CLINICAL STUDY: ACUTE CORONARY SYNDROMES
Prospective analysis of creatine kinase muscle-brain fraction and comparison with troponin T to predict cardiac risk and benefit of an invasive strategy in patients with non–ST-elevation acute coronary syndromes
Neal S. Kleiman, MD*,*,
Nasser Lakkis, MD*,
Christopher P. Cannon, MD ,
Sabina A. Murphy, MPH,
Peter M. DiBattiste, MD ,
Laura A. Demopoulos, MD,
William S. Weintraub, MD ,
Eugene Braunwald, MD TACTICS-TIMI 18 Investigators
* Baylor College of Medicine and The Methodist-DeBakey Heart Center, Houston, Texas, USA
Brigham and Women’s Hospital, Boston, Massachusetts, USA
Merck Inc., West Point, Pennsylvania, USA
Emory University, Atlanta, Georgia, USA
Manuscript received December 18, 2001;
revised manuscript received May 29, 2002,
accepted June 19, 2002.
* Reprint requests and correspondence: Dr. Neal S. Kleiman, The Methodist Hospital, 6565 Fannin, MS F1090, Houston, Texas 77030, USA.
nkleiman{at}bcm.tmc.edu
OBJECTIVES: We sought to determine whether elevation of plasma creatine kinase muscle-brain fraction (CK-MB) would be useful to triage patients with acute coronary syndromes (ACS) to early angiography/revascularization.
BACKGROUND: It is unknown whether the measurement of CK-MB is effective for triage to an aggressive management strategy.
METHODS: Patients in the Treat Angina With Aggrastat and Determine Cost of Therapy With an Invasive or Conservative Strategy (TACTICS-TIMI) 18 study received aspirin, heparin, and tirofiban for treatment of ACS, were randomized to an invasive or a conservative strategy (angiography/revascularization between 4 and 48 h), and were followed up for a composite end point of death, myocardial infarction, or rehospitalization for ACS.
RESULTS: Of 2,220 patients, CK-MB was elevated in 826 (37%). Of the patients with negative CK-MB, troponin T was elevated in 361 (31.2%). Event rates at 30 and 180 days were twice as high in patients with elevated CK-MB than in patients without elevated CK-MB. Both groups had similar benefit from an invasive strategy; there was no evidence of interaction between CK-MB elevation and strategy on the composite end point at 30 or 180 days. When patients were stratified according to both CK-MB and troponin status, there was evidence of a benefit in the invasive strategy among patients who were CK-negative but troponin-positive (odds ratios [95% confidence interval]: 0.13 [0.04 to 0.39] at 30 days and 0.29 [0.16 to 0.52] at 180 days).
CONCLUSIONS: Patients with minimal amounts of recent onset myonecrosis but elevated risk as indicated by CK-MB and troponin, respectively, benefit most from invasive management. Determination of troponin levels yielded significant information regarding triage to an invasive strategy, particularly in CK-MB-negative patients.
|
Abbreviations and Acronyms
| | ACS | | acute coronary syndromes | | CAD | | coronary artery disease | | CK | | creatine kinase | | CK-MB | | creatine kinase muscle-brain fraction | | GUSTO | | Global Utilization of Strategies to Open Occluded Coronary Arteries | | MI | | myocardial infarction | | OR | | odds ratio | | PCI | | percutaneous coronary intervention | | TACTICS-TIMI | | Treat Angina With Aggrastat and Determine Cost of Therapy With an Invasive or Conservative Strategy |
|
This article has been cited by other articles:
|
|
|
|
 
J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al.
ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
J. Am. Coll. Cardiol.,
August 14, 2007;
50(7):
e1 - e157.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al.
ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
J. Am. Coll. Cardiol.,
August 14, 2007;
50(7):
652 - 726.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. L. Miller, K. N. Garratt, M. F. Burritt, R. J. Lennon, G. S. Reeder, and A. S. Jaffe
Baseline troponin level: key to understanding the importance of post-PCI troponin elevations
Eur. Heart J.,
May 1, 2006;
27(9):
1061 - 1069.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. K. Newby, M. T. Roe, A. Y. Chen, E. M. Ohman, R. H. Christenson, C. V. Pollack Jr, J. W. Hoekstra, W. F. Peacock, R. A. Harrington, R. L. Jesse, et al.
Frequency and Clinical Implications of Discordant Creatine Kinase-MB and Troponin Measurements in Acute Coronary Syndromes
J. Am. Coll. Cardiol.,
January 17, 2006;
47(2):
312 - 318.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. C. Beinart, P. Kolm, E. Veledar, Z. Zhang, E. M. Mahoney, O. Bouin, S. Gabriel, J. Jackson, R. Chen, J. Caro, et al.
Long-Term Cost Effectiveness of Early and Sustained Dual Oral Antiplatelet Therapy With Clopidogrel Given for Up to One Year After Percutaneous Coronary Intervention: Results From the Clopidogrel for the Reduction of Events During Observation (CREDO) Trial
J. Am. Coll. Cardiol.,
September 6, 2005;
46(5):
761 - 769.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. S. Weintraub, E. M. Mahoney, A. Lamy, S. Culler, Y. Yuan, J. Caro, S. Gabriel, S. Yusuf, and CURE Study Investigators
Long-term cost-effectiveness of clopidogrel given for up to one year in patients with acute coronary syndromes without ST-segment elevation
J. Am. Coll. Cardiol.,
March 15, 2005;
45(6):
838 - 845.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. T. Yan, R. T. Yan, M. Tan, C.-M. Chow, D. Fitchett, E. Stanton, A. Langer, S. G. Goodman, and for the Canadian Acute Coronary Syndromes Registr
Troponin is more useful than creatine kinase in predicting one-year mortality among acute coronary syndrome patients
Eur. Heart J.,
November 2, 2004;
25(22):
2006 - 2012.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. B. Granger, J. E. Van Eyk, S. C. Mockrin, N. L. Anderson, and on behalf of the Working Group Members
National Heart, Lung, and Blood Institute Clinical Proteomics Working Group Report
Circulation,
April 13, 2004;
109(14):
1697 - 1703.
[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]
|
|
|
|
