Cardiac Troponin I Increase After Successful Percutaneous Coronary Angioplasty: Predictors and Long-Term Prognostic Value

Abstract

After successful percutaneous coronary interventions (PCI), elevations of cardiac enzymes are not rare, but it is still not clear whether those elevations are associated with adverse late outcome. The purpose of the study was to investigate the relation between cardiac troponin I (cTn-I) increase after successful percutaneous intervention and late outcome. The study consisted of 100 consecutive patients (mean age 56 ±9.8, 84% male) who had successful elective coronary balloon angioplasty with or without stent implantation. Patients with stable angina (n=54) and unstable angina (n=46) were included in the study. Blood samples for measurement of cTn-I were taken before and immediately after the procedure, and every 6 hours for the first 24 hours. Patients with preprocedural cTn-I elevation were excluded from the study. Postprocedural cTn-I elevation was detected in 34 patients (34%, troponin (+) group) and cTn-I levels were normal in 66 patients (66%, troponin (-) group). Logistic regression analysis showed that intervention in patients with unstable angina, stent implantation following balloon dilation, and maximal inflation pressure were the predictors of cTn-I elevation (p=0.035, p=0.038, and p=0.014, respectively). During the prospective follow-up period for 21 ±7.5 months, the incidence of major cardiac events including recurrent angina, acute myocardial infarction, death, and revascularization were not different in patients with and without cTn-I elevation. Overall, major cardiac events occurred in 9 patients (26%) in the troponin (+) group and in 13 patients (20%) in the troponin (-) group. Kaplan-Meier survival analysis showed that cTn-I elevation was not an important correlate of overall cardiac events (log-rank: 1.66, p=0.19). The authors conclude that postprocedural cTn-I elevation is related to unstable angina, stent implantation following predilation, and inflation pressure, and there is no association with minor myocardial injury occurring after successful percutaneous coronary intervention and late adverse cardiac events.

References

Abdelmeguid A , Topol E , Whitlow P , et al : Significance of mild transient release of creatine kinase-MB fraction after percutaneous coronary interventions. Circulation 94:1528-1536, 1996.

Ravkilde J , Nissen H , Mickley H , et al : Cardiac troponin T and CK-MB mass release after visually successful percutaneous transluminal coronary angioplasty in stable angina pectoris. Am Heart J 127:13-20, 1994.

Karim MA , Shinn M , Oskarsson H , et al : Significance of cardiac troponin T release after percutaneous transluminal coronary angioplasty. Am J Cardiol 76: 521-523, 1995.

Abbas SA , Glazier J , WU AHB , et al : Factors associated with the release of cardiac troponin T following percutaneous transluminal coronary angioplasty. Clin Cardiol 19:782-786, 1996.

Garbaz E , Lung B , Lefevre G , et al : Frequency and prognostic value of cardiac troponin I elevation after coronary stenting. Am J Cardiol 84:515-518, 1999.

La Vecchia L , Bedogni F , Finocchi G , et al : Troponin T, troponin I and creatine kinase-MB mass after elective coronary stenting. Coron Artery Dis 7:535-540, 1996.

Cantor WJ , Newby LK , Christenson RH , et al , and The SYMPHONY and 2nd SYMPHONY Cardiac Markers Substudy Investigators : Prognostic significance of elevated troponin I after percutaneous coronary intervention. J Am Coll Cardiol 39:1738-1744, 2002.

Kong T , Davidson C , Meyers S , et al : Prognostic implication of creatine kinase elevation following elective coronary artery interventions. JAMA 277:461-466, 1997.

Adams JE , Bodor GS , Davila-Roman VG , et al : Cardiac troponin I. A marker with high specificity for cardiac injury. Circulation 88:101-106, 1993.

10.

Bertinchant JP , Larue C , Pernel I , et al : Release kinetics of serum cardiac troponin I in ischemic myocardial injury. Clin Biochem 29:684-694, 1996.

11.

Mair J , Genser N , Morandell D , et al : Cardiac troponin I in the diagnosis of myocardial injury and infarction. Clin Chim Acta 245:19-38, 1996.

12.

Adams JE , Davila-Roman VG , Bessey PQ , et al : Diagnosis of perioperative myocardial infarction with measurement of cardiac troponin I. N Engl J Med 330:670-674, 1994.

13.

Hunt AC , Chow SL , Shiu MF , et al : Release of creatine kinase-MB and cardiac specific troponin-I following percutaneous transluminal coronary angioplasty. Eur Heart J 12:690-694, 1991.

14.

