CLINICAL STUDIES
Clinical outcomes after detection of elevated cardiac enzymes in patients undergoing percutaneous intervention
Barbara E. Tardiff, MDa,
Robert M. Califf, MD, FACCa,
James E. Tcheng, MD, FACCa,
A. Michael Lincoff, MD, FACC*,
Kristina N. Sigmon, MAa,
Robert A. Harrington, MD, FACCa,
Kenneth W. Mahaffey, MDa,
E. Magnus Ohman, MD, FACCa,
Paul S. Teirstein, MD, FACC ,
James C. Blankenship, MD, FACC ,
Michael M. Kitt, MD ,
Eric J. Topol, MD, FACC* for the IMPACT-II Investigators
a Duke Clinical Research Institute, Durham, North Carolina, USA
* the Cleveland Clinic Foundation, Cleveland, Ohio, USA
Scripps Clinic, La Jolla, California, USA
Geisinger Medical Center, Danville, Pennsylvania, USA
COR Therapeutics, South San Francisco, California, USA
Manuscript received May 21, 1998;
revised manuscript received August 6, 1998,
accepted September 4, 1998.
Address for correspondence: Dr. Barbara E. Tardiff, Duke Clinical Research Institute, P.O. Box 17969, Durham, North Carolina 27710
tardi002{at}mc.duke.edu
Objectives. We examined the relations of elevated creatine kinase (CK) and its myocardial band isoenzyme (CK-MB) to clinical outcomes after percutaneous coronary intervention (PCI) in patients enrolled in Integrilin (eptifibatide) to Minimize Platelet Aggregation and Coronary Thrombosis-II (trial) (IMPACT-II), a trial of the platelet glycoprotein IIb/IIIa inhibitor eptifibatide.
Background. Elevation of cardiac enzymes often occurs after PCI, but its clinical implications are uncertain.
Methods. Patients undergoing elective, scheduled PCI for any indication were analyzed. Parallel analyses investigated CK (n = 3,535) and CK-MB (n = 2,341) levels after PCI (within 4 to 20 h). Clinical outcomes at 30 days and 6 months were stratified by postprocedure CK and CK-MB (multiple of the site’s upper normal limit).
Results. Overall, 1,779 patients (76%) had no CK-MB elevation; CK-MB levels were elevated to 1 to 3 times the upper normal limit in 323 patients (13.8%), to 3 to 5 times normal in 84 (3.6%), to 5 to 10 times normal in 86 (3.7%), and to >10 times normal in 69 patients (2.9%). Elevated CK-MB was associated with an increased risk of death, reinfarction, or emergency revascularization at 30 days, and of death, reinfarction, or surgical revascularization at 6 months. Elevated total CK to above three times normal was less frequent, but its prognostic significance paralleled that seen for CK-MB. The degree of risk correlated with the rise in CK or CK-MB, even for patients with successful procedures not complicated by abrupt closure.
Conclusions. Elevations in cardiac enzymes, including small increases (between one and three times normal) often not considered an infarction, are associated with an increased risk for short-term adverse clinical outcomes after successful or unsuccessful PCI.
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Abbreviations and Acronyms
| | CK-MB | = creatine kinase (myocardial band isoenzyme) | | IMPACT-II | = Integrilin (eptifibatide) to Minimize Platelet Aggregation and Coronary Thrombosis-II (trial) | | MI | = myocardial infarction | | PCI | = percutaneous coronary intervention |
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|
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|
|
|
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May 27, 2008;
51(21):
2068 - 2074.
[Full Text]
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|
|
|
|
|
|
|
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92(7):
945 - 950.
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|
|
|
|
|
|
|
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27(9):
1061 - 1069.
[Abstract]
[Full Text]
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|
|
|
|
|
|
|
E. Okmen, N. Cam, A. Sanli, S. Unal, Z. Tartan, and M. Vural
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Angiology,
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57(2):
161 - 169.
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[PDF]
|
|
|
|
|
|
|
J. Herrmann
Peri-procedural myocardial injury: 2005 update
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26(23):
2493 - 2519.
