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CLINICAL STUDIES

The relationship between periprocedural myocardial infarction and subsequent target vessel revascularization following percutaneous coronary revascularization

Insights from the EPIC trial

Craig R. Narins, MD^*, Dave P. Miller, MS^*, Robert M. Califf, MD and Eric J. Topol, MD^*

^* Department of Cardiology and the Joseph J. Jacobs Center for Vascular Biology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Duke University Clinical Research Institute, Durham, North Carolina, USA

Manuscript received June 8, 1998; revised manuscript received September 18, 1998, accepted October 30, 1998.

Reprint requests and correspondence: Dr. Eric J. Topol, Department of Cardiology, F25, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195
topole{at}cesmtp.ccf.org

OBJECTIVES

We sought to determine whether periprocedural myocardial infarction complicating percutaneous coronary revascularization is associated with subsequent clinical restenosis, as judged by the need for target vessel revascularization.

BACKGROUND

Although myocardial enzyme elevation following angioplasty is associated with increased late mortality, its effect on subsequent clinical restenosis, as assessed by the need for late target vessel revascularization (TVR), is unknown.

METHODS

Serial myocardial enzyme determinations were performed on 2,099 patients who underwent angioplasty or atherectomy in the Evaluation of IIb/IIIa platelet receptor antagonist 7E3 in Preventing Ischemic Complications (EPIC) trial. Thirty-day survivors were prospectively followed for three years for adverse clinical events including death and need for TVR.

RESULTS

Within the study population, periprocedural creatine kinase (CK) elevation was a predictor of late mortality. Among patients with elevated CK, however, a paradoxical decrease in the need for late TVR was present. This relationship became progressively more profound as the magnitude of CK release increased. Late TVR occurred in 29.8% of patients with no CK elevation, 24.8% with CK elevation to >3 times normal, and 16.9% with >10 times elevation (hazard ratio 0.51, 95% CI 0.29, 0.91).

CONCLUSIONS

In the EPIC study, patients with periprocedural MI were less likely to develop clinical restenosis as measured by the need for TVR. Mechanistically, although it is unlikely that CK elevation prevents vascular renarrowing per se, myocardial necrosis impairs the clinical manifestation of restenosis, thereby reducing the need for ischemia-driven TVR. This novel finding 1) highlights the potential discordance between angiographic and clinical measures of restenosis, and 2) has implications for clinical trials, as therapies that reduce periprocedural MI may be associated with a perceived excess of restenosis when measured by the need for TVR.

Abbreviations and Acronyms   CAVEAT = Coronary Angioplasty Versus Excisional Atherectomy Trial   EPIC = Evaluation of IIb/IIIa platelet receptor antagonist 7E3 in Preventing Ischemic Complications trial   EPILOG = Evaluation of PTCA to Improve Long-Term Outcome by 7E3 GP IIb/IIIa receptor blockade trial   IMPACT = Integrelin to Manage Platelet Aggregation to Combat Thrombosis trial   MI = myocardial infarction   TVR = target vessel revascularization

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