Usefulness of periprocedural creatinine phosphokinase-MB release to predict adverse outcomes after intracoronary radiation therapy for in-stent restenosis

doi:10.1016/j.amjcard.2003.10.010

The American Journal of Cardiology

Volume 93, Issue 3, 1 February 2004, Pages 313-317

https://doi.org/10.1016/j.amjcard.2003.10.010 Get rights and content

Abstract

We aimed to analyze periprocedural creatinine phosphokinase (CPK)-MB elevation in patients treated with intracoronary radiation therapy (IRT) for in-stent restenosis (ISR) to risk stratify these patients. The clinical significance of periprocedural CPK-MB elevation after IRT for ISR is unknown. An elevated CPK-MB has been associated with increased mortality after conventional angioplasty. We evaluated 1,326 patients who were enrolled in radiation trials for ISR at the Washington Hospital Center using γ- and β- emitters. Patients were analyzed according to degree of CPK-MB increase within 24 hours of the index IRT procedure (normal CPK-MB, CPK-MB 1 to 3 times the upper limit of normal, or CPK-MB >3 times the upper limit of normal). Patients with CPK-MB >3 times the upper limit of normal were older (64 ± 12 years, p = 0.04), more likely to be smokers (64%, p = 0.04), hypertensive (85%, p <0.01), and diabetic (49%, p = 0.04). The cohort with the highest CPK-MB release (CPK-MB >3 times the upper limit of normal) had significantly higher rates of adverse clinical events at 12 months (major adverse cardiac events 40%, p <0.01), including death (9.3%, p <0.01) and late thrombosis (6.3%, p <0.01). Periprocedural CPK-MB elevation is of prognostic importance in patients treated with IRT for ISR, and its analysis appears to be mandatory to risk stratify these patients. The impact of glycoprotein IIb/IIIa antagonists in reducing periprocedural CPK-MB release awaits evaluation.

Section snippets

Study population

We analyzed 1,326 consecutive patients with ISR who were enrolled in clinical radiation trials conducted at the Washington Hospital Center, Washington DC, and who had completed 12-month clinical follow-up (February 1997 to October 2002). Most of the patients were selected from the Washington Radiation for In-Stent restenosis Trial (WRIST) series of trials, which utilized γ- and β- emitters. All studies selected were sponsored by the Medlantic Research Institute (Washington, DC), and for each

Characteristics of study population

Of 1,326 patients who were treated with IRT for ISR, 727 patients (55%) had normal CPK-MB, 336 patients (25%) had CPK-MB 1 to 3 times the upper normal limit, and 263 patients (20%) had CPK-MB >3 times the upper normal limit (Table 1). Compared with patients with normal or CPK-MB 1 to 3 times the upper normal limit, the ISR population with CPK-MB >3 times the upper normal limit were older, and were more likely to be smokers, hypertensive, and diabetic. Patients in the highest CPK-MB group had

Discussion

The principal findings of this study include: (1) the rate of CPK-MB elevation (CPK-MB >1 times the upper normal limit) in 1,326 patients after IRT for ISR was frequent (45%); (2) CPK-MB elevation after IRT is associated with an increased rate of 12-month clinical events, including mortality, late thrombosis, and need for target vessel revascularization; (3) IRT for ISR of saphenous vein grafts is not associated with increased CPK-MB release compared with native coronary ISR; (4) independent

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Stenting is associated with an aggressive proliferative response with severe intimal hyperplasia, and the tissue inside the stent has been demonstrated to be rich in the highly thrombogenic tissue factor, which may provide the substrate for the development of an acute coronary syndrome.9 Second, although treatment of in-stent restenosis is usually uneventful, in 1% to 20% of cases, it may be complicated with a periprocedural AMI (especially non–Q-wave infarction)3–5; this risk is higher in elderly and diabetic patients.5 The main limitation of this work is that due to the follow-up of the trials included (≤12 months), the effect of very late stent thrombosis over the risk of myocardial infarction has not been evaluated.
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Usefulness of periprocedural creatinine phosphokinase-MB release to predict adverse outcomes after intracoronary radiation therapy for in-stent restenosis

Abstract

Section snippets

Study population

Characteristics of study population

Discussion

Am J Cardiol

Lancet

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Catheter-based radiotherapy to inhibit restenosis after coronary stenting

N Engl J Med

Three-year clinical and angiographic follow-up after intracoronary radiationresults of a randomized clinical trial

Circulation

Localized intracoronary gamma-radiation therapy to inhibit the recurrence of restenosis after stenting

N Engl J Med

Intracoronary radiation therapy after angioplasty inhibits recurrence in patients with in-stent restenosis

Circulation

Intracoronary beta-radiation therapy inhibits recurrence of in-stent restenosis

Circulation