[Prognostic significance of the elevation of the indices of myocardial damage after percutaneous coronary revascularization interventions].
In the last 10 years a large number of studies have clearly shown that mild to moderate elevation of biochemical markers of myocardial damage is quite common following otherwise successful percutaneous coronary revascularization. The true significance of these findings is not fully understood and the question if they carry sufficient adverse clinical impact to be categorized as a "complication" of the procedure is still debatable. The majority of experience published so far has reported an association between post-procedure enzyme release and long-term mortality, with a direct link between the level of elevation of the creatine kinase myocardial band (CK-MB) and the risk of death. Side branch occlusion and microembolization are the most frequent factors responsible for myocardial damage after stent implantation. Potential mechanisms of adverse prognosis include increased susceptibility to ventricular arrhythmias via microreentrant circuits, compromised coronary collaterals, or dysfunction of microvascular circulation. A cause and effect relationship between post-procedure enzyme elevation and a worse outcome has not been clearly demonstrated; patients in whom CK-MB elevation develops are older and have more extensive coronary artery disease than patients without enzymatic infarct; it is difficult therefore to determine whether the elevations are causative or whether they are associated with mortality due to their association with higher risk at baseline. Consequently it is not clear if prevention of procedural mild myocardial damage is associated with long-term benefit. Numerous other questions remain unanswered, regarding: 1) the biochemical marker most suitable in identifying patients at increased risk of late adverse events; 2) the threshold at which this elevation is clinically significant; 3) the relevance of the type of percutaneous device used. Ongoing large-scale, prospective studies, with extended follow-up, could provide further insights into prognostic significance of elevation of markers of myocardial necrosis following percutaneous coronary interventions.
Cavallini
Claudio
C
Divisione di Cardiologia, Dipartimento Cardiovascolare, Ospedale Regionale Ca' Foncello, Treviso. clcaval@tin.it
Savonitto
Stefano
S
D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects* / Q000401:mortality; D017225:Atherectomy, Coronary / Q000009:adverse effects / Q000401:mortality; D015415:Biomarkers / Q000097:blood; D002986:Clinical Trials as Topic; D003326:Coronary Circulation; D003402:Creatine Kinase / Q000097:blood*; D052279:Creatine Kinase, MB Form; D006801:Humans; D007527:Isoenzymes / Q000097:blood*; D008833:Microcirculation; D009203:Myocardial Infarction / Q000097:blood* / Q000209:etiology / Q000401:mortality; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D011379:Prognosis; D015607:Stents / Q000009:adverse effects*
D015415:Biomarkers; D007527:Isoenzymes; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D003402:Creatine Kinase; D052279:Creatine Kinase, MB Form