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[Full Text]
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|
|
|
|
|
|
|
G. M. Tadros, K. Broder, and F. Bachour
Intracoronary Macrothrombus Formation During Percutaneous Coronary Intervention Despite Optimal Activated Clotting Time Using Bivalirudin: A Case Report
Angiology,
November 1, 2005;
56(6):
761 - 765.
[Abstract]
[PDF]
|
|
|
|
|
|
|
W. E. Boden
Acute Coronary Syndromes without ST-Segment Elevation -- What Is the Role of Early Intervention?
N. Engl. J. Med.,
September 15, 2005;
353(11):
1159 - 1161.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T Nageh, R A Sherwood, B M Harris, and M R Thomas
Prognostic role of cardiac troponin I after percutaneous coronary intervention in stable coronary disease
Heart,
September 1, 2005;
91(9):
1181 - 1185.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. L. Bhatt and E. J. Topol
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Circulation,
August 9, 2005;
112(6):
906 - 922.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Okmen, N. Cam, A. Sanli, F. Yapici, H. Uyarel, M. Vural, and R. Ozturk
Effects of Direct Stent Implantation and Conventional Stent Implantation on Minor Myocardial Injury
Angiology,
September 1, 2004;
55(5):
485 - 491.
[Abstract]
[PDF]
|
|
|
|
|
|
|
A. Angelini, P. Rubartelli, F. Mistrorigo, M. Della Barbera, F. Abbadessa, M. Vischi, G. Thiene, and S. Chierchia
Distal Protection With a Filter Device During Coronary Stenting in Patients With Stable and Unstable Angina
Circulation,
August 3, 2004;
110(5):
515 - 521.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. J. van der Heijden, I. C. D. Westendorp, R. K. Riezebos, F. Kiemeneij, T. Slagboom, L. R. van der Wieken, and G.-J. Laarman
Lack of efficacy of clopidogrel pre-treatment in the prevention of myocardial damage after elective stent implantation
J. Am. Coll. Cardiol.,
July 7, 2004;
44(1):
20 - 24.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M.T. Roe, K.W. Mahaffey, R. Kilaru, J.H. Alexander, K.M. Akkerhuis, M.L. Simoons, R.A. Harrington, B.E. Tardiff, C.B. Granger, E.M. Ohman, et al.
Creatine kinase-MB elevation after percutaneous coronary intervention predicts adverse outcomes in patients with acute coronary syndromes
Eur. Heart J.,
February 2, 2004;
25(4):
313 - 321.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. L. Miller, K. N. Garratt, M. F. Burritt, G. S. Reeder, and A. S. Jaffe
Timing of Peak Troponin T and Creatine Kinase-MB Elevations After Percutaneous Coronary Intervention
Chest,
January 1, 2004;
125(1):
275 - 280.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. O. Williams
A twist in our understanding of enzyme elevation after coronary intervention
J. Am. Coll. Cardiol.,
December 3, 2003;
42(11):
1906 - 1908.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. P. A. Ioannidis, E. Karvouni, and D. G. Katritsis
Mortality risk conferred by small elevations of creatine kinase-MB isoenzyme after percutaneous coronary intervention
J. Am. Coll. Cardiol.,
October 15, 2003;
42(8):
1406 - 1411.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. A. Gavard, B. R. Chaitman, S. Sakai, K. Stocke, N. Danchin, L. Erhardt, R. Gallo, E. Chi, A. Jessel, and P. Theroux
Prognostic significance of elevated creatine kinase MB after coronary bypass surgery and after an acute coronary syndrome: results from the GUARDIAN trial
J. Thorac. Cardiovasc. Surg.,
September 1, 2003;
126(3):
807 - 813.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. R. Kizer, M. R. Muttrej, W. H. Matthai, J. McConnell, H. Nardone, A. F. Sonel, M. G. Keane, and R. L. Wilensky
Role of cardiac troponin T in the long-term risk stratification of patients undergoing percutaneous coronary intervention
Eur. Heart J.,
July 2, 2003;
24(14):
