Peak Creatine Kinase-myocardial Band Research Articles

The Course of Ischemic Mitral Regurgitation in Acute Myocardial Infarction After Primary Percutaneous Coronary Intervention: From Emergency Room to Long-Term Follow-Up.

Previously published evidence on ischemic mitral regurgitation (IMR) and its adverse prognosis after myocardial infarction has been based on the severity of IMR in the subacute or chronic period of myocardial infarction. However, the state of IMR can vary from the early stage to the chronic stage as a result of various responses of myocardium after primary percutaneous coronary intervention (PCI). Standard echocardiography was serially performed in 546 consecutive patients with first-onset acute myocardial infarction (1) immediately after their arrival (pre-PCI), (2) before discharge (early post-PCI), and (3) 6 to 8 months after PCI (late post-PCI). The course of IMR after primary PCI and the prognostic impact of the IMR in each phase were investigated. IMR was found in 193/546 (35%) patients at the emergency room. In the acute phase after PCI, IMR improved in 63 patients. IMR worsened in 78 patients despite successful PCI. Shorter onset-to-reperfusion time and nontotal occlusion before PCI were the independent predictors of early improvement of IMR. In the chronic phase, IMR improved in 79 patients and worsened in 36 patients. Lower peak creatine kinase-myocardial band was an independent predictor of late improvement of IMR. IMR before PCI worsened 30-day prognosis (P=0.02), and persistent IMR in the chronic phase worsened long-term prognosis (P=0.04) after primary PCI. Degrees of IMR changed in the early and chronic phase after primary PCI for acute myocardial infarction. IMR on arrival and persistent IMR in the chronic phase worsened short-term and long-term prognosis after acute myocardial infarction, respectively.

Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IMPACT): a randomized controlled trial.

Remote ischemic preconditioning is a simple therapy that may reduce cardiac and kidney injury. We undertook a randomized controlled trial to evaluate the effect of this therapy on markers of heart and kidney injury after cardiac surgery. Patients at high risk of death within 30 days after cardiac surgery were randomly assigned to undergo remote ischemic preconditioning or a sham procedure after induction of anesthesia. The preconditioning therapy was three 5-minute cycles of thigh ischemia, with 5 minutes of reperfusion between cycles. The sham procedure was identical except that ischemia was not induced. The primary outcome was peak creatine kinase-myocardial band (CK-MB) within 24 hours after surgery (expressed as multiples of the upper limit of normal, with log transformation). The secondary outcome was change in creatinine level within 4 days after surgery (expressed as log-transformed micromoles per litre). Patient-important outcomes were assessed up to 6 months after randomization. We randomly assigned 128 patients to remote ischemic preconditioning and 130 to the sham therapy. There were no significant differences in postoperative CK-MB (absolute mean difference 0.15, 95% confidence interval [CI] -0.07 to 0.36) or creatinine (absolute mean difference 0.06, 95% CI -0.10 to 0.23). Other outcomes did not differ significantly for remote ischemic preconditioning relative to the sham therapy: for myocardial infarction, relative risk (RR) 1.35 (95% CI 0.85 to 2.17); for acute kidney injury, RR 1.10 (95% CI 0.68 to 1.78); for stroke, RR 1.02 (95% CI 0.34 to 3.07); and for death, RR 1.47 (95% CI 0.65 to 3.31). Remote ischemic precnditioning did not reduce myocardial or kidney injury during cardiac surgery. This type of therapy is unlikely to substantially improve patient-important outcomes in cardiac surgery. ClinicalTrials.gov, no. NCT01071265.

Efficacy of Short‐Term High‐Dose Atorvastatin Pretreatment in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Meta‐analysis of Nine Randomized Controlled Trials

