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CLINICAL RESEARCH: ACUTE MYOCARDIAL INFARCTION

Prognostic Implications of Creatine Kinase Elevation After Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

Amir Halkin, MD^_*, Gregg W. Stone, MD, FACC^,_*, Cindy L. Grines, MD, FACC, David A. Cox, MD, FACC, Barry D. Rutherford, MD, FACC^||, Paolo Esente, MD, FACC^¶, Carol M. Meils, MD, FACC^#, Per Albertsson, MD, FACC^_**, Anthony Farah, MD, FACC, James E. Tcheng, MD, FACC, Alexandra J. Lansky, MD, FACC^_*, and Roxana Mehran, MD, FACC^_*,

^_* Cardiovascular Research Foundation, New York, New York
Columbia University Medical Center, New York, New York
William Beaumont Hospital, Royal Oak, Michigan
Mid Carolina Cardiology, Charlotte, North Carolina
^|| St. Luke’s Hospital, Kansas City, Missouri
^¶ St. Joseph’s Hospital, Syracuse, New York
^# St. Joseph Regional Medical Center, Milwaukee, Wisconsin
^_** Sahlgrenska University Hospital, Göteborg, Sweden
Allegheny General Hospital, Pittsburgh, Pennsylvania
Duke Clinical Research Institute, Durham, North Carolina

Manuscript received June 15, 2005; revised manuscript received July 25, 2005, accepted August 20, 2005.

^_* Reprint requests and correspondence: Dr. Gregg W. Stone, The Cardiovascular Research Foundation, 55 East 59th Street, 6th Floor, New York, New York 10022 (Email: gstone{at}crf.org).

OBJECTIVES: We examined the prognostic implications of the absolute level and rate of increase of creatine kinase (CK) elevation after primary percutaneous coronary intervention (PCI).

BACKGROUND: Peak creatine kinase (CK_peak) and the rate of CK increase are related to reperfusion success and clinical outcomes after thrombolytic therapy for acute myocardial infarction (AMI). The utility of routine serial CK monitoring after primary PCI, in which normal antegrade blood flow is restored in most patients, is unknown.

METHODS: In the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial, 1,529 patients with AMI randomized to either stenting or balloon angioplasty, each with or without abciximab, had CK levels determined at baseline and at 8 ± 1 h, 16 ± 1 h, and 24 ± 1 h after PCI.

RESULTS: The CK_peak occurred at baseline in 3.9% of patients, at 8 ± 1 h in 69.6%, at 16 ± 1 h in 20.0%, and at 24 ± 1 h in 6.5%. The CK levels at all post-procedural time points were significantly higher in patients who died compared with the one-year survivors, as was CK_peak (mean, 2,865 U/l vs. 1,885 U/l, respectively, p 0.001). By multivariate analysis, CK_peak was a significant predictor of one-year mortality (hazard ratio = 2.15, p = 0.0002), independent from post-PCI Thrombolysis In Myocardial Infarction (TIMI) flow. Both the improvement in left ventricular ejection fraction from baseline to seven months and its absolute level were inversely correlated with CK_peak (p < 0.001 for both). In contrast, the time to CK_peak was not an independent predictor of mortality or myocardial recovery.

CONCLUSIONS: The CK_peak after primary PCI is a powerful predictor of one-year mortality independent of other clinical and angiographic measures.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CADILLAC = Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications   CK = creatine kinase   CKpeak = peak creatine kinase   LVEF = left ventricular ejection fraction   PCI = percutaneous coronary intervention   TIMI = Thrombolysis In Myocardial Infarction

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