Genser N , Mair J , Talazs H , et al : Cardiac troponin I to diagnose percutaneous transluminal coronary angioplasty-related myocardial injury. Clin Chem Acta 265:207-217, 1997.

15.

Ryan TJ , Bauman WB , Kennedy JW , et al : Guidelines for percutaneous transluminal coronary angioplasty: A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty). Circulation 78:486-502, 1988.

16.

Smith SC Jr , Dove JT , Jacobs AK , et al : ACC/AHA guidelines for percutaneous coronary intervention: A report of American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiol 37:2215-2239, 2001.

17.

Abdelmeguid AE , Topol EJ : The myth of the myocardial “infarctlet” during percutaneous coronary revascularization procedures. Circulation 94:3369-3375, 1996.

18.

Yadav J , Grube E , Rowold S , et al : Detection and characterization of emboli during coronary intervention (abstract). Circulation 100:I-780-I-780, 1999.

19.

Harrington RA , Lincoff AM , Califf RM , et al : Characteristics and consequences of myocardial infarction after percutaneous coronary intervention: Insights from the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT). J Am Coll Cardiol 25:1693-1699, 1995.

20.

Tardiff BE , Califf RM , Tcheng JE , et al , for the IMPACT-II Investigators : Clinical outcomes after detection of elevated cardiac enzymes in patients undergoing percutaneous intervention. J Am Coll Cardiol 33:88-96, 1999.

21.

Mehran R , Dangas G , Mintz GS , et al : Atherosclerotic plaque burden and CK-MB enzyme elevation after coronary interventions intravascular ultrasound study of 2,256 patients. Circulation 101:604-610, 2000.

22.

Kugelmass AD , Cohen DJ , Moscucci M , et al : Elevation of the creatine kinase myocardial isoform following otherwise successful coronary atherectomy and stenting. Am J Cardiol 74:748-754, 1994.

23.

Roberts WC , Kragel AH , Gertz SD , et al : Coronary arteries in unstable angina, acute myocardial infarction and sudden death. Am J Cardiol 127:1588-1593, 1994.

24.

Shyu KG , Kuan PL , Cheng JJ , et al : Cardiac troponin T, creatine kinase, and isoform release after successful percutaneous transluminal coronary angioplasty with or without stenting. Am Heart J 135-862-867, 1998.

25.

EPIC Investigators : Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 330:956-961, 1994.

26.

Ellis SG , Lincoff AM , Miller D , et al , for the EPIC and EPILOG Investigators : Reduction in complications of angioplasty with abciximab occurs largely independently of baseline lesion morphology: Evaluation of 7E3 for the prevention of ischemic complications: Evaluation of PTCA to improve long-term outcome with abciximab GP IIb/IIIa receptor blockade. J Am Coll Cardiol 32:1619-1623, 1998.

27.

EPILOG Investigators : Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 336:1689-1696, 1997.

28.

CAPTURE Investigators : Randomised placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina. Lancet 349:1428-1435, 1997.

29.

Briguori C , Sheiban I , De Gregorio J , et al : Direct coronary stenting without predilation. J Am Coll Cardiol 34:1910-1915, 1999.

30.

Herz I , Assali A , Solodky A , et al : Effectiveness of coronary stent deployment without predilation. Am J Cardiol 84:89-91, 1999.

31.

Oemrawsingh P , Schalij M , Srimahachota S , et al : Clinical and angiographic outcome of stent implantation without predilatation using the Jostent Flex Stent. J Invas Cardiol 12:187-193, 2000.

32.

Commeau P , Huret B , Leclerq C , et al : Stenting without predilation with balloon in non-complex lesions: Immediate and mid-term results in a series of 106 consecutive implantations. Am J Cardiol 82:51S-51S, 1998.

33.

Attali P , Alleil B , Pettpas G , et al : Sensitivity and long-term prognostic value of cardiac troponin-I increase shortly after percutaneous transluminal coronary angioplasty. Clin Cardiol 21:353-356, 1998.

34.

Bertinchant JP , Polge A , Lederman B , et al : Relation of minor cardiac troponin I elevation to late cardiac events after uncomplicated elective successful percutaneous transluminal coronary angioplasty for angina pectoris. Am J Cardiol 84:51-57, 1999.

35.

Antman EM , Tanasijevic MJ , Thompson B , et al : Cardiac specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 335:1342-1349, 1996.

36.

Hamm CW , Ravkilde J , Gerhardt W , et al : The prognostic value of serum troponin T in unstable angina. N Engl J Med 327:146-150, 1992.