The efficacy of short-term high-dose atorvastatin pretreatment in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) remains unclear. This meta-analysis was undertaken to assess the efficacy of short-term high-dose atorvastatin pretreatment in patients with ACS undergoing PCI. Short-term high-dose atorvastatin pretreatment may be beneficial in reducing major adverse cardiac events (MACEs) and improving myocardial blood flow in patients with ACS undergoing PCI. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically reviewed for randomized controlled trials (RCTs) published up to March 2013, in which short-term high-dose atorvastatin pretreatment was compared with control for patients with ACS undergoing PCI. The primary outcome measure was the incidence of MACEs at 30 days. The meta-analysis was performed with the fixed effect model or random-effects model according to the heterogeneity. Meta-analysis was performed by RevMan 5.0 software (Cochrane Collaboration, Copenhagen, Denmark). Nine RCTs incorporating 952 patients met the inclusion criteria and were included in this meta-analysis. Short-term high-dose atorvastatin pretreatment significantly reduced the incidence of MACEs at 30-day follow-up (risk ratio [RR] 0.39, 95% confidence interval [Cl]: 0.25 to 0.61, P < 0.001) and improved the final Thrombolysis in Myocardial Infarction (TIMI) flow grade (RR 1.08, 95% Cl: 1.02 to 1.14, P = 0.01) compared with controls. There were no significant differences in peak creatine kinase-myocardial band and high-sensitivity C-reactive protein level post-PCI between the 2 groups, though there were favorable trends related to statin use. As to the safety end points, no significant difference was observed in elevated liver aminotransferase level between short-term high-dose atorvastatin pretreatment and control groups (RR 1.36, 95% Cl: 0.67 to 2.74). The use of short-term high-dose atorvastatin pretreatment is safe and significantly improves the final TIMI flow grade as well as reduces the 30-day MACEs in ACS patients post-PCI. This finding encourages the use of short-term high-dose atorvastatin pretreatment as an alternative for ACS patients undergoing PCI, but more high-quality randomized clinical trials are still needed to confirm the long-term efficacy and safety.

Deceleration time of diastolic coronary flow velocity as a predictor of transmural extent of infarction in patients with acute myocardial infarction after primary percutaneous coronary intervention

Purpose: The purpose of this study was to investigate whether deceleration time of diastolic coronary flow velocity after primary percutaneous coronary intervention (PCI) can predict the transmural extent of infarction (TEI) defined by contrast-enhanced cardiac magnetic resonance (ce-CMR) in patients with acute myocardial infarction (MI). Methods: In 96 patients after successful PCI for first acute MI, deceleration time of diastolic coronary flow velocity (DDT) were measured by transthoracic echocardiography. Ce-CMR were performed 7 days after onset of acute MI. TEI was graded from 1 to 4 based on the transmural extent of hyperenhanced tissue (grade 1: 0-25% of left ventricular wall thickness, 2: 26-50%, 3: 51-75%, and 4: 76-100%). Infarct size by ce-CMR was also calculated. Results: Adequate recording of DDT were obtained in 92 of 96 patients (96%). Infarct size by ce-CMR and peak creatine kinase-myocardial band values were significantly correlated with DDT (r=0.51, p<0.0001 and (r=0.30, p=0.006, respectively). Moreover, decreased DDT was significantly related to increased TEI-grade (p<0.0001) and existence of microvascular obstruction (p<0.0001). ![Figure][1] Conclusion: DDT measured after primary PCI is a useful predictor for the TEI in patients with acute MI. [1]: pending:yes

Mean platelet volume is associated with poor postinterventional myocardial blush grade in patients with ST-segment elevation myocardial infarction

In a significant proportion of patients with ST-elevation myocardial infarction (STEMI), microvascular and myocardial reperfusion cannot be regained despite successfully restored thrombolysis in myocardial infarction (TIMI) grade 3 epicardial blood flow. Myocardial blush grade (MBG) is a reliable marker for microvascular patency and predicts short-term and long-term mortality after primary percutaneous coronary intervention (PCI) in patients with acute STEMI, independent of other variables. Mean platelet volume (MPV), a unique measure of platelet size, is an indicator of platelet reactivity. In this study, we aimed to investigate the relation of admission MPV with postinterventional MBG in patients with STEMI and TIMI grade 3 flow at infarct artery after primary PCI. Three hundred and ten patients were selected as a study group among patients with STEMI and TIMI grade 3 epicardial blood flow after primary PCI. Blood samples for analysis were obtained during the initial evaluation of patients at the emergency department. MBGs of patients were classified at the end of angioplasty. Patients with MBG 0 and 1 were defined as having poor myocardial blush and patients with MBG 2 and 3 were defined as having normal myocardial blush. Patients with poor myocardial blush had higher admission MPV (10.5±1.3 to 9.1±1 fl, P<0.001), higher peak creatine kinase myocardial band isoenzyme levels (260±53 to 190±38 U/l, P<0.001), higher white blood cell count (11.3±4 to 10.3±3×10/μl, P=0.012), and lower left ventricular ejection fraction (42±7 to 51±8%, P<0.001) compared with patients with normal myocardial blush. Linear regression analysis showed that admission MPV was significantly associated with postinterventional MBG (coefficient=0.598, P<0.001). Cardiovascular mortality (13-5%, P=0.013) and acute-subacute stent thrombosis at 3 months (12-8%, P=0.028) were significantly higher in patients with poor postinterventional myocardial blush compared with those with normal myocardial blush. The MPV measured at admission is significantly associated with poor postinterventional MBG in patients with STEMI and TIMI grade 3 flow at infarct artery after primary PCI.

