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      Relationship of Serum Cardiac Markers following Successful Percutaneous Coronary Intervention and Subsequent Exercise Capacity in Patients with Chronic Stable Angina: A Pilot Study

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          Abstract

          We performed a pilot study to assess the significance of modest, asymptomatic, elevated serum cardiac markers – troponin T (TnT) and creatinine kinase-MB (CK-MB) – 18–24 h following successful elective percutaneous coronary intervention (PCI) and to explore their relationship with changes in aerobic exercise capacity, as measured by peak oxygen consumption (VO<sub>2</sub>), 6 weeks following the procedure. Twenty-three patients with single-vessel disease and chronic angina performed an incremental cardiopulmonary exercise test before and 6 weeks after successful uncomplicated PCI. A venous blood sample was taken at rest before PCI and 18–24 h after the procedure. Successful PCI resulted in a trend towards an increased peak VO<sub>2</sub> [21.62 ± 0.64 (pre) vs. 23.03 ± 0.75 ml/ kg/min (post), p = 0.07; mean ± SEM]. There was a significant increase [median (IQR)] in TnT, from 0.00 (0.00) µg/l at baseline increasing to 0.02 (0.03) µg/l at 18–24 h, p = 0.002. CK-MB levels showed no significant difference. In the group of 15/23 (65%) patients with an elevation in serum TnT (≧0.01 µg/l), 18–24 h after successful PCI, there was no significant increase in peak VO<sub>2</sub> [23.31 ± 0.96 (pre) vs. 23.89 ± 1.09 ml/kg/min (post), p = 0.57]. In 8 (35%) patients with no rise in TnT at 18–24 h, a significant increase in peak VO<sub>2</sub> was observed following successful PCI [23.10 ± 0.91 (pre) vs. 25.09 ± 0.75 ml/kg/min (post), p = 0.02]. Although 7 of these 8 patients increased their peak VO<sub>2</sub>, the absence of a TnT rise at 18–24 h was not significantly associated with an increase in peak VO<sub>2</sub> following successful PCI (p = 0.18). To confirm these interesting initial results and investigate the relationship of serum cardiac markers following successful PCI and subsequent exercise capacity, further studies are required.

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          Most cited references 11

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          Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials.

          To determine whether percutaneous transluminal coronary angioplasty (angioplasty) is superior to medical treatment in non-acute coronary artery disease. Meta-analysis of randomised controlled trials. Randomised controlled trials conducted worldwide and published between 1979 and 1998. 953 patients treated with angioplasty and 951 with medical treatment from six randomised controlled trials, three of which included patients with multivessel disease and pre-existing myocardial infarction. Angina, fatal and non-fatal myocardial infarction, death, repeated angioplasty, and coronary artery bypass grafting. In patients treated with angioplasty compared with medical treatment the risk ratios were 0. 70 (95% confidence interval 0.50 to 0.98; heterogeneity P<0.001) for angina; 1.42 (0.90 to 2.25) for fatal and non-fatal myocardial infarction, 1.32 (0.65 to 2.70) for death, 1.59 (1.09 to 2.32) for coronary artery bypass graft, and 1.29 (0.71 to 3.36; heterogeneity P<0.001) for repeated angioplasty. Differences in the methodological quality of the trials, in follow up, or in single versus multivessel disease did not explain the variability in study results in any analysis. Percutaneous transluminal coronary angioplasty may lead to a greater reduction in angina in patients with coronary heart disease than medical treatment but at the cost of more coronary artery bypass grafting. Trials have not included enough patients for informative estimates of the effect of angioplasty on myocardial infarction, death, or subsequent revascularisation, though trends so far do not favour angioplasty.
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            Frequency and long-term impact of myonecrosis after coronary stenting.

