid to multivariable analysis of risk factors for poor long-term outcome, to determine the extent to which enzyme elevation is an independent risk factor after considering clinical history, coronary anatomy, left ventricular function and clinical evidence of ischemia. In addition, tracking of enzyme levels in clinical trials is needed to determine whether interventions that reduce periprocedural enzyme elevation also improve mortality.

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				M. A. Costa, R. G. Carere, S. V. Lichtenstein, D. P. Foley, V. de Valk, W. Lindenboom, P. C.H. Roose, T. R. van Geldorp, C. Macaya, J. L. Castanon, et al. Incidence, Predictors, and Significance of Abnormal Cardiac Enzyme Rise in Patients Treated With Bypass Surgery in the Arterial Revascularization Therapies Study (ARTS) Circulation, November 27, 2001; 104(22): 2689 - 2693. [Abstract] [Full Text] [PDF]

				N. Danchin Recent advances in cardioprotection during myocardial revascularization procedures: benefit of a metabolic intervention Eur. Heart J. Suppl., November 1, 2001; 3(suppl_O): O21 - O25. [Abstract] [PDF]

				M. Yacoub Off-Pump Coronary Bypass Surgery: In Search of an Identity Circulation, October 9, 2001; 104(15): 1743 - 1745. [Full Text] [PDF]

				D. van Dijk, A. P. Nierich, E. W.L. Jansen, H. M. Nathoe, W. J.L. Suyker, J. C. Diephuis, W.-J. van Boven, C. Borst, E. Buskens, D. E. Grobbee, et al. Early Outcome After Off-Pump Versus On-Pump Coronary Bypass Surgery: Results From a Randomized Study Circulation, October 9, 2001; 104(15): 1761 - 1766. [Abstract] [Full Text] [PDF]

				K. Klatte, B. R. Chaitman, P. Theroux, J. A. Gavard, K. Stocke, S. Boyce, C. Bartels, B. Keller, A. Jessel, and for the GUARDIAN Investigators Increased mortality after coronary artery bypass graft surgery is associated with increased levels of postoperative creatine kinase-myocardial band isoenzyme release: Results from the GUARDIAN trial J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1070 - 1077. [Abstract] [Full Text] [PDF]

				D. R. Holmes Jr and P. B. Berger Troponisms, Necrosettes, Enzyme Leaks, Creatinine Phosphokinase Bumps, and Infarctlets: What's Behind This New Lexicon and What Does It Add? Circulation, August 7, 2001; 104(6): 627 - 629. [Full Text] [PDF]

				G. W. Stone, R. Mehran, G. Dangas, A. J. Lansky, R. Kornowski, and M. B. Leon Differential Impact on Survival of Electrocardiographic Q-Wave Versus Enzymatic Myocardial Infarction After Percutaneous Intervention: A Device-Specific Analysis of 7147 Patients Circulation, August 7, 2001; 104(6): 642 - 647. [Abstract] [Full Text] [PDF]

				K. M. Anderson, R. M. Califf, G. W. Stone, F.-J. Neumann, G. Montalescot, D. P. Miller, J. J. Ferguson III, J. T. Willerson, H. F. Weisman, and E. J. Topol Long-term mortality benefit with abciximab in patients undergoing percutaneous coronary intervention J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2059 - 2065. [Abstract] [Full Text] [PDF]

				S. C. Smith Jr, J. T. Dove, A. K. Jacobs, J. Ward Kennedy, D. Kereiakes, M. J. Kern, R. E. Kuntz, J. J. Popma, H. V. Schaff, D. O. Williams, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines): A report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2239 - 2239. [Full Text] [PDF]

				M. J. Ricciardi, E. Wu, C. J. Davidson, K. M. Choi, F. J. Klocke, R. O. Bonow, R. M. Judd, and R. J. Kim Visualization of Discrete Microinfarction After Percutaneous Coronary Intervention Associated With Mild Creatine Kinase-MB Elevation Circulation, June 12, 2001; 103(23): 2780 - 2783. [Abstract] [Full Text] [PDF]

				T. Petzold, P. Feindt, U. Sunderdiek, U. Boeken, Y. Fischer, and E. Gams Heart-type fatty acid binding protein (hFABP) in the diagnosis of myocardial damage in coronary artery bypass grafting Eur. J. Cardiothorac. Surg., June 1, 2001; 19(6): 859 - 864. [Abstract] [Full Text] [PDF]

