Long-term prognostic value of CK-MB and the troponins after angioplasty in patients with stable angina.

OBJECTIVES: The long-term prognostic value (> 5 years) of elevated cardiac biomarkers after elective coronary angioplasty is yet not clear. Most previous studies have included high risk, unstable patients and with conflicting results. The aim of this study was to determine the prognostic value of CK-MB mass vs. the cardiac troponins (values ≥ 3 times the reference) after elective angioplasty in low-risk patients with stable angina. METHODS: A total of 202 consecutive patients were included in the final analysis. Patients with elevated values at baseline, and those suffering an acute coronary syndrome < 1 month before the time of inclusion, were excluded. Blood samples were drawn just before, 1-3 hours and 4-8 hours after the procedure and the next morning. Using a cutoff value of three times the reference, patients with high and low values (= controls) of CK-MB mass, cardiac troponin T (TnT) and troponin I (TnI) were compared. No patient developed new Q-waves on ECG. The median follow-up time was 82 months equalising 1600 patient years. RESULTS: None of the patients died during the procedure or within the first 30 days after angioplasty, confirming a low risk cohort. There was an increasingly number of patients with levels ≥ 3 times the reference post procedure in TnT (10.4%) and TnI (16.8%) vs. CK-MB (6.9%). All cause mortality, readmission for acute coronary syndromes and target lesion revascularisation were more frequent in patients with high CK-MB, 42.9% vs. 22.3 %, p = 0.05 (log-rank test). Corresponding values for TnT were 33.3% vs. 22.7%, p = 0.22. In the TnI patients, there were more adverse events in controls vs. the high group, 25.0% vs. 17.6%, p = 0.34. CONCLUSIONS: CK-MB mass values ≥ 3 times, contrary to the cardiac troponins, predicts worse long-term event-free survival after elective angioplasty in low-risk patients.

Long-term prognostic value of cardiac troponin I and T versus creatine kinase-MB mass after cardiac surgery in low-risk patients with stable symptoms.

The long-term prognostic value of elevated cardiac biomarkers after elective cardiac surgery is not clear. The recent guidelines for diagnosing perioperative infarcts have advocated the use of similar thresholds for creatine kinase-MB (CK-MB) mass and the cardiac troponins. However, few previous data are available comparing these biomarkers after cardiac surgery, and it is not clear whether postoperative elevations of the troponins can be treated the same as elevations of CK-MB. We sought to compare the prognostic value of the cardiac troponins versus the CK-MB mass after elective cardiac surgery in low-risk patients with stable symptoms. A total of 204 consecutive patients undergoing cardiac surgery were included in the final analysis. Blood samples were drawn just before and 1 to 3 and 4 to 8 hours after the procedure, and every morning for 3 days thereafter. Patients with elevated baseline values were excluded. Using a cutoff value of 5 times the reference, patients with high and low values (controls) of CK-MB mass, cardiac troponin T (cTnT) and cardiac troponin I (cTnI) were compared. The median follow-up time was 92 months. None developed new Q-waves on the electrocardiogram. The incidence of the composite end point of all-cause mortality, readmission for acute coronary syndrome, and target vessel revascularization in the high CK-MB group was 41.2% compared to 21.8% in the controls (p = 0.004). The corresponding values for cTnT were 33.3% and 20.4% (p = 0.075) and for cTnI were 27.0% and 34.6% (p = 0.237). The p value in the isolated coronary artery bypass grafting subgroup (n = 156) was p = 0.043 for CK-MB, p = 0.137 for cTnT, and p = 0.795 for cTnI. High CK-MB (p = 0.001), ejection fraction (p = 0.002), and body mass index (p = 0.010) were the only variables independently related to reduced event-free survival. No such relation was found for high cTnT and cTnI. In conclusion, CK-MB was superior to the cardiac troponins (values > or =5 times the reference) in predicting long-term event-free survival after elective cardiac surgery in low-risk patients with stable symptoms undergoing coronary artery bypass grafting and/or valve surgery.

Elevated CK-MB values after routine angioplasty predicts worse long-term prognosis in low-risk patients.

OBJECTIVES: The long-term prognostic value (>5 years) of elevated cardiac biomarkers after elective coronary angioplasty is yet not clear. Most previous studies have included high risk, unstable patients. The aim of this study was to determine the prognostic value of CK-MB mass > or = three times the reference after elective angioplasty in low-risk patients with stable angina. METHODS: A total of 278 consecutive patients were included in the final analysis. Patients with elevated CK-MB values at baseline, and those suffering an acute coronary syndrome <1 month before the time of inclusion, were excluded. Blood samples were drawn just before and 1-3 hours, 4-8 hours after the procedure and the next morning. Nineteen patients (6.8%) had peak CK-MB mass values > or =15 microg/L (three times the reference), and 259 patients had values <15 microg/L (defined as controls). No patient developed new Q-waves on ECG. The median follow-up time was 80.5 months. RESULTS: None of the patients died during the procedure or within the first 30 days after angioplasty, confirming a low risk cohort. All cause mortality, readmission for acute coronary syndromes and target lesion revascularisation (TLR) were more frequent in patients with high CK-MB, 42.1% vs. 22.8%, p=0.034 (log rank). In a multivariate logistic regression analysis, high CK-MB and former angioplasty were the only variables independently related to a reduced event-free survival. CONCLUSIONS: CK-MB mass values > or = three times the reference after elective angioplasty predicts reduced long-term event-free survival.

Long-term prognostic value of creatine kinase-myocardial band mass after cardiac surgery in low-risk patients with stable angina.

