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CLINICAL RESEARCH: ACUTE CORONARY SYNDROME

Prognostic Significance of Periprocedural Versus Spontaneously Occurring Myocardial Infarction After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndromes

An Analysis From the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) Trial

Abhiram Prasad, MD^_*, Bernard J. Gersh, MB, ChB, DPhil, MD^_*, Michel E. Bertrand, MD, A. Michael Lincoff, MD, Jeffrey W. Moses, MD, E. Magnus Ohman, MD^||, Harvey D. White, MD^¶, Stuart J. Pocock, PhD^#, Brent T. McLaurin, MD^_**, David A. Cox, MD, Alexandra J. Lansky, MD, Roxana Mehran, MD and Gregg W. Stone, MD^,_*

^_* Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
Hôpital Cardiologique, Lille, France
Cleveland Clinic, Cleveland, Ohio
Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
^|| Duke University Medical Center, Durham, North Carolina
^¶ Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
^# London School of Hygiene and Tropical Medicine, London, United Kingdom
^_** Anderson Heart, Anderson, South Carolina
Mid Carolina Cardiology, Charlotte, North Carolina

Manuscript received December 30, 2008; revised manuscript received February 19, 2009, accepted March 24, 2009.

^_* Reprint requests and correspondence: Dr. Gregg W. Stone, The Cardiovascular Research Foundation, Columbia University Medical Center, Herbert Irving Pavilion, 5th Floor, 161 Fort Washington Avenue, New York, New York 10032 (Email: gs2184{at}columbia.edu).

Objectives: The aim of this study was to evaluate the relative impact of spontaneously occurring and periprocedural myocardial infarction (MI) on survival after percutaneous coronary intervention (PCI).

Background: The clinical significance of periprocedural MI after PCI remains uncertain.

Methods: Outcomes during a 1-year follow-up were evaluated among 7,773 patients enrolled in the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial with a non–ST-segment elevation acute coronary syndrome in whom PCI was performed.

Results: Periprocedural MI developed in 466 patients (6.0%), and spontaneous MI unrelated to PCI subsequently developed in 200 patients (2.6%). Patients developing spontaneous and periprocedural MI compared with those patients without MI had significantly greater unadjusted rates of mortality at 30 days (5.0% vs. 3.2% vs. 0.8%, respectively, p < 0.0001) and at 1 year (16.0% vs. 6.0% vs. 2.6%, respectively, p < 0.0001). In a time-updated multivariable analysis, after adjusting for differences in baseline and procedural characteristics between the groups, we found that spontaneous MI was a powerful independent predictor of subsequent mortality (hazard ratio: 7.49, 95% confidence interval: 4.95 to 11.33, p < 0.0001), whereas periprocedural MI was not a significant predictor of mortality (hazard ratio: 1.30, 95% confidence interval: 0.85 to 1.98, p = 0.22).

Conclusions: Among patients with acute coronary syndrome undergoing PCI, the spontaneous development of an MI unrelated to PCI is a powerful predictor of subsequent mortality. In contrast, periprocedural MI is a marker of baseline risk, atherosclerosis burden, and procedural complexity but in most cases does not have independent prognostic significance. (Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes [ACS]; NCT00093158)

Key Words: angioplasty • myocardial infarction • prognosis

Abbreviations and Acronyms   ACS = acute coronary syndrome   CK-MB = creatine phosphokinase MB fraction   MI = myocardial infarction   PCI = percutaneous coronary intervention   ULN = upper limit of normal

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