(Circulation. 1996;94:3369-3375.)
© 1996 American Heart Association, Inc.
Articles |
The Myth of the Myocardial `Infarctlet' During Percutaneous Coronary Revascularization Procedures
the Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio. Dr Abdelmeguid is now with the Cardiology Division, Henry Ford Cardiovascular Institute, Detroit, Mich.
Correspondence to Eric J. Topol, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. E-mail topole@cesmtp.ccf.org.
Key Words: myocardial infarction • angioplasty • atherosclerosis • embolism • creatine kinase • ischemia
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Introduction |
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One of the most controversial issues in interventional cardiology today is whether small MIs, diagnosed by enzymatic abnormalities coincident with percutaneous coronary interventional procedures, are clinically relevant.1 2 3 4 5 Among interventional cardiologists, the commonly used term "infarctlet" implies a small and insignificant event. However, the importance of these myocardial infarctlets after coronary revascularization procedures is both understudied and underappreciated, despite the well-established prognostic importance of even small enzymatic infarctions in the setting of unstable angina6 or after acute MI.7 The controversy is related in part to the difficulty associated with the diagnosis of nonfatal MI in trials involving myocardial revascularization. This problem was a major issue in the evaluation of coronary artery bypass surgery and was never satisfactorily resolved.8 In the setting of bypass surgery, elevation of CK and CK-MB is routine, and other noninvasive tests designed to detect myocardial injury are also commonly positive. Because a definition for an abnormal extent of necrosis with bypass surgery could not be established or adapted via consensus, the commonly used definition of postbypass infarction is the presence of new Q waves on the postoperative ECG. Unfortunately, this definition misclassifies patients with non–Q-wave infarction as not experiencing myocardial damage, and patients with new, major conduction disturbances (eg, left bundle branch block) may not be accurately diagnosed. A similar problem is evident in the evaluation of percutaneous procedures, and defining postangioplasty infarction exclusively by the presence of Q waves on ECG does not seem appropriate for these percutaneous procedures, in which the absence of any necrosis
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