OBJECTIVES: The long-term prognostic value (>5 years) of elevated cardiac biomarkers after elective cardiac surgery is not clear. Most previous studies have included high-risk, unstable patients. The aim of this study was to determine the prognostic value of creatine kinase-myocardial band (CK-MB) mass after elective cardiac surgery in low-risk patients with stable angina. METHODS: A total of 230 consecutive patients undergoing cardiac surgery were included in the final analysis. Blood samples were drawn just before and 1-3 and 4-8 h after the procedure, and every morning thereafter for 3 days. Using a cutoff value of 5 times the reference, 100 patients (43.6%) had peak CK-MB mass values > or =25 microg/l, and 130 patients had values <25 microg/l (defined as controls). No patient developed new Q waves on ECG. The median follow-up time was 95 months. RESULTS: All-cause mortality and readmission for acute coronary syndromes were more frequent in the high-CK-MB group (30.0 vs. 17.9%, p = 0.022), as was target vessel revascularization (20.6 vs. 5.4%). Comparing the quartiles of peak CK-MB values in a Kaplan-Meier survival plot, event-free survival for the upper quartile (n = 60) was 68.3%, and for the lower quartile (n = 55), it was 83.6% (p = 0.046). In a multivariate logistic regression analysis, high CK-MB and ejection fraction were the only variables independently related to reduced event-free survival. CONCLUSIONS: CK-MB values > or =5 times the reference after elective cardiac surgery are associated with reduced long-term event-free survival.

Temporal pattern of cardiac troponin I after thoracotomy and lung surgery.

BACKGROUND: Several studies have shown that patients with perioperative myocardial infarction (MI) are at higher risk for subsequent cardiac events and the identification of these patients is important. However, the diagnosis of perioperative MI can be difficult in many cases. The cardiac troponins are biomarkers with high cardiospecificity, and the aim of this study was to assess cTnI and cTnT among other cardiac biomarkers after thoracotomy and lung surgery. METHODS: 24 consecutive patients were included in the final analysis. Venous blood samples were drawn prior to the procedure, 1-3, 4-6, 16-18 and 30-32 h after surgery. Thoracotomy was performed as a standard posterolateral incision on the left or right side under general anesthesia. RESULTS: Both cTnI and cTnT were completely unaffected by the thoracotomy and the lung surgery. Furthermore, no single value of the troponins was above the 99th percentile at any time. In contrast, CK-MB was elevated in nearly half the patients, although the mean values complied well with the reference limit. CK and myoglobin were both considerably elevated and did not discriminate between acute myocardial infarction and release of the markers due to extracardiac injury. CONCLUSIONS: Only the troponins were unaffected by extracardiac surgery and were, thus, reliable markers of myocardial injury in patients who underwent thoracotomy and lung surgery. If the troponins are unavailable, CK-MB mass combined with the CK-MB/CK percentage should be preferred.

Release of cardiac troponin I after temporally graded acute coronary ischaemia with electrocardiographic ST depression.

BACKGROUND: Elevation of cardiac biochemical markers and ST segment depression in the electrocardiogram have important roles in the risk stratification of unstable coronary syndromes. We assessed graded duration of acute coronary ischaemia with ST depression versus release of cardiac troponin I (cTnI) and conventional cardiac markers in 15 ischaemic pigs and 11 controls. METHODS: Coronary ischaemia was induced via percutaneous technique by semiinflating an angioplasty balloon in the left circumflex artery. Blood velocity monitored by Doppler was reduced until ST depression > or =0.1 mV was obtained. Among 26 pigs, six controls had jugular vein sheath introduced only, five controls jugular vein and bilateral femoral sheaths, and 15 pigs were divided into three equal groups (n=5) in which ischaemia was maintained for 10, 20 and 30 min, respectively. RESULTS: Mean blood flow velocity (cm/s) at baseline was 16.3+/-6.5 and was reduced to 4.1+/-3.2 (25% of normal, range 20-29%) during ischaemia. cTnI (microg/l) did not increase in controls but increased from 0.05 to 0.52 (P<0.05) and 0.76 (P<0.05) with 10 and 20 min of ischaemia, and to 30.77 (P<0.05) with 30 min of ischaemia. A rise of myoglobin and conventional cardiac enzymes did not distinguish controls with arterial cut-down from the ischaemia groups. CONCLUSION: Release of cTnI depends on the duration of ST depression ischaemia. The critical time for a major release seems to be between 20 and 30 min. Thus, very early intervention in patients with prolonged ST depression ischemia should be focused on in future clinical trials.

Percutaneous assessment of coronary blood flow and cardiac biomarkers.

The aim of this study was to compare blood flow determined by coloured microspheres vs. Doppler intravascular ultrasound (US) combined with angiography. A second endpoint was to assess cardiac troponin I (cTnI) as a marker of myocardial injury. Doppler and microspheres were compared in 11 closed chest pigs. Blood flow was measured by catheter-based percutaneous technique in the left circumflex artery (LCx) and compared with coloured microspheres injected in the left ventricle. cTnI was measured in all pigs (73). The mean blood flow (mL/min-1) was 23.3 +/- 8.7 vs. 21.9 +/- 12.1 by Doppler vs. microspheres (p = 0.156), correlation coefficient r = 0.90, p = 0.006. The mean coronary flow with Doppler technique and microspheres in the middle LCx was 22.9 +/- 7.6 vs. 21.2 +/- 6.2 (p = 0.077), and distal 23.9 +/- 10.9 vs. 23.1 +/- 12.1 (p = 0.698). Coronary blood flow measured by Doppler and angiography was comparable to myocardial blood flow measured by coloured microspheres injected in the left atrium or the left ventricle. cTnI was more sensitive to ischaemia than CK-MB mass.