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Use of troponins in the diagnosis and management of peri-procedural myocardial infarction

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.

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Use of troponins in the diagnosis and management of peri-procedural myocardial infarction

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  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

  5. BASICS OF PERI-PCI MI Herrmann et al, Eur Heart J 2005

  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 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? 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 attentionFor any correspondence: gbiondizoccai@gmail.comFor these and further slides on these topics feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html

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