OCT Analysis in Patients With Very Late Stent Thrombosis

We report optical coherence tomography (OCT) findings in 33 patients who presented with very late stent thrombosis (VLST) after either drug-eluting stent (DES) or bare-metal stent (BMS) implantation. VLST is a potentially life-threatening complication, but the underlying mechanisms remain unclear. In 33 patients (27 DES- and 6 BMS-treated lesions) with definite VLST, OCT images were acquired before either thrombus aspiration or intravascular ultrasonography (IVUS) imaging. The median duration from implantation was 61.5 months in the DES group and 109.1months in the BMS group. In the overall cohort, combining DES and BMS, 94% showed intraluminal thrombi. VLST was associated with in-stent neointimal rupture in 23 patients (70%); 22 had thrombi near the site of neointimal rupture. Stent malapposition was observed in 14 (42%) lesions, but only 9 of them showed thrombi at the site of stent malapposition; moreover, 6 (18%) stented segments with malapposition also had neointimal rupture. Only 2 (6%) lesions had no evidence of neointimal rupture or malapposition. Stent fracture was detected in 3 DES-treated lesions, all with concomitant neointimal rupture. Compared with lesions without neointimal rupture, lesions with neointimal rupture showed a higher frequency of ST-segment elevation myocardial infarction (65% vs. 20%, respectively, p= 0.040) as well as a higher peak creatine kinase-myocardial band level (163.1 ng/ml vs. 15.7 ng/ml, respectively, p= 0.017). OCT imaging indicated that advanced neoatherosclerosis with neointimal rupture and thrombosis was the most common mechanism of definite VLST and was associated with a high frequency of ST-segment elevation myocardial infarction.

Abstract 18884: Coronary Flow Velocity Pattern After Primary Percutaneous Coronary Intervention as a Predictor of Transmural Extent of Infarction in Patients with St-segment Elevation Acute Myocardial Infarction

Purpose: The purpose of this study was to investigate whether coronary flow velocity pattern after primary percutaneous coronary intervention (PCI) can predict the transmural extent of infarction (TEI) defined by contrast-enhanced cardiac magnetic resonance (ce-CMR) in patients with acute myocardial infarction (MI). Methods: In 91 patients after successful PCI for first acute MI, deceleration time of diastolic coronary flow velocity (DDT) were measured by transthoracic echocardiography. Ce-MRI were performed 7 days after onset of AMI. TEI was graded from 1 to 4 based on the transmural extent of hyperenhanced tissue (grade 1: 0-25% of left ventricular wall thickness, 2: 26-50%, 3: 51-75%, and 4: 76-100%). Infarct size by ce-CMR was also calculated. Results: Adequate recording of DDT were obtained in 87 of 91 patients (96%). Infarct size by ce-CMR and peak creatine kinase-myocardial band values were significantly correlated with DDT (r=0.54, p &lt;0.0001 and (r=0.40, p=0.006, respectively). Moreover, decreased DDT was significantly related to increased TEI-grade (p&lt; 0.0001) (figure) and existence of microvascular obstruction (p&lt;0.0001). Conclusion: DDT measured after primary PCI is a useful predictor for the TEI in patients with acute MI.

