Prognostic Relevance of Type 4a Myocardial Infarction and Periprocedural Myocardial Injury in Patients With Non-ST-Segment-Elevation Myocardial Infarction.

IF 35.5 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS
Circulation Pub Date : 2025-03-18 Epub Date: 2025-02-19 DOI:10.1161/CIRCULATIONAHA.124.070729
Matteo Armillotta, Luca Bergamaschi, Pasquale Paolisso, Marta Belmonte, Francesco Angeli, Angelo Sansonetti, Andrea Stefanizzi, Davide Bertolini, Francesca Bodega, Sara Amicone, Lisa Canton, Damiano Fedele, Nicole Suma, Andrea Impellizzeri, Francesco Pio Tattilo, Daniele Cavallo, Ornella Di Iuorio, Khrystyna Ryabenko, Andrea Rinaldi, Gabriele Ghetti, Francesco Saia, Cinzia Marrozzini, Gianni Casella, Paola Rucci, Alberto Foà, Carmine Pizzi
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引用次数: 0

Abstract

Background: Periprocedural myocardial injury (PMI) with or without type 4a myocardial infarction (MI) might occur in patients with non-ST-segment-elevation MI (NSTEMI) after percutaneous coronary intervention (PCI). This study investigated the incidence and prognostic relevance of these events, according to current definitions, in patients with NSTEMI undergoing PCI. The best cardiac troponin I (cTnI) threshold of PMI for prognostic stratification is also suggested.

Methods: Consecutive patients with NSTEMI from January 2017 to April 2022 undergoing PCI with stable or falling pre-PCI cTnI levels were enrolled. According to the Fourth Universal Definition of Myocardial Infarction, the study population was stratified into those experiencing (1) PMI with type 4a MI, (2) PMI without type 4a MI, or (3) no PMI. Post-PCI cTnI increase >20% with an absolute postprocedural value of ≥5 times the 99th percentile upper reference limit within 48 hours after PCI was used to define PMI. The primary end point was 1-year all-cause mortality, and the secondary end point consisted of major adverse cardiovascular events at 1 year, including all-cause mortality, nonfatal reinfarction, urgent revascularization, nonfatal ischemic stroke, and hospitalization for heart failure. Internal validation was performed in patients enrolled between May 2022 and April 2023.

Results: Among 1412 patients with NSTEMI undergoing PCI with stable or falling cTnI levels at baseline, 240 (17%) experienced PMI with type 4a MI, 288 (20.4%) experienced PMI without type 4a MI, and 884 (62.6%) experienced no PMI. PMI was associated with an increased risk of adverse clinical outcomes, with patients with type 4a MI demonstrating the highest rates of 1-year all-cause mortality and major adverse cardiovascular events. A post-PCI ΔcTnI >20% but ≤40% showed similar outcomes to patients without PMI, whereas >40% was identified as the optimal threshold for prognostically relevant PMI, confirmed in an internal validation cohort of 305 patients.

Conclusions: Periprocedural ischemic events were frequent in patients with NSTEMI undergoing PCI with prognostic implications. A post-PCI ΔcTnI >40%, combined with an absolute postprocedural value of ≥5 times the 99th percentile upper reference limit, was identified as the optimal threshold for diagnosing prognostically relevant PMI. Recognizing these events may improve risk stratification and management of patients with NSTEMI.

非st段抬高型心肌梗死患者4a型心肌梗死与围手术期心肌损伤的预后相关性
背景:经皮冠状动脉介入治疗(PCI)后非st段抬高型心肌梗死(NSTEMI)患者可能发生伴或不伴4a型心肌梗死(MI)的围手术期心肌损伤(PMI)。本研究调查了这些事件的发生率和预后相关性,根据目前的定义,NSTEMI患者接受PCI。同时提出了心肌肌钙蛋白I (cTnI)的最佳阈值。方法:纳入2017年1月至2022年4月连续接受PCI且PCI前cTnI水平稳定或下降的NSTEMI患者。根据心肌梗死的第四种通用定义,研究人群分为(1)PMI伴4a型心肌梗死,(2)PMI伴4a型心肌梗死,(3)无PMI。PCI术后cTnI增加20%,术后绝对值≥5倍于PCI定义PMI后48小时内的第99百分位上限。主要终点是1年内的全因死亡率,次要终点是1年内的主要心血管不良事件,包括全因死亡率、非致死性再梗死、紧急血运重建、非致死性缺血性卒中和因心力衰竭住院。在2022年5月至2023年4月期间入组的患者中进行了内部验证。结果:在1412例基线cTnI水平稳定或下降的NSTEMI患者中,240例(17%)出现了伴有4a型心肌梗死的PMI, 288例(20.4%)出现了无4a型心肌梗死的PMI, 884例(62.6%)没有PMI。PMI与不良临床结果风险增加相关,4a型心肌梗死患者1年全因死亡率和主要不良心血管事件发生率最高。pci后ΔcTnI >20%但≤40%与无PMI的患者结果相似,而>40%被确定为预后相关PMI的最佳阈值,在305例患者的内部验证队列中得到证实。结论:行PCI的非stemi患者术中缺血事件频发,影响预后。pci后ΔcTnI >40%,结合绝对术后值≥5倍的第99个百分位上限,被确定为诊断预后相关PMI的最佳阈值。认识到这些事件可以改善NSTEMI患者的风险分层和管理。
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来源期刊
Circulation
Circulation 医学-外周血管病
CiteScore
45.70
自引率
2.10%
发文量
1473
审稿时长
2 months
期刊介绍: Circulation is a platform that publishes a diverse range of content related to cardiovascular health and disease. This includes original research manuscripts, review articles, and other contributions spanning observational studies, clinical trials, epidemiology, health services, outcomes studies, and advancements in basic and translational research. The journal serves as a vital resource for professionals and researchers in the field of cardiovascular health, providing a comprehensive platform for disseminating knowledge and fostering advancements in the understanding and management of cardiovascular issues.
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