Definition and Prediction of Periprocedural Myocardial Infarction in Elective Percutaneous Coronary Intervention: The ALPHEUS-MI Study.

BACKGROUND

Percutaneous coronary intervention (PCI)-related myocardial infarction (MI) or injury are frequent events associated with long-term ischemic outcomes and mortality. The objective of the prespecified Assessment of Loading with the P2Y12 inhibitor ticagrelor or clopidogrel to Halt ischemic Events in patients Undergoing elective coronary Stenting (ALPHEUS-MI) study was to describe factors associated with periprocedural MI.

METHODS

Within the trial population of 1883 patients with chronic coronary syndrome who underwent elective PCI, we analyzed periprocedural myocardial necrosis using: (1) the ALPHEUS primary end point; a combination of Academic Research Consortium (ARC) type 4a/4b MI and major myocardial injury (post-PCI troponin > 5 times the upper reference limit); (2) the ALPHEUS main secondary end point; a combination of ARC type 4a/4b MI and any myocardial injury corresponding to the fourth universal definition of MI; (3) the ARC-2/Society for Cardiovascular Angiography and Interventions definition of significant myocardial injury; and (4) the ARC-2 definition of periprocedural MI.

RESULTS

The primary and secondary end points of the ALPHEUS trial occurred in 35.9% and 77.2% of the patients, respectively. The ARC-2/Society for Cardiovascular Angiography and Interventions periprocedural MI occurred in 2.0% of the patients and the ARC-2 significant myocardial injury in 3.2% of the patients. With all end point definitions, event rates increased gradually with the number of high-risk features including patients' characteristics, complexity of the coronary lesion, and the complexity of the PCI procedure. After multivariable analysis, total length of stent implanted (> 60 mm) was the only common correlate of MI or myocardial injury (adjusted odds ratio ranging between 2.2 and 6.0 for the 4 definitions).

CONCLUSIONS

The accumulation of high-risk features exposes patients to periprocedural MI or injury within all definitions. Extensive atherosclerosis, which leads to longer coronary stents, plays a major role in the occurrence of periprocedural MI or injury.

CLINICAL TRIAL REGISTRATION: NCT02617290.