1314 - 1322.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Labugger, J. A. Simpson, M. Quick, H. A. Brown, C. E. Collier, I. Neverova, and J. E. Van Eyk
Strategy for Analysis of Cardiac Troponins in Biological Samples with a Combination of Affinity Chromatography and Mass Spectrometry
Clin. Chem.,
June 1, 2003;
49(6):
873 - 879.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Holmvang, P. Clemmensen, B. Lindahl, B. Lagerqvist, P. Venge, G. Wagner, L. Wallentin, and P. Grande
Quantitative analysis of the admission electrocardiogram identifies patients with unstable coronary artery disease who benefit the most from early invasive treatment
J. Am. Coll. Cardiol.,
March 19, 2003;
41(6):
905 - 915.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. J. Brener, B. W. Lytle, J. P. Schneider, S. G. Ellis, and E. J. Topol
Association between CK-MB elevation after percutaneous or surgical revascularization and three-year mortality
J. Am. Coll. Cardiol.,
December 4, 2002;
40(11):
1961 - 1967.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. G. Ellis, D. Chew, A. Chan, P. L. Whitlow, J. P. Schneider, and E. J. Topol
Death Following Creatine Kinase-MB Elevation After Coronary Intervention: Identification of an Early Risk Period: Importance of Creatine Kinase-MB Level, Completeness of Revascularization, Ventricular Function, and Probable Benefit of Statin Therapy
Circulation,
September 3, 2002;
106(10):
1205 - 1210.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. W. Bonz, B. Lengenfelder, J.o. Strotmann, S. Held, O. Turschner, K. Harre, C. Wacker, C. Waller, N. Kochsiek, M. Meesmann, et al.
effect of additional temporary glycoprotein IIb/IIIa receptor inhibition on troponin release in elective percutaneous coronary interventions after pretreatment with aspirin and clopidogrel (TOPSTAR trial)
J. Am. Coll. Cardiol.,
August 21, 2002;
40(4):
662 - 668.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. J. Cantor, L. K. Newby, R. H. Christenson, R. H. Tuttle, V. Hasselblad, P. W. Armstrong, D. J. Moliterno, R. M. Califf, E. J. Topol, E. M. Ohman, et al.
Prognostic significance of elevated troponin i after percutaneous coronary intervention
J. Am. Coll. Cardiol.,
June 5, 2002;
39(11):
1738 - 1744.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Colombo and G. Stankovic
Nothing is lower than 0, and 3 is closer to 0 than to 5--medicine is not arithmetic
Eur. Heart J.,
June 1, 2002;
23(11):
840 - 842.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S.J. Brener, S.G. Ellis, J. Schneider, and E.J. Topol
Frequency and long-term impact of myonecrosis after coronary stenting
Eur. Heart J.,
June 1, 2002;
23(11):
869 - 876.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J Herrmann, C von Birgelen, M Haude, L Volbracht, N Malyar, H Eggebrecht, T F M Konorza, D Baumgart, and R Erbel
Prognostic implication of cardiac troponin T increase following stent implantation
Heart,
June 1, 2002;
87(6):
549 - 553.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. S Kilpatrick, A. C H Pell, and J. P Pell
Was it a heart attack?
BMJ,
May 18, 2002;
324(7347):
1216 - 1216.
[Full Text]
|
|
|
|
|
|
|
T. Nageh, R. A. Sherwood, and M. R. Thomas
Prognostic Implications of Cardiac Marker Elevation After Percutaneous Coronary Intervention
Circulation,
March 26, 2002;
105
(12):
e73 - e73.
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. M. Akkerhuis, J. H. Alexander, B. E. Tardiff, E. Boersma, R. A. Harrington, A. M. Lincoff, and M. L. Simoons
Minor Myocardial Damage and Prognosis: Are Spontaneous and Percutaneous Coronary Intervention-Related Events Different?
Circulation,
February 5, 2002;
105(5):
554 - 556.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Kovesi and D. Royston
Editorial I: Is there a bleeding problem with platelet-active drugs?
Br. J. Anaesth.,
February 1, 2002;
88(2):
159 - 163.