Periprocedural myocardial infarction is not associated with an increased risk of long-term cardiac mortality after coronary bifurcation stenting

BackgroundDebate continues over the importance of periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI). We evaluated the prognostic significance of PMI in patients undergoing PCI for bifurcation lesions. MethodsBetween January 2004 and June 2006, patients from 16 centers who received non-left main bifurcation lesion PCIs were enrolled. PMI was defined as a peak creatine kinase-myocardial band (CK-MB) ≥3 times the upper limit of normal after PCI. We compared long-term cardiac mortality between patients with and without PMI. ResultsAmong the 1188 patients, PMI occurred in 119 (10.0%). Left ventricular ejection fraction<50% (adjusted hazard ratio [HR]: 2.08, 95% confidence interval [CI]: 1.13–3.82, p=0.018), multi-vessel coronary artery disease (adjusted HR: 2.28, 95% CI: 1.36–3.81, p=0.002), and PCI-related acute closure in a side branch (adjusted HR: 3.34, 95% CI: 1.23–9.02, p=0.018) were the significant risk factors for PMI. During the median follow-up of 22.7months, the unadjusted rate of long-term cardiac mortality was significantly higher in patients with PMI than in those without PMI (2.5% vs. 0.7%, p=0.026). After multivariable adjustment, the relationship between PMI and short-term (≤30day) cardiac mortality was significant (adjusted HR: 12.32, 95% CI: 1.07–141.37, p=0.044). However, PMI was not an independent prognostic factor of long-term cardiac mortality (adjusted HR: 2.59, 95% CI: 0.62–10.85, p=0.20). ConclusionsPMI occurs in patients with a higher prevalence of adverse cardiac risks and predicts short-term but not long-term cardiac mortality in patients undergoing bifurcation lesion PCI.

Comparison of the Prognostic Value of Peak Creatine Kinase‐MB and Troponin Levels Among Patients With Acute Myocardial Infarction: A Report from the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines

Although peak creatine kinase-myocardial band (CK-MB) and troponin levels have been correlated with mortality among patients with acute myocardial infarction (AMI), the independent prognostic implications of these markers have not been compared. We hypothesized that in patients with AMI, peak troponin levels (as compared to peak CK-MB levels) would have greater prognostic value. We examined AMI patients in the National Cardiovascular Data Registry ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines) with CK-MB and troponin I levels recorded, excluding patients who were transferred in or out. Peak marker levels, standardized by the local laboratory upper limit of normal and assay standard deviation, were fitted into the previously validated ACTION Registry-GWTG mortality model to compare prognostic value. Between January 2007 and March 2009, 16 009 ST-segment elevation myocardial infarction (STEMI) and 26854 non-ST-segment elevation myocardial infarction (NSTEMI) patients were identified. Peak marker ratios were directly associated with in-hospital mortality in both STEMI and NSTEMI patients. Peak CK-MB had slightly greater discrimination compared with peak troponin I in predicting mortality in both STEMI (model C-statistic 0.881 vs 0.877, P = 0.011) and NSTEMI (C-statistic 0.831 vs 0.824, P = 0.001) patients. Both peak CK-MB and peak troponin I levels are independently associated with in-hospital mortality in this large contemporary database of AMI patients treated in routine practice. Peak marker values slightly improved model performance in prognosticating in-hospital mortality; the incremental value was higher with CK-MB than with troponin I. These findings may help to guide future risk stratification algorithms and contribute to more efficient use of serial cardiac marker measurements in clinical practice.

Relationship between symptom-onset-to-balloon time and long-term mortality in patients with acute myocardial infarction treated with drug-eluting stents

Time from hospital arrival to reperfusion in ST-segment elevation myocardial infarction (STEMI) has been predictive of in-hospital mortality. The purpose of this study was to evaluate the relationship between symptom-onset-to-balloon time and long-term mortality in patients with STEMI in the drug-eluting stent (DES) era. A series of 393 patients with STEMI treated with DES from 2005 to 2007 was stratified according to risk profile and preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow grade, and clinical, angiographic, and follow-up data were collected. A total of 98 (24.9%) low-risk patients and 295 (75.1%) non-low-risk patients were identified. Three-year mortality rate was 3.1% for low-risk patients and 10.2% for non-low-risk patients (p=0.034), respectively; however it did not differ according to symptom-onset-to-balloon time in either low-risk (p=0.333) or non-low-risk patients (p=0.881). Similarly, symptom-onset-to-balloon time and mortality were not related to preprocedural TIMI flow (p=0.474 for TIMI 0-1; p=0.428 for TIMI 2-3). In multivariate analysis, final TIMI flow 0-2, systolic blood pressure <100 mmHg at admission, age ≥70 years, anterior infarction, C-reactive protein level, and peak creatine kinase myocardial band isoenzyme level were identified as independent predictors of 3-year mortality while symptom-onset-to-balloon time and preprocedural TIMI flow were not. In STEMI patients treated with DES, symptom-onset-to-balloon time does not affect long-term outcomes even in individuals at non-low risk and with poor preprocedural TIMI flow grade.

