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Www.metcardio.org Use of troponins in the diagnosis and management of peri-procedural myocardial infarction Giuseppe Biondi Zoccai Division of Cardiology,

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Presentazione sul tema: "Www.metcardio.org Use of troponins in the diagnosis and management of peri-procedural myocardial infarction Giuseppe Biondi Zoccai Division of Cardiology,"— Transcript della presentazione:

1 Use of troponins in the diagnosis and management of peri-procedural myocardial infarction Giuseppe Biondi Zoccai Division of Cardiology, University of Modena and Reggio Emilia Meta-analysis and Evidence-based medicine Training in Cardiology (METCARDIO), Ospedaletti, Italy

2 LEARNING MILESTONES Scope of the problem Diagnosis of peri-procedural infarction Management of peri-procedural infarction

3 LEARNING MILESTONES Scope of the problem Diagnosis of peri-procedural infarction Management of peri-procedural infarction

4 BASICS OF PERI-PCI MI Herrmann et al, Eur Heart J 2005 ItemComment Denition and diagnosis Cardiac serum marker elevation above the ULN after PCI related presumably to myocardial necrosis (ideally, rise and fall pattern on serial blood sampling; spot check at 24 (–48) h after PCI may be permissible) Incidence On average, 25-30% of all coronary procedures (range 0-70%) Risk factors Patient-related: diffuse, multivessel CAD, age, UAP, (hs)CRP; lesion-related: complex, de novo lesions, especially SVG lesions; procedure-related: new device use, procedural complications

5 BASICS OF PERI-PCI MI Herrmann et al, Eur Heart J 2005 ItemComment Pathophysiology Blood ow impairment on epicardial level (proximal type, type I) or, in the majority of cases, on microcirculatory level (distal type, type II) Presentation Mainly clinically silent, in some cases CP, arrhythmias, hypotension Prognosis Increased risk of cardiac mortality Prevention and treatment Acute: supportive, symptomatic therapy per MI recommendations; chronic: CAD/CHF management Mechanical: distal lter/balloon occlusion systems, pre- conditioning; pharmacological: antiplatelet agents, statins, IC non-selective beta-blocker

6 TYPES OF PERI-PCI MI Herrmann et al, Eur Heart J 2005

7 MECHANISMS OF PERI-PCI MI Zimarino et al, Atherosclerosis 2011

8 MECHANISMS OF PERI-PCI MI Side-branch closure Thrombo-embolism Dissection Microvascular impairment Prolonged occlusion Spasm Zimarino et al, Atherosclerosis 2011

9 TOOLS TO RECOGNIZE PERI-PCI MI EKG MRI Echo Nuclear scan ALT/AST CK CK-MB activity CK-MB mass Troponin HS troponin

10 WHY I HATE TROPONINS Hickman et al, Clin Chim Acta 2010

11 WHY I HATE TROPONINS Hickman et al, Clin Chim Acta 2010

12 WHY I HATE TROPONINS Hickman et al, Clin Chim Acta 2010

13 WHY I HATE TROPONINS Hickman et al, Clin Chim Acta 2010

14 (SOME) MECHANISMS OF TROPONIN RELEASE Kociol et al, JACC 2010

15 EVOLUTION OF TROPONIN Mahajan et al, Circulation 2011

16 HS TROPONIN T ASSAYS Twerenbold et al, Swiss Med Wkly 2011

17 HS TROPONIN T ASSAYS Twerenbold et al, Swiss Med Wkly 2011

18 STANDARD VS HIGH- SENSITIVITY TROPONIN ASSAYS Twerenbold et al, Swiss Med Wkly 2011 Standard cTnT cTnI (Siemens) cTnI (Abbott) cTnT (Roche) cTnI (Roche)

19 COMPREHENSIVE TROPONIN ASSESSMENT IN ACS Ndrepepa et al, Clin Chim Acta 2011

20 COMPREHENSIVE TROPONIN ASSESSMENT IN ACS Ndrepepa et al, Clin Chim Acta 2011

21 COMPREHENSIVE TROPONIN ASSESSMENT IN ACS Ndrepepa et al, Clin Chim Acta 2011

22 HS TROPONIN IN STABLE CAD Ndrepepa al, Am J Cardiol 2011

23 USEFULNESS AT ADMISSION Celik et al, Clin Res Cardiol 2011

24 USEFULNESS AT ADMISSION Celik et al, Clin Res Cardiol 2011

25 IMPACT ON OUTCOMES Brener et al, Eur Heart J 2002

26 ANY SYNTHESIS POSSIBLE? CK-MB massStandard troponin HS troponinMRI Cutoff: normal vs. pathologic Well-definedWell-denedEvolving SensitivityLowHighVery highHigh LocalizationNo Yes Time pattern of rise and fall Well-defined EvolvingWell-defined Method of standardization High Evolving Relation with prognosis Well-definedControversialEvolving Fullls universal denition of MI Yes No Schoenhagen et al, JACCInt 2010

