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Original Articles

Significance of Periprocedural Myonecrosis on Outcomes After Percutaneous Coronary Intervention

An Analysis of Preintervention and Postintervention Troponin T Levels in 5487 Patients

Abhiram Prasad, MD, FRCP; Charanjit S. Rihal, MD; Ryan J. Lennon, MS; Mandeep Singh, MD, MPH; Allan S. Jaffe, MD and David R. Holmes, Jr, MD

From the Division of Cardiovascular Diseases and Department of Internal Medicine (A.P., C.S.R., M.S., A.S.J., D.R.H.) and Section of Biostatistics (R.J.L.), Mayo Clinic and Mayo Foundation, Rochester, Minn.

Reprint requests to Abhiram Prasad, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail prasad.abhiram{at}mayo.edu

Received January 9, 2008; accepted June 16, 2008.

Background— Myonecrosis after percutaneous coronary intervention (PCI) has been correlated with a worse prognosis, but controversy exists about the clinical significance and potential mechanisms for the association. The aim of this study was to evaluate the relative impact of preprocedural and postprocedural cardiac troponin T (cTnT) levels on survival rate after PCI.

Methods and Results— We evaluated 5487 patients from the Mayo Clinic registry who required nonemergency PCI, and we examined the relationship between periprocedural cTnT levels, with the 99th percentile cutoff value used for normal (<0.01 ng/mL), and outcomes. The patients were divided into 3 groups: normal preprocedural and postprocedural cTnT levels (no myonecrosis), normal preprocedural but elevated postprocedural cTnT levels (PCI-related myonecrosis), and abnormal preprocedural cTnT. The 30-day death rates were 0.1%, 0.6%, and 2.3%, respectively, in the 3 groups. In a multivariable model, an abnormal pre-PCI cTnT level (hazard ratio 9.66 [2.30–40.57]; P=0.002), and PCI-related myonecrosis (4.71 [1.02–21.83]; P=0.048) were independent predictors of 30-day mortality. Over a median follow-up of 28 months, an abnormal pre-PCI cTnT level (hazard ratio 1.79 [1.35–2.39]; P<0.001) independently predicted death, but the occurrence of PCI-related myonecrosis did not. A postprocedural elevation in creatine kinase MB fraction was not an independent predictor of long-term risk of death (0.912 [0.70–1.19]; P=0.5).

Conclusions— A preprocedural cTnT level >0.01 is a powerful independent predictor of prognosis after PCI and is of greater prognostic significance than the postprocedural biomarker levels. PCI-related myonecrosis occurs frequently and predicts short-term but not long-term risk of death.

Key Words: troponin • angioplasty • coronary disease • outcome

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CLINICAL PERSPECTIVE

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