Incidence, correlates, and significance of abnormal cardiac enzyme rises in patients treated with surgical or percutaneous based revascularisation A substudy from the Synergy between Percutaneous Coronary Interventions with Taxus and Cardiac Surgery (SYNTAX) Trial
The aim of the present investigation was to determine the long-term prognostic association of post-procedural cardiac enzyme elevation within the randomised Synergy between Percutaneous Coronary Intervention (PCI) with TAXUS and Cardiac Surgery (SYNTAX) Trial.
1800 patients with unprotected left main or de novo three-vessel coronary artery disease were randomised to undergo coronary artery bypass graft (CABG) surgery or PCI. Per protocol patients underwent post-procedural blood sampling with creatine kinase (CK), and the cardiac specific MB iso-enzyme (CK-MB) only if the preceding CK ratio was ≥2× the upper limit of normal (ULN). An independent chemistry laboratory evaluated all collected blood samples.
Post-procedural CK sampling was available in 1629 of 1800 patients (90.5%). As per protocol, CK-MB analyses were undertaken in 474 of 491 patients (96.5%) in the CABG arm, and 53 of 61 patients (86.9%) in the PCI arm. Within the CABG arm, despite the limitations of incomplete data, a post-procedural CK-MB ratio <3/≥3 ULN separated 4-year mortality into low- and high-risk groups (2.3% vs. 9.5%, p=0.03). Additionally, in the CABG arm, a post-procedural CK-MB ratio ≥3 ULN was associated with an increased frequency of a high SYNTAX Score (≥33) tertile (high [≥33] SYNTAX Score: 39.5%, intermediate [23-32] SYNTAX Score 31.0%, low [≤22] SYNTAX Score 29.5%, p=0.02). Within the PCI arm, a post-procedural CK ratio of <2 or ≥2 ULN separated 4-year mortality into low- and high-risk groups (10.8% vs. 23.3%, p=0.001). Notably, there was an early (within 6months) and late (after 2years) peak in mortality in patients with a post-PCI CK ratio of ≥2 ULN. Lack of pre-procedural thienopyridine, carotid artery disease, type 1 diabetes, and presence of coronary bifurcations were independent correlates of a CK ratio ≥2 ULN post-PCI.
Cardiac enzyme elevations post-CABG or post-PCI are associated with an adverse long-term mortality; the causes of which are multifactorial.
[Show abstract][Hide abstract] ABSTRACT: The study sought to report the short and long-term clinical impact of stent thrombosis (ST) and graft occlusion (GO) in the final 5-year outcomes of the SYNTAX Trial.
The clinical impact effect of newer generation drug eluting stents and operative factors in complex coronary artery disease is uncertain.
The incidence of 5-year ST and GO, and their association with clinical outcomes, were analysed in the randomised PCI and CABG cohorts. ST and GO were defined with the SYNTAX protocol definitions (clinical presentation with acute coronary syndrome and angio-graphic/pathological evidence), Academic Research Consortium (ARC) definition for ST, and the newly devised 'ARC-like' definition for GO (i.e. definite, probable or possible GO).
At 5 years, 871/903 (96·5%) in the PCI cohort, and 805/897 (89·7%) in the CABG cohort completed follow-up. As compared to other vessel locations, protocol ST (72 lesions) occurred more frequently in the left main (14/72, 19%) and proximal coronary vasculature (37/72, 51%), and protocol GO (41 lesions) with grafts anastomosed to the distal right coronary artery (17/41, 42%). Incidences of 5-year ARC definite ST and ARC-like definite GO did not significantly differ (7% [n=48] vs. 6% [n=32], p=0.34); landmark analyses indicated significantly increased ARC definite ST within 30 days (3% [n=19] vs. 1.0% [n=6], p=0.033), but not >30 days to 5 years (4.2% [n=29] vs. 4.5% [n=26], p=0.78). At presentation, ARC definite ST (n=48) and ARC-like definite GO (n=32) were adjudicated to be linked to 4 (8%) and 0 deaths respectively. At 5 years, ARC definite ST (n=48) and ARC definite/probable ST (n=75) were associated with 17 (35.4%, median days to death 0 days, interquartile range [IQR] 0-16 days, max. 321 days) and 31 (41.3%, median 0 days, IQR 0-9 days, max. 721 days) cardiac deaths respectively. At 5 years, ARC-like definite GO (n=32) and ARC-like definite/probable GO (n=53) were associated with 0 and 12 (22.6%, median 0 days, IQR 0-14 days, max. 257 days) cardiac deaths respectively.
Although ST and GO had similar incidences at 5 years, the clinical impact of ST appeared greater, with a negative impact on short to longer term mortality.
ClinicalTrials.gov, number NCT00114972.
Journal of the American College of Cardiology 10/2013; 62(25). DOI:10.1016/j.jacc.2013.07.106 · 16.50 Impact Factor
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