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Giuseppe Biondi Zoccai

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Presentazione sul tema: "Giuseppe Biondi Zoccai"— Transcript della presentazione:

1 Giuseppe Biondi Zoccai
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 Herrmann et al, Eur Heart J 2005
BASICS OF PERI-PCI MI Item Comment Definition 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 Herrmann et al, Eur Heart J 2005

5 Herrmann et al, Eur Heart J 2005
BASICS OF PERI-PCI MI Item Comment Pathophysiology Blood flow 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 filter/balloon occlusion systems, pre-conditioning; pharmacological: antiplatelet agents, statins, IC non-selective beta-blocker Herrmann et al, Eur Heart J 2005

6 Herrmann et al, Eur Heart J 2005
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
ALT/AST CK CK-MB activity CK-MB mass Troponin HS troponin EKG MRI Echo Nuclear scan

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

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

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

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

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

15 Mahajan et al, Circulation 2011
EVOLUTION OF TROPONIN Mahajan et al, Circulation 2011

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

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

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

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 mass Standard troponin HS troponin MRI Cutoff: normal vs. pathologic Well-defined Well-defined Evolving Sensitivity Low High Very high Localization No Yes Time pattern of rise and fall Method of standardization Relation with prognosis Controversial Fulfills universal definition of MI 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 G1: no necrosis
G2: Peri-PCI myocardial injury (PMI) G3: Peri-PCI MI LGE: MRI late gadolinium enhancement Lim et al, JACC 2011

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 l’infarto 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. L’impatto 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. L’utilità 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 l’angioplastica E. Identificare i pazienti con aumentato rischio di eventi a partire da 1 anno dopo l’angioplastica 4. I meccanismi più frequenti di infarto peri-procedurale sono: A. La trombosi intrastent e l’occlusione di branche laterali B. Lo spasmo occlusivo e la trombosi intrastent C. L’occlusione di branche laterali e l’embolizzazione di materiale atero-trombotico D. L’embolizzazione di materiale atero-trombotico e la trombosi intrastent E. Lo spasmo occlusivo e l’occlusione 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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