This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bhatt, D. L. Articles by Topol, E. J. Search for Related Content PubMed PubMed Citation Articles by Bhatt, D. L. Articles by Topol, E. J. Related Collections Platelet function inhibitors Catheter-based coronary and valvular interventions: other Catheter-based coronary interventions: stents Acute coronary syndromes CT and MRI Acute myocardial infarction Chronic ischemic heart disease

(Circulation. 2005;112:906-922.)
© 2005 American Heart Association, Inc.

Controversies in Cardiovascular Medicine

Does creatinine kinase-MB elevation after percutaneous coronary intervention predict outcomes in 2005?

Periprocedural Cardiac Enzyme Elevation Predicts Adverse Outcomes

Deepak L. Bhatt, MD; Eric J. Topol, MD

From the Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio (D.L.B., E.J.T.); and the Harvard Clinical Research Institute, Division of Cardiology, Beth Israel Deaconess Medical Center, Division of Cardiology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Mass (D.E.C., R.E.K.).

Correspondence to Deepak L. Bhatt, MD, Dept of Cardiovascular Medicine, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195 (e-mail bhattd@ccf.org); or Donald E. Cutlip, MD, Interventional Cardiology Section, Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, Baker 4, Boston, MA 02215 (e-mail dcutlip@bidmc.harvard.edu).

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Extensive clinical investigation throughout the 1990s validated periprocedural myonecrosis as a powerful predictor of adverse outcomes, so it is surprising that this remains a contentious point. Originally derided as "enzyme leaks" or "myocardial infarctlets," periprocedural myocardial infarction (MI) has now been definitively linked in large data sets to long-term adverse outcomes, most notably mortality. It is not, however, always directly contributory or causative. For example, a large creatine kinase (CK) elevation caused by closure of a major side branch resulting in chest pain and development of new Q waves is obviously undesirable and causally related to the interventional procedure. Alternatively, even small, asymptomatic CK elevations have been clearly associated with worse long-term outcome, and although this may in part be causally related to the procedure, it is more likely that the relationship is caused by the underlying predisposing factors that led to the periprocedural MI, such as arterial inflammation predilecting to the occurrence of embolization or to a large degree of atheroma burden leading to more myonecrosis. Under these circumstances, it is likely that the heightened inflammatory state and the diffuse disease that is present are the real causative factors for worse long-term outcomes. Recently, aspirin resistance has been demonstrated to predict periprocedural myonecrosis. Thus, both through direct causation and also as an epiphenomenon, embolization and attendant periprocedural myonecrosis are associated with short, intermediate, and long-term adverse outcomes (Table 1). This review details this evolution in thought.

View this table:   TABLE 1. Mechanisms Behind Periprocedural Myonecrosis

	Periprocedural Myonecrosis and Outcome

 
Periprocedural myonecrosis is a frequent . . . [Full Text of this Article]

This article has been cited by other articles:

				K Rahimi, A P Banning, A S H Cheng, T J Pegg, T D Karamitsos, K M Channon, S Darby, D P Taggart, S Neubauer, and J B Selvanayagam Prognostic value of coronary revascularisation-related myocardial injury: a cardiac magnetic resonance imaging study Heart, December 1, 2009; 95(23): 1937 - 1943. [Abstract] [Full Text] [PDF]

				D. L. Bhatt, A. M. Lincoff, C. M. Gibson, G. W. Stone, S. McNulty, G. Montalescot, N. S. Kleiman, S. G. Goodman, H. D. White, K. W. Mahaffey, et al. Intravenous Platelet Blockade with Cangrelor during PCI N. Engl. J. Med., November 15, 2009; (2009) NEJMoa0908629v1. [Abstract] [Full Text] [PDF]

				J. B. Lindsey, S. P. Marso, M. Pencina, J. M. Stolker, K. F. Kennedy, C. Rihal, G. Barsness, R. N. Piana, S. L. Goldberg, D. E. Cutlip, et al. Prognostic Impact of Periprocedural Bleeding and Myocardial Infarction After Percutaneous Coronary Intervention in Unselected Patients: Results From the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry J. Am. Coll. Cardiol. Intv., November 1, 2009; 2(11): 1074 - 1082. [Abstract] [Full Text] [PDF]

				A. Prasad, B. J. Gersh, M. E. Bertrand, A. M. Lincoff, J. W. Moses, E. M. Ohman, H. D. White, S. J. Pocock, B. T. McLaurin, D. A. Cox, et al. 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. J. Am. Coll. Cardiol., July 28, 2009; 54(5): 477 - 486. [Abstract] [Full Text] [PDF]