[Full Text]
[PDF]
|
|
|
|
|
|
|
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]
|
|
|
|
|
|
|
J. C. Blankenship, G. Tasissa, J. C. O'Shea, E. A. Iliadis, F. A. Bachour, D. J. Cohen, H. K. Lui, T. Mann III, E. Cohen, J. E. Tcheng, et al.
Effect of glycoprotein IIb/IIIa receptor inhibition on angiographic complications during percutaneous coronary intervention in the ESPRIT trial
J. Am. Coll. Cardiol.,
September 1, 2001;
38(3):
653 - 658.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. S. Kabbani, M. W. Watkins, T. Ashikaga, E. F. Terrien, P. A. Holoch, B. E. Sobel, and D. J. Schneider
Platelet Reactivity Characterized Prospectively: A Determinant of Outcome 90 Days After Percutaneous Coronary Intervention
Circulation,
July 10, 2001;
104(2):
181 - 186.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. G. McGovern, D. R. Jacobs Jr, E. Shahar, D. K. Arnett, A. R. Folsom, H. Blackburn, and R. V. Luepker
Trends in Acute Coronary Heart Disease Mortality, Morbidity, and Medical Care From 1985 Through 1997 : The Minnesota Heart Survey
Circulation,
July 3, 2001;
104(1):
19 - 24.
[Abstract]
[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]
|
|
|
|
|
|
|
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]
|
|
|
|
|
|
|
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]
|
|
|
|
|
|
|
J. F. Saucedo, R. Mehran, G. Dangas, M. K. Hong, A. Lansky, K. M. Kent, L. F. Satler, A. D. Pichard, G. W. Stone, and M. B. Leon
Long-term clinical events following creatine kinase-myocardial band isoenzyme elevation after successful coronary stenting
J. Am. Coll. Cardiol.,
April 1, 2000;
35(5):
1134 - 1141.
[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]
|
|
|
|
|
|
|
R. Kornowski, B. Bhargava, D. M. S. Fuchs, A. J. Lansky, L. F. Satler, A. D. Pichard, M. K. Hong, K. M. Kent, R. Mehran, G. W. Stone, et al.
Procedural results and late clinical outcomes after percutaneous interventions using long (>=25 mm) versus short (<20 mm) stents
J. Am. Coll. Cardiol.,
March 1, 2000;
35(3):
612 - 618.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Mehran, G. Dangas, G. S. Mintz, A. J. Lansky, A. D. Pichard, L. F. Satler, K. M. Kent, G. W. Stone, and M. B. Leon
Atherosclerotic Plaque Burden and CK-MB Enzyme Elevation After Coronary Interventions : Intravascular Ultrasound Study of 2256 Patients
Circulation,
February 15, 2000;
101(6):
604 - 610.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. H. Alexander, R. A. Sparapani, K. W. Mahaffey, J. W. Deckers, L. K. Newby, E. M. Ohman, R. Corbalan, S. L. Chierchia, J. B. Boland, M. L. Simoons, et al.
Association Between Minor Elevations of Creatine Kinase-MB Level and Mortality in Patients With Acute Coronary Syndromes Without ST-Segment Elevation
JAMA,
January 19, 2000;
283(3):
347 - 353.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Kini, J. D. Marmur, S. Kini, G. Dangas, T. P. Cocke, S. Wallenstein, E. Brown, J. A. Ambrose, and S. K. Sharma
Creatine kinase-MB elevation after coronary intervention correlates with diffuse atherosclerosis, and low-to-medium level elevation has a benign clinical course: Implications for early discharge after coronary intervention
J. Am. Coll. Cardiol.,
September 1, 1999;
34(3):
663 - 671.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. E. Chambers, S. T Riebel, and M. Kozak
Interventional Cardiology: Advances in Percutaneous Techniques for the Treatment of Cardiac Disease
Seminars in Cardiothoracic and Vascular Anesthesia,
July 1, 1999;
3(2):
109 - 125.
[Abstract]
[PDF]
|
|
|
|
|
|
|
Postprocedure CK Elevations Predict Risk
Journal Watch Cardiology,
February 12, 1999;
1999(212):
6 - 6.
[Full Text]
|
|
|
|
