Impact of large periprocedural myocardial infarction on mortality after percutaneous coronary intervention and coronary artery bypass grafting for left main disease: an analysis from the EXCEL trial. Academic Article uri icon

Overview

abstract

  • AIMS: The prognostic implications of periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remain controversial. We examined the 3-year rates of mortality among patients with and without PMI undergoing left main coronary artery intervention randomized to PCI with everolimus-eluting stents vs. CABG in the large-scale, multicentre, prospective, randomized EXCEL trial. METHODS AND RESULTS: By protocol, PMI was defined using an identical threshold for PCI and CABG [creatinine kinase-MB (CK-MB) elevation >10× the upper reference limit (URL) within 72 h post-procedure, or >5× URL with new Q-waves, angiographic vessel occlusion, or loss of myocardium on imaging]. Cox proportional hazards modelling was performed controlling for age, sex, hypertension, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and chronic obstructive pulmonary disease (COPD). A total of 1858 patients were treated as assigned by randomization. Periprocedural MI occurred in 34/935 (3.6%) of patients in the PCI group and 56/923 (6.1%) of patients in the CABG group [odds ratio 0.61, 95% confidence interval (CI) 0.40-0.93; P = 0.02]. Periprocedural MI was associated with SYNTAX score, COPD, cross-clamp duration and total procedure duration, and not using antegrade cardioplegia. By multivariable analysis, PMI was associated with cardiovascular death and all-cause death at 3 years [adjusted hazard ratio (HR) 2.63, 95% CI 1.19-5.81; P = 0.02 and adjusted HR 2.28, 95% CI 1.22-4.29; P = 0.01, respectively]. The effect of PMI was consistent for PCI and CABG for cardiovascular death (Pinteraction = 0.56) and all-cause death (Pinteraction = 0.59). Peak post-procedure CK-MB ≥10× URL strongly predicted mortality, whereas lesser degrees of myonecrosis were not associated with prognosis. CONCLUSION: In the EXCEL trial, PMI was more common after CABG than PCI, and was strongly associated with increased 3-year mortality after controlling for potential confounders. Only extensive myonecrosis (CK-MB ≥10× URL) was prognostically important.

authors

  • Ben-Yehuda, Ori
  • Chen, Shmuel
  • Redfors, Björn
  • McAndrew, Thomas
  • Crowley, Aaron
  • Kosmidou, Ioanna
  • Kandzari, David E
  • Puskas, John D
  • Morice, Marie-Claude
  • Taggart, David P
  • Leon, Martin B
  • Lembo, Nicholas J
  • Brown, W Morris
  • Simonton, Charles A
  • Dressler, Ovidiu
  • Kappetein, Arie Pieter
  • Sabik, Joseph F
  • Serruys, Patrick W
  • Stone, Gregg W

publication date

  • June 21, 2019

Research

keywords

  • Coronary Artery Bypass
  • Coronary Artery Disease
  • Myocardial Infarction
  • Percutaneous Coronary Intervention

Identity

Scopus Document Identifier

  • 85067190386

Digital Object Identifier (DOI)

  • 10.1093/eurheartj/ehz113

PubMed ID

  • 30919909

Additional Document Info

volume

  • 40

issue

  • 24