				J. C. O'Shea, G. E. Hafley, S. Greenberg, V. Hasselblad, T. J. Lorenz, M. M. Kitt, J. Strony, J. E. Tcheng, and for the ESPRIT Investigators Platelet Glycoprotein IIb/IIIa Integrin Blockade With Eptifibatide in Coronary Stent Intervention: The ESPRIT Trial: A Randomized Controlled Trial JAMA, May 16, 2001; 285(19): 2468 - 2473. [Abstract] [Full Text] [PDF]

				J. Herrmann, M. Haude, A. Lerman, R. Schulz, L. Volbracht, J. Ge, A. Schmermund, H. Wieneke, C. von Birgelen, H. Eggebrecht, et al. Abnormal Coronary Flow Velocity Reserve After Coronary Intervention Is Associated With Cardiac Marker Elevation Circulation, May 15, 2001; 103(19): 2339 - 2345. [Abstract] [Full Text] [PDF]

				P. W. Serruys, F. Unger, J. E. Sousa, A. Jatene, H. J.R.M. Bonnier, J. P.A.M. Schonberger, N. Buller, R. Bonser, M. J.B. van den Brand, L. A. van Herwerden, et al. Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease N. Engl. J. Med., April 12, 2001; 344(15): 1117 - 1124. [Abstract] [Full Text] [PDF]

				M. S. Chauhan, R. E. Kuntz, K. K. L. Ho, D. J. Cohen, J. J. Popma, J. P. Carrozza Jr, D. S. Baim, and D. E. Cutlip Coronary artery stenting in the aged J. Am. Coll. Cardiol., March 1, 2001; 37(3): 856 - 862. [Abstract] [Full Text] [PDF]

				H. Dorge, T. Neumann, M. Behrends, A. Skyschally, R. Schulz, C. Kasper, R. Erbel, and G. Heusch Perfusion-contraction mismatch with coronary microvascular obstruction: role of inflammation Am J Physiol Heart Circ Physiol, December 1, 2000; 279(6): H2587 - H2592. [Abstract] [Full Text] [PDF]

				B. A. Ference and D. J. Cohen Unraveling the pathophysiology of percutaneous coronary intervention: is it in the genes? J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1526 - 1528. [Full Text] [PDF]

				A. S. Jaffe, J. Ravkilde, R. Roberts, U. Naslund, F. S. Apple, M. Galvani, and H. Katus It's Time for a Change to a Troponin Standard Circulation, September 12, 2000; 102(11): 1216 - 1220. [Full Text] [PDF]

				Myocardial Myocardial infarction redefined--A consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction Eur. Heart J., September 2, 2000; 21(18): 1502 - 1513. [Abstract] [PDF]

				E. Braunwald, E. M. Antman, J. W. Beasley, R. M. Califf, M. D. Cheitlin, J. S. Hochman, R. H. Jones, D. Kereiakes, J. Kupersmith, T. N. Levin, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina) J. Am. Coll. Cardiol., September 1, 2000; 36(3): 970 - 1062. [Full Text] [PDF]

				G. W. Vetrovec Acute and Delayed Benefits of {beta}-Blockers During Coronary Intervention : True, True and Unrelated Circulation, July 11, 2000; 102(2): 147 - 148. [Full Text] [PDF]

				R. Erbel and G. Heusch Coronary microembolization J. Am. Coll. Cardiol., July 1, 2000; 36(1): 22 - 24. [Full Text] [PDF]

				S. Kaul and P. K. Shah Low molecular weight heparin in acute coronary syndrome: evidence for superior or equivalent efficacy compared with unfractionated heparin? J. Am. Coll. Cardiol., June 1, 2000; 35(7): 1699 - 1712. [Abstract] [Full Text] [PDF]

				R. A. Harrington Cardiac enzyme elevations after percutaneous coronary intervention: myonecrosis, the coronary microcirculation and mortality J. Am. Coll. Cardiol., April 1, 2000; 35(5): 1142 - 1144. [Full Text] [PDF]

				L. Gruberg, G. Dangas, R. Mehran, M. K. Hong, R. Waksman, G. S. Mintz, K. M. Kent, A. D. Pichard, L. F. Satler, A. J. Lansky, et al. Percutaneous revascularization of the internal mammary artery graft: short- and long-term outcomes J. Am. Coll. Cardiol., March 15, 2000; 35(4): 944 - 948. [Abstract] [Full Text] [PDF]