Relationship between serum neutrophil count and infarct size in patients with acute myocardial infarction

We investigated the relationship between scintigraphic infarct size and neutrophil counts after acute myocardial infarction (AMI), which has not been adequately studied with imaging tools. Twenty-eight consecutive patients with anterior AMI were included in the study. Total white blood cell (WBC), neutrophil counts, creatine kinase-myocardial band (CKMB), and cardiac troponin (cTnT) were obtained at admission and daily during the first 72 h after a patient's arrival. Single photon emission computed tomography studies were performed at a median interval of 4 days (range, 3-5 days) after the AMI. The severity scores of perfusion defects were calculated. WBC and neutrophil counts correlated with enzymatic and single photon emission computed tomography infarct size. Leukocyte and neutrophil counts on admission and first day were positively correlated with peak CKMB, peak cTnT, and scintigraphic infarct size. There were no statistical correlations on the second and third days (P>0.05). The most significant relationship was between basal neutrophil counts and scintigraphic infarct size (r = 0.602, P<0.001). Overall, the correlation coefficients with scintigraphy were better than those with peak CKMB and cTnT levels for both WBC and neutrophil counts. Measuring basal neutrophil counts may be considered as an alternative solution in the prediction of infarct size.

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 ≥25 μg/l, and 130 patients had values <25 μg/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 ≥5 times the reference after elective cardiac surgery are associated with reduced long-term event-free survival.

Off-pump bypass grafting in patients with significant left main coronary artery stenosis.

The aim of this study was to investigate and determine whether patients with significant (> or = %50) left main coronary artery stenosis could undergo coronary bypass on the beating heart and compare the results to those obtained using the conventional method. Prospectively collected data of patients with significant left main coronary artery disease who had undergone coronary bypass on the beating heart (group A, n = 100) or with the conventional method (group B, n = 100) were evaluated retrospectively. EuroSCORE values, preoperative and operative details, postoperative morbidity and mortality, and early results were compared. Groups were similar in terms of EuroSCORE, demographics, and preoperative variables. Number of distal anastomoses per patient was 3.1 +/- 0.9 in the beating heart group while it was 3.3 +/- 0.9 in the conventional group ( P = 0.09). Patients operated on with the conventional method had higher levels of peak creatine kinase-myocardial band, blood and blood product transfusions, and inotropic requirements, while mechanical ventilation times and hospital stay were longer. The incidence of postoperative atrial fibrillation, mediastinitis, and intra-aortic balloon usage were comparable between the groups. There was no neurological complication in group A whereas five major neurological complications (three transient ischemic attacks, two strokes) occurred in group B ( P = 0.06). Thirty-day mortality occurred in one patient in the beating heart group whereas five early deaths were observed in the conventional group ( P = 0.21). In significant left main coronary artery stenosis coronary bypass on the beating heart is a safe and effective alternative to the conventional method with the same or better early results. The long-term results need to be evaluated.

Prognostic significance of elevated creatine kinase MB after coronary bypass surgery and after an acute coronary syndrome: results from the GUARDIAN trial