27 LEARNING MILESTONES Scope of the problem Diagnosis of peri-procedural infarction Management of peri-procedural infarction

28 UNIVERSAL DEFINITION OF MI Thygesen et al, Eur Heart J 2007

29 UNIVERSAL DEFINITION OF MI Thygesen et al, Eur Heart J 2007

30 Testa et al, QJM 2009

31 IMPACT OF TROPONIN ON MACE Testa et al, QJM 2009

32 BIAS OF REGISTRIES VS RCT Tzoulaki et al, BMJ 2011

33 CK-MB BESTS TROPONIN Lim et al, JACC 2011 G1: no necrosis G2: Peri-PCI myocardial injury (PMI) G3: Peri-PCI MI LGE: MRI late gadolinium enhancement

34 CK-MB BESTS TROPONIN Lim et al, JACC 2011

35 CK-MB BESTS TROPONIN Lim et al, JACC 2011

36 PERI-PCI MI AND SYNTAX SCORE van Gaal et al, Int J Cardiol 2009

37 PERI-PCI MI AND LESION TYPE van Gaal et al, Int J Cardiol 2009

38 OTHER CAUSES OF TROPONIN Thygesen et al, Eur Heart J 2007

39 PERI-PCI INCREASE >ULN Wiseth et al, EuroIntervention 2006

40 REVISED ACADEMIC RESEARCH CONSORTIUM CRITERIA Vranckx et al, EuroIntervention 2010

41 REVISED ACADEMIC RESEARCH CONSORTIUM CRITERIA Vranckx et al, EuroIntervention 2010

42 LEARNING MILESTONES Scope of the problem Diagnosis of peri-procedural infarction Management of peri-procedural infarction

43 WHAT SHOULD YOU DO IF A patient has an increased post-PCI level of cTn or CKMB: –If not an MI (cTn>3 x ULN but CKMB < 3 x ULN): Reassess Hx/PE, EKG, angio and procedural features to define individual risk Maximize medical Rx Proceed with discharge and set up follow-up

44 WHAT SHOULD YOU DO IF If a patient has an increased post-PCI level of cTn or CKMB: –It qualifies as MI (CKMB>3 x ULN): Reassess Hx/PE, EKG, angio and procedural features to define individual risk Enforce continuous EKG monitoring Assess whether repeat cath is required Continue blood draws for CKMB curve Maximize medical Rx Do not discharge until CK-MB below ULN Then, proceed with discharge and set up follow-up

45 HOW CAN YOU MAXIMIZE MEDICAL RX AFTER PCI Biondi-Zoccai et al, Int J Cardiol 2011

46 HOW CAN YOU MAXIMIZE MEDICAL RX AFTER PCI Biondi-Zoccai et al, Int J Cardiol 2011

47 HOW CAN YOU MAXIMIZE MEDICAL RX AFTER PCI Biondi-Zoccai et al, Int J Cardiol 2011

48 MCQ 1. Come si definisce linfarto miocardico periprocedurale nei pazienti sottoposti ad angioplastica coronarica? A. Rialzo di oltre 2 volte il 99° percentile del limite superiore di riferimento B. Rialzo di oltre 5 volte il 99° percentile del limite superiore di riferimento C. Rialzo di oltre 1 volta il 99° percentile del limite superiore di riferimento D. Rialzo di oltre 3 volte il 99° percentile del limite superiore di riferimento E. Rialzo di oltre 10 volte il 99° percentile del limite superiore di riferimento 2. Limpatto prognostico del rialzo periprocedural dei marker miocardici nei pazienti sottoposti ad angioplastica coronarica è stato: A. Dimostrato in alcuni studi, ma non dopo aggiustamento multivariabile in altri B. Dimostrato in alcuni pazienti, ma non in quelli a basso rischio C. Dimostrato in alcuni pazienti, ma non in quelli ad alto rischio D. Dimostrato in tutti i pazienti e in tutti gli studi E. Negato incontrovertibilmente 3. Lutilità di monitorare la troponina nei pazienti sottoposti ad angioplastica coronarica risiede nella sua capacità di: A. Identificare i pazienti con quadro angiografico a maggior rischio di infarto o morte B. Identificare i pazienti che necessitano di procedura complessa a maggior rischio di infarto o morte C. Identificare i pazienti che manifestano complicanze inattese precoci successivamente alla procedura D. Identificare i pazienti con aumentato rischio di eventi a partire da 1 mese dopo langioplastica E. Identificare i pazienti con aumentato rischio di eventi a partire da 1 anno dopo langioplastica 4. I meccanismi più frequenti di infarto peri-procedurale sono: A. La trombosi intrastent e locclusione di branche laterali B. Lo spasmo occlusivo e la trombosi intrastent C. Locclusione di branche laterali e lembolizzazione di materiale atero-trombotico D. Lembolizzazione di materiale atero-trombotico e la trombosi intrastent E. Lo spasmo occlusivo e locclusione di branche laterali

49 Thank you for your attention For any correspondence: For these and further slides on these topics feel free to visit the metcardio.org website:


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