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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

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