            To study the frequency of creatine kinase MB elevation in stent recipients and to correlate the magnitude of myonecrosis with long-term ischaemic events. We evaluated the frequency and impact (major adverse ischaemic events) of creatine kinase MB elevation in 3478 patients undergoing planned coronary stenting and divided them in five strata according to peak creatine kinase MB: normal, 1-3 x, 3-5 x, 5-10 x and >10 x above upper limit of normal. Graft intervention was done in 15% and 61% received platelet glycoprotein IIb/IIIa receptor inhibitors. The average follow-up period was 15+/-15 (range 1-72) months. Creatine kinase MB elevation above upper limit of normal occurred in 24% and in 5.3% it was greater than 5 x upper limit of normal. The unadjusted rates of actuarial mortality in the five strata were: 7.5% (198/2637), 8.0% (40/502), 11.0% (17/155), 10.8% (11/102) and 29.3% (24/82), respectively, P<0.001. Logistic regression analysis including 18 demographic and procedural variables revealed that, in addition to age, extent of coronary disease, ventricular function and coronary risk profile, creatine kinase MB elevation was associated with a significant increase in major ischaemic events at follow-up. The excess risk was concentrated mainly in the highest stratum of creatine kinase MB elevation. Thus, in the era of stenting and aggressive adjunctive pharmacology, peri-procedural myonecrosis still remains frequent and has an important impact on long-term event-free survival. Intensive efforts to reduce creatine kinase MB elevation after revascularization are warranted and should lead to important benefits. Copyright 2001 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.
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              Relation of minor cardiac troponin I elevation to late cardiac events after uncomplicated elective successful percutaneous transluminal coronary angioplasty for angina pectoris.

              There is little information about the relation between mild cardiac troponin I (cTn-I) increase after coronary interventions and late outcome. We therefore focused on the long-term outcome and the clinical, morphologic, and procedural correlates of elevation of cTn-I compared with cardiac troponin T, creatine kinase (CK), CK-MB activity and mass, and myoglobin in 105 patients with successful elective percutaneous transluminal coronary angioplasty (PTCA) for stable or unstable angina. Patients with myocardial infarction and those with unstable angina who had a detectable increase in serum markers before PTCA were excluded. Markers were measured before and after the procedure and for 2 days. Patients were followed up to record recurrent angina, myocardial infarction, cardiac death, repeat PTCA, or elective coronary artery bypass graft surgery. Procedure success was achieved in all cases. Elevation in cTn-I (> or =0.1 microg/L) was observed in 23 of 105 patients (22%) (median peak: 0.25 microg/L); 18% had cardiac troponin T (cTn-T) release (> or = 0.1 microg/L, median peak 0.21); 11.4% CK-MB mass (> or =5 microg/L), and 7.6% myoglobin (> or =90 microg/L) release. Five and 2 patients had elevated CK and CK-MB activity, respectively. Fourteen of 18 patients with cTn-T elevation had a corresponding elevation in cTn-I (kappa 0.68; p = 0.001). Patients positive for cTn-I had more unstable angina (p = 0.042) and heparin before PTCA (p = 0.046), and had longest total time (p = 0.004) and single inflation (p = 0.01). By multivariate logistic regression, predictors of postprocedure cTnI elevation were maximum time of each inflation (odds ratio 9.2; p = 0.0012), type B lesions (odds ratio 6.6; p = 0.013), unstable angina (p = 0.041), and age > or =60 years (p = 0.032). Clinical follow-up was available in 103 patients (98%) (mean 19+/-10 months). Kaplan-Meier survival analysis showed that cTn-I elevation was not an important correlate of cardiac events (p = 0.34, by log-rank analysis). The incidence of recurrent angina, myocardial infarction, cardiac death, and repeat revascularization after 12 months was not different in patients positive or negative for cTn-I. We conclude that cTn-I elevation after successful PTCA is not associated with significantly worse late clinical outcome. Levels of cTn-I allow a much higher diagnostic accuracy in detecting minor myocardial injury after PTCA compared with other markers, but there is no association with periprocedural myocardial cell injury and late outcome when cTn-I and other markers are considered.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2005
                February 2005
                07 February 2005
                : 103
                : 2
                : 63-67
                Affiliations
                aCardiothoracic Centre, Liverpool, bDepartment of Mathematical Sciences, University of Liverpool, Liverpool, cMolecular Vascular Medicine, Chemical Biochemistry and Cardiology Departments, Leeds General Infirmary, Leeds, UK
                Article
                82049 Cardiology 2005;103:63–67
                10.1159/000082049
                15539783
                © 2005 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Tables: 4, References: 18, Pages: 5
                Categories
                General Cardiology

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