Significance of Periprocedural Myocardial Infarctions in Percutaneous Coronary Interventions A New Look at an Old Topic

1. Significance of Periprocedural Myocardial Infarctions in Percutaneous Coronary InterventionsA New Look at an Old Topic Abhiram Prasad, MD, FRCP, FESC, FACC Consultant, Cardiac Catheterization Laboratory, Associate Professor of Medicine Mayo Clinic CP1331879-1

2. Periprocedural MI Background • Incidence varies 5-45% • Correlate with delayed enhancement on MRI • Associated with increased morbidity and mortality • Often considered equivalent to “spontaneous MI” in clinical trials CP1331879-2

3. Limitations of Prior Studies • Most PCI outcome studies have not included the baseline troponin levels as a covariant • When measured and included in the analysis, low cut-off values have not been used CP1331879-7

4. Periprocedural MyonecrosisMayo Clinic Study – Aim Evaluate the relative impact of preprocedural and postprocedural cTnT levels on short- and long-term survival rate after PCI, with the 99th percentile value of 0.01 ng/mL used as the cutoff for normal Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-8

5. Periprocedural Myonecrosis Mayo Clinic Study • 5,487 nonemergency PCI • Pre, 8- and 16-hr post PCI troponin T • 30-day and long-term outcomes Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-9

6. Periprocedural Myonecrosis Mayo Clinic Study • 63% had normal pre-PCI cTnT • Of these, 43% had an elevated post-PCI cTnT • Patients with elevated baseline cTnT values had significantly more adverse clinical(older, congestive heart failure, MI within7 days of PCI, etc) and angiographic (multivessel disease, type C lesions, etc)and procedural characteristics Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-10

7. 30-Day Mortality According to Periprocedural cTnT Levels Kaplan-Meier Estimates Pre 0.01 2.3% P<0.001 Independent predictor HR 22.4 (5.4-92.1); P=0.001 Mortality (%) Independent predictor HR 6.00 (1.30-27.8); P=0.02 Pre <0.01, post >0.01 0.6% Pre <0.01, post <0.01 0.1% Days from PCI Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-11

8. <0.01 0.01-0.03 >0.03-0.1 >0.1-0.5 >0.5-1.0 >1.0 Pre-PCI Troponin and Long-Term Mortality P<0.001 Death or MI (%) Months from PCI Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-12

9. <0.01 0.01-0.03 >0.03-0.1 >0.1-0.5 >0.5-1.0 >1.0 Post-PCI Troponin and Long-Term Mortality P<0.001 Mortality (%) Months from PCI Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-13

10. Long-Term Mortality According to Periprocedural cTnT Levels Pre 0.01 Pre <0.01, post >0.01 P<0.001 Mortality (%) Pre <0.01, post <0.01 Months from PCI Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-14

11. Multivariable Cox Modelfor Long-Term Risk of Death 95% hazardVariable 2 Hazard ratio ratio CL P Pre-PCI cTnT elevation 15.9 1.79 1.35, 2.39 <0.001 Age 83.0 * … <0.001 Congestive heart failure 42.8 2.11 1.69, 2.65 <0.001 Body mass index 25.5 * … <0.001 Chronic renal failure 22.5 2.256 1.61, 3.16 <0.001 Diabetes 19.4 1.60 1.30, 1.97 <0.001 Ejection fraction 11.3 * … 0.010 Cerebrovascular disease 9.3 1.43 1.14, 1.80 0.002 Smoking 5.3 1.28 1.04, 1.60 0.021 Isolated post-PCI cTnT elevation 3.4 1.31 0.98, 1.75 0.065 Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-15

12. Conclusions Mayo Clinic Study • A preprocedural cTnT level >0.01 is a powerful independent predictor of prognosis after PCI • PCI-related myonecrosis occurs frequently and predicts short-term but not long-term risk of death • Association between post-PCI myonecrosis and outcomes in prior studies is a reflection of the preprocedural risk that may be estimated by using baseline cTnT and clinical characteristics Prasad et al: Circ Cardiovasc Intervent 1:10, 2008 CP1331879-16