Patients at Low Risk for Periprocedural Myocardial Infarction
Patients at Low Risk for Periprocedural Myocardial Infarction
Despite utilizing optimal anticoagulant therapy during percutaneous coronary intervention (PCI), the incidence of periprocedural myocardial infarction (PPMI) remains 5-7% and evaluation of preprocedural clinical/angiographic characteristics has failed to reliably predict the likelihood of a PPMI. We hypothesized that immediate post-PCI assessment could identify a group of patients at very low risk for PPMI. A consecutive series of 258 PCI patients was stratified into 3 groups based on immediate post-PCI assessment. Group I (PPMI not expected) included those with an acceptable angiographic result of treated vessel (residual stenosis < 50%), TIMI 3 flow and absence of any intraprocedural complications. Group II (PPMI not unexpected) included those with an acceptable angiographic result, TIMI 3 flow but with any/all of the following: saphenous vein graft (SVG) PCI, transient closure of culprit vessel or major sidebranch, intracoronary thrombus, prolonged chest pain, electrocardiographic (ECG) changes, hypotension, resolved slow flow/no reflow, bailout glycoprotein IIb/IIIa inhibitor use, loss of a minor sidebranch or any angiographic residual stenosis > 50% with TIMI 3 flow. Group III (PPMI expected) included those with any angiographic result of native coronary artery or SVG with < TIMI 3 flow, unresolved chest pain, hypotension or ECG changes at the end of the PCI, loss of a major sidebranch or vessel, or persistent no-reflow. Group stratification was analyzed in relation to the incidence of PPMI (CK-MB > 3 times the upper limit of normal; 18-24 hours post-PCI). Rate of PPMI: Group I (1/141; 0.7%), Group II (7/71; 9.9%), Group III (5/11; 45.5%) (p < 0.001). The 3 groups did not differ in age, clinical presentation or stent use (p = NS). Sixty out of 105 patients (57.1%) with unstable angina, seventy-seven out of 146 patients (52.7%) with B2/C lesions, and 105/180 patients (58.3%) with unstable angina or B2/C lesions were stratified to Group I. This study demonstrates that immediate post-PCI evaluation of the clinical/angiographic characteristics can predict the likelihood of PPMI and a group of patients at a very low risk for a PPMI can be identified, in whom implications exist for limited hospitalization and post-procedural antithrombotic therapy.
Despite advances in the technical and pharmacologic aspects of percutaneous coronary intervention (PCI), periprocedural myocardial infarction (PPMI) remains a significant complication of the procedure. Previous studies identified clinical characteristics including age, unstable angina, renal insufficiency and low operator volume to be risk factors for unsuccessful PCI and subsequent PPMI. Similarly, angiographic characteristics considered to be features placing patients at high risk for PPMI during PCI include multivessel coronary artery disease, left ventricular dysfunction, lesion complexity and presence of intracoronary thrombus. However, these risk factors are relatively weak, and many patients who exhibit them have excellent PCI results and vice versa.
The identification of patients at low risk for PPMI has implications for post-procedure therapy, level of in-hospital care and timing of hospital discharge. We hypothesized that evaluation of the clinical and angiographic characteristics present immediately after PCI more accurately predict the risk of PPMI than those prior to intervention. Furthermore, the accuracy of this immediate post-PCI evaluation could outweigh the presence of preprocedural high-risk characteristics.
Despite utilizing optimal anticoagulant therapy during percutaneous coronary intervention (PCI), the incidence of periprocedural myocardial infarction (PPMI) remains 5-7% and evaluation of preprocedural clinical/angiographic characteristics has failed to reliably predict the likelihood of a PPMI. We hypothesized that immediate post-PCI assessment could identify a group of patients at very low risk for PPMI. A consecutive series of 258 PCI patients was stratified into 3 groups based on immediate post-PCI assessment. Group I (PPMI not expected) included those with an acceptable angiographic result of treated vessel (residual stenosis < 50%), TIMI 3 flow and absence of any intraprocedural complications. Group II (PPMI not unexpected) included those with an acceptable angiographic result, TIMI 3 flow but with any/all of the following: saphenous vein graft (SVG) PCI, transient closure of culprit vessel or major sidebranch, intracoronary thrombus, prolonged chest pain, electrocardiographic (ECG) changes, hypotension, resolved slow flow/no reflow, bailout glycoprotein IIb/IIIa inhibitor use, loss of a minor sidebranch or any angiographic residual stenosis > 50% with TIMI 3 flow. Group III (PPMI expected) included those with any angiographic result of native coronary artery or SVG with < TIMI 3 flow, unresolved chest pain, hypotension or ECG changes at the end of the PCI, loss of a major sidebranch or vessel, or persistent no-reflow. Group stratification was analyzed in relation to the incidence of PPMI (CK-MB > 3 times the upper limit of normal; 18-24 hours post-PCI). Rate of PPMI: Group I (1/141; 0.7%), Group II (7/71; 9.9%), Group III (5/11; 45.5%) (p < 0.001). The 3 groups did not differ in age, clinical presentation or stent use (p = NS). Sixty out of 105 patients (57.1%) with unstable angina, seventy-seven out of 146 patients (52.7%) with B2/C lesions, and 105/180 patients (58.3%) with unstable angina or B2/C lesions were stratified to Group I. This study demonstrates that immediate post-PCI evaluation of the clinical/angiographic characteristics can predict the likelihood of PPMI and a group of patients at a very low risk for a PPMI can be identified, in whom implications exist for limited hospitalization and post-procedural antithrombotic therapy.
Despite advances in the technical and pharmacologic aspects of percutaneous coronary intervention (PCI), periprocedural myocardial infarction (PPMI) remains a significant complication of the procedure. Previous studies identified clinical characteristics including age, unstable angina, renal insufficiency and low operator volume to be risk factors for unsuccessful PCI and subsequent PPMI. Similarly, angiographic characteristics considered to be features placing patients at high risk for PPMI during PCI include multivessel coronary artery disease, left ventricular dysfunction, lesion complexity and presence of intracoronary thrombus. However, these risk factors are relatively weak, and many patients who exhibit them have excellent PCI results and vice versa.
The identification of patients at low risk for PPMI has implications for post-procedure therapy, level of in-hospital care and timing of hospital discharge. We hypothesized that evaluation of the clinical and angiographic characteristics present immediately after PCI more accurately predict the risk of PPMI than those prior to intervention. Furthermore, the accuracy of this immediate post-PCI evaluation could outweigh the presence of preprocedural high-risk characteristics.
