QJM Advance Access originally published online on March 13, 2009
QJM 2009 102(6):369-378; doi:10.1093/qjmed/hcp005
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Myocardial infarction after percutaneous coronary intervention: a meta-analysis of troponin elevation applying the new universal definition
From the 1Institute of Cardiology, John Radcliffe Hospital, Oxford, UK, 2Interventional Cardiology Department, Sant'Ambrogio Clinical Institute, Milan, Italy, 3Institute of Cardiology, The Northern Hospital, Melbourne, Australia, 4Institute of Cardiology, University of Turin, Turin, Italy, 5Antwerp Cardiovascular Institute Middelheim, Antwerp, Belgium, and 6Institute of Cardiology, Catholic University, Rome, Italy
Address correspondence to Dr Luca Testa, MD, PhD, Cardiology Ward, Level 2, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. email: luctes{at}gmail.com
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Abstract |
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Aim: Elevation of Troponin after scheduled percutaneous coronary intervention (PCI) is a recognized consequence. We sought to evaluate the prognostic significance and impact of the newly published definition of PCI-related myocardial infarction (MI) according to which any troponin elevation >3 times the upper reference limit identify a peri-procedural MI.
Methods: Search of BioMedCentral, CENTRAL, mRCT and PubMed (updated May 2008). Outcomes of interest were: MACE [the composite of all cause death, MI, repeat target vessel PCI (re-PCI) and coronary artery bypass grafting (CABG)]; single end points were also assessed.
Results: Fifteen studies have been included totalling 7578 patients. Troponin elevation occurred in 28.7% of the procedures. The incidence of PCI-related MI according to the new definition was 14.5%. During the hospitalization, any level of raised troponin was associated with an increased risk of MACE [OR 11.29 (3.00–42.48), Number needed to harm (NNH) 5], death [OR 7.16 (1.95–26.27), NNH = 100], MI [OR 30.85 (6.05–157.38), NNH = 4] and re-PCI [OR 4.13 (1.23–13.88), NNH = 50]. Patients with PCI-related MI had an increased risk of death [OR 17.25 (2.71–109.96), NNH = 100] and re-PCI [OR 10.86 (3.2–36.94), NNH = 25]. At follow up of 18 months any troponin elevation was associated with an increased risk of MACE [OR 1.48 (1.12–1.96), NNH = 20], death [OR 2.19 (1.59–3.00), NNH = 50], MI [OR 3.29 (2.71–6.31), NNH = 33] and re-PCI [OR 1.47 (1.06–2.03), NNH = 25]. In patients with PCI-related MI the risk of MACE was further increased: OR 2.25 (1.26–4.00), NNH = 3. An increase of the troponin level below the cut-off was not associated with MACE.
Conclusion: A diagnosis of MI according to the new guidelines applies to 15% of patients undergoing PCI and these patients are at high risk of further adverse events both during the hospital stay and at 18 months.