ObjectiveTo determine if the correlation between magnitude of creatine kinase-myocardial band release after coronary artery bypass surgery and 6-month mortality is comparable to that of patients admitted with an acute coronary syndrome. MethodsThe GUARDIAN trial tested the efficacy of cariporide, an Na+/H+ exchange inhibitor, on reduction of myocardial ischemia or death in high-risk patients. We compared 6-month survival in a cohort of 2332 GUARDIAN patients scheduled for coronary artery bypass surgery at entry with 4233 acute coronary syndrome patients stratified by level of creatine kinase-myocardial band release. Cumulative 6-month survival by creatine kinase-myocardial band categories was performed using life table analysis, adjusting for variables known to impact prognosis using Cox regression. ResultsThe 6-month mortality rates for coronary artery bypass surgery patients with peak creatine kinase-myocardial band ratios of <1, ≥1 and <5, ≥5 and <10, and ≥10 upper limits of normal (ULN) were 5.8, 2.8, 5.9, and 12.0%, respectively (P < .0001). The 6-month mortality rates for acute coronary syndrome patients with peak creatine kinase-myocardial band ratios of <1, ≥1 and <5, ≥5 and <10, and ≥10 ULN were 6.3, 9.8, 10.0, and 12.3%, respectively (P < .0001). Patients with coronary artery bypass surgery or acute coronary syndrome had similar adjusted 6-month survival estimates at normal creatine kinase-myocardial band levels and when the creatine kinase-myocardial band level was ≥10 ULN. Patients with coronary artery bypass surgery had significantly better survival at intermediate enzyme levels (≥1 and <10 ULN; P < .001). ConclusionsModest elevations of creatine kinase-myocardial band release (≥1 and <10 ULN) after coronary artery bypass surgery are not associated with adverse 6-month survival, in contrast to that seen in acute coronary syndrome patients. Routine creatine kinase-myocardial band sampling should be considered in all higher-risk patients undergoing coronary artery bypass surgery procedures to identify the sizable cohort of patients with creatine kinase-myocardial band release ≥10 ULN; these patients may benefit from postoperative angiotensin-converting enzyme inhibitor and beta-blocker therapy. Newer cardioprotective agents that reduce the number of patients with marked creatine kinase-myocardial band release are currently being tested in large randomized controlled clinical trials.

Reduction in periprocedural enzyme elevation by abciximab after rotational atherectomy of type B2 lesions: Results of the Rota ReoPro randomized trial

Background Abciximab has been shown to reduce ischemic complications and creatine kinase-myocardial band (CK-MB) elevation of both simple and complex coronary interventions. In addition to the procedural complications, one of the important mechanisms for CK-MB elevation after rotational atherectomy is an interaction between platelets and the atheromatous debris. Methods This study was conducted to determine whether abciximab would limit the extent of periprocedural CK-MB release after rotational atherectomy of American Heart Association/American College of Cardiology type B2 lesions in a double-blind, randomized, placebo-controlled manner. A total of 100 lesions in 100 patients were randomized with the primary end point being a CK-MB elevation of >16 U/L. Results Procedural success was achieved in 100% in the abciximab arm compared with 98% in the placebo group with any CK-MB elevation >16 U/L of 8% in the abciximab versus 22% in the placebo group (P = .04). The peak creatine phosphokinase level (units per liter) was 102 ± 14 versus 153 ± 22 (P = .05) and the peak CK-MB level was 12.8 ± 1.8 versus 24.6 ± 3.5 (P = .06) between the abciximab and placebo groups, respectively. Slow-flow or postprocedure chest pain occurred in 14% in the abciximab group versus 30% in the placebo group (P = .04). There was 1 Q-wave myocardial infarction in the placebo arm and 1 nonhemorrhagic stroke in the abciximab group. Conclusions Therefore the Rota ReoPro randomized trial revealed the benefit of abciximab during rotational atherectomy in reducing procedural morbidity and CK-MB elevation, and its routine use can be justified even in moderately complex lesions undergoing rotational atherectomy. (Am Heart J 2001;142:965-9.)

Increased mortality after coronary artery bypass graft surgery is associated with increased levels of postoperative creatine kinase-myocardial band isoenzyme release: Results from the GUARDIAN trial

OBJECTIVESWe sought to determine if elevated cardiac serum biomarkers after coronary artery bypass graft surgery (CABG) are associated with increased medium-term mortality and to identify patients that may benefit from better postoperative myocardial protection.BACKGROUNDThe relationship between the magnitude of cardiac serum protein elevation and subsequent mortality after CABG is not well defined, partly because of the lack of large, prospectively studied patient cohorts in whom postoperative elevations of cardiac serum markers have been correlated to medium- and long-term mortality.METHODSThe GUARD during Ischemia Against Necrosis (GUARDIAN) study enrolled 2,918 patients assigned to the entry category of CABG and considered as high risk for myocardial necrosis. Creatine kinase-myocardial band (CK-MB) isoenzyme measurements were obtained at baseline and at 8, 12, 16 and 24 h after CABG.RESULTSThe unadjusted six-month mortality rates were 3.4%, 5.8%, 7.8% and 20.2% for patients with a postoperative peak CK-MB ratio (peak CK-MB value/upper limits of normal [ULN] for laboratory test) of <5, ≥5 to <10, ≥10 to <20 and ≥20 ULN, respectively (p < 0.0001). The relationship remained statistically significant after adjustment for ejection fraction, congestive heart failure, cerebrovascular disease, peripheral vascular disease, cardiac arrhythmias and the method of cardioplegia delivery. Receiver operating characteristic curve analysis revealed an area under the curve of 0.648 (p < 0.001); the optimal cut-point to predict six-month mortality ranged from 5 to 10 ULN.CONCLUSIONSProgressive elevation of the CK-MB ratio in clinically high-risk patients is associated with significant elevations of medium-term mortality after CABG. Strategies to afford myocardial protection both during CABG and in the postoperative phase may serve to improve the clinical outcome.