				D. A. Morrow, S. D. Wiviott, H. D. White, J. C. Nicolau, E. Bramucci, S. A. Murphy, M. P. Bonaca, C. T. Ruff, B. M. Scirica, C. H. McCabe, et al. Effect of the Novel Thienopyridine Prasugrel Compared With Clopidogrel on Spontaneous and Procedural Myocardial Infarction in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis in Myocardial Infarction 38: An Application of the Classification System From the Universal Definition of Myocardial Infarction Circulation, June 2, 2009; 119(21): 2758 - 2764. [Abstract] [Full Text] [PDF]

				A. S. Flett, M. A. Westwood, L. C. Davies, A. Mathur, and J. C. Moon The Prognostic Implications of Cardiovascular Magnetic Resonance Circ Cardiovasc Imaging, May 1, 2009; 2(3): 243 - 250. [Full Text] [PDF]

				A. A. Bavry, D. J. Kumbhani, and D. L. Bhatt Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta-analysis of randomized trials Eur. Heart J., December 2, 2008; 29(24): 2989 - 3001. [Abstract] [Full Text] [PDF]

				D. L. Bhatt Resisting the Temptation to Oversimplify Antiplatelet Resistance J. Am. Coll. Cardiol. Intv., December 1, 2008; 1(6): 660 - 662. [Full Text] [PDF]

				E. M. Antman and D. A. Morrow Biomarker Release After Percutaneous Coronary Intervention: A Message From the Heart Circ Cardiovasc Interv, August 1, 2008; 1(1): 3 - 6. [Full Text] [PDF]

				A. Prasad, C. S. Rihal, R. J. Lennon, M. Singh, A. S. Jaffe, and D. R. Holmes Jr Significance of Periprocedural Myonecrosis on Outcomes After Percutaneous Coronary Intervention: An Analysis of Preintervention and Postintervention Troponin T Levels in 5487 Patients Circ Cardiovasc Interv, August 1, 2008; 1(1): 10 - 19. [Abstract] [Full Text] [PDF]

				T. Uetani, T. Amano, H. Ando, K. Yokoi, K. Arai, M. Kato, N. Marui, M. Nanki, T. Matsubara, H. Ishii, et al. The correlation between lipid volume in the target lesion, measured by integrated backscatter intravascular ultrasound, and post-procedural myocardial infarction in patients with elective stent implantation Eur. Heart J., July 2, 2008; 29(14): 1714 - 1720. [Abstract] [Full Text] [PDF]

				J. K. Shim, S. H. Choi, Y. J. Oh, C. S. Kim, K. J. Yoo, and Y. L. Kwak The effect of mannitol on oxygenation and creatine kinase MB release in patients undergoing multivessel off-pump coronary artery bypass surgery J. Thorac. Cardiovasc. Surg., March 1, 2007; 133(3): 704 - 709. [Abstract] [Full Text] [PDF]

				A. Prasad, M. Singh, A. Lerman, R. J. Lennon, D. R. Holmes Jr, and C. S. Rihal Isolated Elevation in Troponin T After Percutaneous Coronary Intervention Is Associated With Higher Long-Term Mortality J. Am. Coll. Cardiol., November 7, 2006; 48(9): 1765 - 1770. [Abstract] [Full Text] [PDF]

				D. L. Bhatt Shifting the Diagnosis of Periprocedural Myocardial Infarction Upstream Circulation, October 31, 2006; 114(18): 1898 - 1900. [Full Text] [PDF]

				V. Balian, M. Galli, C. Marcassa, G. Cecchin, M. Child, F. Barlocco, E. Petrucci, G. Filippini, R. Michi, and M. Onofri Intracoronary ST-Segment Shift Soon After Elective Percutaneous Coronary Intervention Accurately Predicts Periprocedural Myocardial Injury Circulation, October 31, 2006; 114(18): 1948 - 1954. [Abstract] [Full Text] [PDF]

				A. A. Bavry, D. J. Kumbhani, A. N. Rassi, D. L. Bhatt, and A. T. Askari Benefit of Early Invasive Therapy in Acute Coronary Syndromes: A Meta-Analysis of Contemporary Randomized Clinical Trials J. Am. Coll. Cardiol., October 3, 2006; 48(7): 1319 - 1325. [Abstract] [Full Text] [PDF]

				A. S. Jaffe, L. Babuin, and F. S. Apple Biomarkers in Acute Cardiac Disease: The Present and the Future J. Am. Coll. Cardiol., July 4, 2006; 48(1): 1 - 11. [Abstract] [Full Text] [PDF]

				G. Tarantini, A. Ramondo, S. Iliceto, D. E. Newby, K. A. Fox, A. Ionescu, A. Garg, C. Spaulding, O. Varenne, S. Weber, et al. Management of Acute Coronary Syndromes N. Engl. J. Med., December 22, 2005; 353(25): 2714 - 2718. [Full Text] [PDF]