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• Response to –‘Immediate versus deferred Coronary Angioplasty in non-ST-elevation ACS
  Abhishek Kumar
  Published on: 23 November 2015
• What's the value of Biomarkers in NSTACS management after a PCI?
  Ameet Bakhai
  Published on: 23 November 2015

• Published on: 23 November 2015

  Response to –‘Immediate versus deferred Coronary Angioplasty in non-ST-elevation ACS

  • Abhishek Kumar, Cardiology Research Registrar
  • Other Contributors:
    • David H. Roberts

  Dear Editor, Riezebos et al.1 should be commended for trying to define the optimal timing of early coronary intervention (PCI) in patients with non-ST elevation acute coronary syndrome (ACS), an area that lacks robust evidence. However, we believe there are some deficiencies in this study that may alter the conclusions. Although the recruitment was done at ‘Three high Volume Centres’, the slow recruitment and small populati...

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  Dear Editor, Riezebos et al.1 should be commended for trying to define the optimal timing of early coronary intervention (PCI) in patients with non-ST elevation acute coronary syndrome (ACS), an area that lacks robust evidence. However, we believe there are some deficiencies in this study that may alter the conclusions. Although the recruitment was done at ‘Three high Volume Centres’, the slow recruitment and small population size begs the question whether the patients were carefully selected, excluding other ACS patients who stand to benefit from early intervention. Further, some authors have previously questioned the use of CK-MB in defining the end-point in this setting.2 Any rise in CK-MB post procedure does reflect myocardial necrosis but to what extent minor rises ( 1  ULN) correlate with myocardial damage is questionable. This may well reflect higher baseline risk of the patients from an evolving ACS event, which after initial treatment may not be of any clinical significance. This point is evident when looking at the 30-day clinical outcome with no significant increase in death, MI, and revascularisation rate. A significantly higher percentage of patients in the immediate PCI group had history of previous CABG and hypertension. This represents a group of patients who are at a higher risk of peri-procedural MI as it is possible that there was higher percentage of SVG intervention.3 The authors have also not commented on the left ventricular function status. Ellis et al. 4 have noted that left ventricular systolic dysfunction increases the risk for periprocedural CK-MB elevation and patients with a history of CABG are more likely to have left ventricular dysfunction. We are surprised that a higher loading dose of clopidogrel (600mg), which has been shown to reduce periprocedural MI 5, was not used and also we question whether patients should have been pre-treated with high dose statins, as beneficial effects in reducing peri-procedural MI are well documented.6, 7. The results of this study must be interpreted with caution and any change in clinical practice resisted until alternative methods of assessing peri-procedural MI (such as novel biomarkers like NT-proBNP 8, intra-coronary multi-channel ECG recording 9 and myocardial scintigraphy) and the optimal timing of coronary intervention have been further evaluated in ACS patients. Newer anti-thrombotic and second-generation anti-platelet agents may also confer benefit in this situation. References: 1) Riezebos et al. Immediate versus deferred coronary angioplasty in non-ST-elevation acute coronary syndromes. Heart 2008; 0: hrt.2008.154815v2 2) Cutlip et al. Cardiac Enzyme Elevation After Successful Percutaneous Coronary Intervention Is Not an Independent Predictor of Adverse Outcomes. Circulation. 2005; 112: 916-923 3) Abdelmeguid AE, Topol EJ, Whitlow PL, Sapp SK, Ellis SG. Significance of mild transient release of creatine kinase-MB fraction after percutaneous coronary interventions. Circulation. 1996; 94:1528–1536 4) Ellis SG, Chew D, Chan A, Whitlow PL, Schneider JP, Topol EJ. Death following creatine kinase-MB elevation after coronary intervention: identification of an early risk period: importance of creatine kinase-MB level, completeness of revascularization, ventricular function, and probable benefit of statin therapy. Circulation. 2002; 106: 1205–1210 5) Patti G et al. Randomized trial of high loading dose of clopidogrel for reduction of periprocedural myocardial infarction in patients undergoing coronary intervention: results from the ARMYDA-2 (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty) study. Circulation. 2005 Apr 26; 111(16): 2099-106 6) Patti G, Pasceri V, Colonna G, Miglionico M, Fischetti D, Sardella G, Montinaro A, Di Sciascio G. Atorvastatin pretreatment improves outcomes in patients with acute coronary syndromes undergoing early percutaneous coronary intervention: results of the ARMYDA-ACS randomized trial. J Am Coll Cardiol.2007 Mar 27; 49(12): 1272-8 7) Clergeau MR, Morello R, Lepage O, Hamon M. Statin in prevention of periprocedural myonecrosis after percutaneous coronary angioplasty: systematic review and meta-analysis. Ann Cardiol Angeiol (Paris). 2008 Jun; 57(3): 181-6 8) Bonaca MP, Wiviott SD, Sabatine MS, Buros J, Murphy SA, Scirica BM, Rifai N, Antman EM, Morrow DA. Hemodynamic significance of periprocedural myocardial injury assessed with N-terminal pro-B-type natriuretic peptide after percutaneous coronary intervention in patients with stable and unstable coronary artery disease (from the JUMBO-TIMI 26 trial). Am J Cardiol 2007 Feb 1; 99(3): 344-8 9) Balian et al. Intracoronary ST-Segment Shift Soon After Elective Percutaneous Coronary Intervention Accurately Predicts Periprocedural Myocardial Injury. Circulation 2006; 114:1948-1954 We confirm that we have no conflict of interests.

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  Conflict of Interest:
  None declared.

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• Published on: 23 November 2015

  What's the value of Biomarkers in NSTACS management after a PCI?

  • Ameet Bakhai, Cardiologist
  • Other Contributors:
    • Robert I. Hughes, Joanna R Peters

  Riezebos et al. have published an elegant study trying to inform a critically important question on the optimal timing of patients admitted with a non-ST elevantion ACS suitable for revascularization. In this study which despite being multicentric had a very slow recruitment rate, the main difficulty lies in understanding the value of cardiac enzyme measurements as an outcome, given that patients were considered to have a...

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  Riezebos et al. have published an elegant study trying to inform a critically important question on the optimal timing of patients admitted with a non-ST elevantion ACS suitable for revascularization. In this study which despite being multicentric had a very slow recruitment rate, the main difficulty lies in understanding the value of cardiac enzyme measurements as an outcome, given that patients were considered to have an MI if the CK-MB was elevated above x1. If these endpoints were entirely removed, then the event rates are identical both at an early and intermediate timepoint of 6 months. Perhaps an LVEF or cardiac MRI measure of size of infarct would be the ideal method of assessment. Certainly if patient orientated measures were used - length of stay, rehospitalisation, further procedures, other late events, quality of life and functional status at 6 months - these measures would fare equally or an advantage to an early revascularization strategy for measures such as length of stay. Furhtermore the recruitment period of upto 2007 practice may not reflect the higher loading doses of clopidogrel commonly used and also often these medications are now prescribed in the ambulance en route to the interventional centre. These factors impose an important limitation to the interpretation of the OPTIMA trial, whose concept is still valid for a decision making larger trial based on more complete assessment of infarct size.

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  Conflict of Interest:
  None declared.

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