Myocardial Injury During Reoperation for Coronary Artery Bypass Surgery

Objectives: To determine the incidence, triggers, and timing of myocardial injury during reoperation for coronary artery bypass surgery. Design: Prospective observational. Setting: One tertiary care university hospital. Participants: 15 patients undergoing reoperation. Interventions: Multilead electrocardiographic monitoring approximately every 3 minutes during surgery. Measurements and Main Results: The occurrence of a new ischemic ST elevation or depression on the electrocardiogram (ECG) was determined. A major deterioration in ventricular function after cardiopulmonary bypass (CPB) also was determined. Peak creatine kinase myocardial band (CK-MB) ≥ 25 IU/L was considered to be the marker of myocardial injury. Seven patients demonstrated myocardial injury, all intraoperatively. Five of these patients had new ST elevation episodes before CPB. Three of the episodes were temporally associated with an abrupt increase in the heart rate. The other two episodes were temporally associated with surgical manipulation of the heart and the old grafts. The sixth patient had a significant deterioration of ventricular function during CPB. One of the patients who had ST elevation before CPB and the seventh patient developed ST elevation towards the end of protamine administration. Conclusions: In patients undergoing reoperation, the intraoperative incidence of myocardial injury, especially before CPB, was found to be substantially higher than that previously reported.

Myocardial injury during reoperation for coronary artery bypass surgery

To determine the incidence, triggers, and timing of myocardial injury during reoperation for coronary artery bypass surgery. Prospective observational. One tertiary care university hospital. 15 patients undergoing reoperation. Multilead electrocardiographic monitoring approximately every 3 minutes during surgery. The occurrence of a new ischemic ST elevation or depression on the electrocardiogram (ECG) was determined. A major deterioration in ventricular function after cardiopulmonary bypass (CPB) also was determined. Peak creatine kinase myocardial band (CK-MB) > or = 25 IU/L was considered to be the marker of myocardial injury. Seven patients demonstrated myocardial injury, all intraoperatively. Five of these patients had new ST elevation episodes before CPB. Three of the episodes were temporally associated with an abrupt increase in the heart rate. The other two episodes were temporally associated with surgical manipulation of the heart and the old grafts. The sixth patient had a significant deterioration of ventricular function during CPB. One of the patients who had ST elevation before CPB and the seventh patient developed ST elevation towards the end of protamine administration. In patients undergoing reoperation, the intraoperative incidence of myocardial injury, especially before CPB, was found to be substantially higher than that previously reported.

Early peak of creatine kinase-MB in acute myocardial infarction with a nondiagnostic electrocardiogram

This study compared the time from the onset of symptoms to the peak of the creatine kinase-myocardial band (CK-MB) in 34 consecutive patients with acute myocardial infarction. Patients were separated into two groups: group 1 (n = 21) had diagnostic (≥0.1 mV) ST segment elevation on the initial ECG, and group 2 (n = 13) did not have diagnostic ST segment elevation on the initial ECG. In group 1 the time to the peak CK-MB was 16.2 ± 50 hours vs 10.0 ± 2.0 hours for group 2 ( p = 0.0001). Peak CK-MB was 331 ± 276 IU/L in group 1 vs 81 ± 54 IU/L in group 2 ( p < 0.005). In group 1 there were 16 patients who subsequently had a Q wave myocardial infarction as opposed to one patient in group 2 ( p = 0.0001). Patients who do not have diagnostic ST segment elevation on the initial ECG have an early but low peak of CK-MB and typically have a non-Q wave infarction. These findings are consistent with early spontaneous restoration of blood flow during the infarction process in these patients. This early restoration of blood flow may provide the substrate for the high incidence of recurrent ischemic events noted in patients with non-Q wave myocardial infarction.