Markers for Perioperative Myocardial Ischemia: What Both Interventional Cardiologists and Cardiac Surgeons Need to Know
AbstractAll novel markers of myocardial ischemia (ischemia-modified albumin, choline, unbound free fatty acids) lack cardiac specificity. Therefore, for the specific detection of myocardial ischemia selective blood sampling from an inserted coronary sinus catheter is needed, which limits the applicability of these markers in most clinical routine settings. In addition, the superiority of these novel markers over the calculation of myocardial lactate production, the current criterion standard for the laboratory diagnosis of myocardial ischemia, has not been demonstrated so far, and even comparative data is frequently lacking. Further the superiority of these new candidate markers over lactate determination for the diagnosis of myocardial ischemia in peripherally drawn blood samples has not been demonstrated either, and these novel parameters appear not to be a breakthrough for laboratory diagnosis of myocardial ischemia during or after percutaneous coronary interventions or coronary artery bypass grafting. The determination of cardiac troponin I or troponin T is the current criterion standard for the laboratory diagnosis of myocardial damage due to their higher sensitivities and specificities compared to creatine kinase isoenzyme MB. According to current knowledge, troponin increases in peripherally drawn blood samples must be regarded as an indicator of myocardial necrosis which, however, may be limited, only detectable by troponin and may be missed by creatine kinase isoenzyme MB determination. After on-pump coronary artery bypass grafting the generally applied troponin discriminator limits are not valid as there is limited, inevitable cardiac tissue damage occurring during the surgical procedure. Therefore, troponins are significantly increased after reperfusion of the arrested heart over values seen before bypass and also in patients without complications. Perioperative myocardial infarctions can be reliably identified by their characteristic troponin time courses, and both peak concentrations and time of peak values are diagnostic criteria. Troponin release is lower in off-pump compared to on-pump bypass surgery. Despite the controversy over the significance of troponin elevations after clinically uncomplicated and successful procedures, it is tempting to postulate that less myocardial damage as detected by troponin release is beneficial for the patient. After elective percutaneous coronary interventions, only troponin increases >8-fold the upper reference limit were associated with increased mortality in long-term follow-up.
Mandadi VR, DeVoe MC, Ambrose JA, et al. 2004. Predictors of troponin elevation after percutaneous coronary interventions. Am J Cardiol 93:747-50.nNallamothu BK, Chetcuti S, Mukherjee D, et al. 2003. Prognostic implication of troponin I elevation after percutaneous coronary intervention. Am J Cardiol 91:1272-4.nNewman MF. 2001. Troponin I in cardiac surgery: marking the future. Am Heart J 141:325-6.nMair J. 1997. Progress in myocardial damage detection: new biochemical< markers for clinicians. Crit Rev Cl Lab Sci 34:1-66.nSimeone F, Biagioli B, Dolci A, et al. 1999. The diagnostic and prognostic value of cardiac troponin T in bypass surgery. J Cardiovasc Surg 40:211-6.nTalasz H, Genser N, Mair J, et al. 1992. Side-branch occlusion during percutaneous transluminal coronary angioplasty. Lancet 339:1380-2.nKhan NE, De Souza A, Mister R, et al. 2004. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med 350:21-8.nHerrmann J, von Birgelen C, Haude M, et al. 2002. Prognostic implication of cardiac troponin T increase following stent implantation. Heart 87:549-53.nKilger E, Pichler B, Weis F, et al. 2000. Markers of myocardial ischemia after minimally invasive and conventional coronary operations. Ann Thorac Surg 70:2023-8.nMahaffey KW, Alpert JS. 2001. Cardiac enzyme elevations after cardiac surgery: the cardiologist's perspective. Am Heart J 141:321-3.nMair J, Wieser C, Seibt I, et al. 1991. Troponin T to diagnose myocardial infarction in bypass surgery (letter). Lancet 337:434-5.nMair J, Larue C, Mair P, et al. 1994. Cardiac troponin I to diagnose perioperative myocardial infarction in coronary artery bypass grafting. Clin Chem 40:2066-70.nAlpert J, Thygesen K for the Joint European Society of Cardiology/American College of Cardiology Committee. 2000. Myocardial infarction redefined - a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. Eur Heart J 21:1502-13.nBenoit MO, Paris M, Silleran J, Fiemeyer A, Moatti N. 2001. Cardiactroponin I: its contribution to diagnosis of perioperative myocardial infarction and various complications of cardiac surgery. Crit Care Med 29:1880-6.nBhagavan NV, Lai EM, Rios PA, Yang J, Ortega-Lopez AM, Shinoda H. 2003. Evaluation of human serum albumin cobalt binding assay for assessment of myocardial ischemia and infarction. Clin Chem 49:581-5.nBleier J, Vorderwinkler KP, Falkensammer J, et al. 1998. Different intracellular compartmentations of cardiac troponins and myosin heavy chains: a causal connection to their different early release after myocardial damage. Clin Chem 44:1912-8.nLasocki S, Provenchere S, Benessiano J, et al. 2002. Cardiac troponin I is an independent predictor of in-hospital death after adult cardiac surgery. Anesthesiology 97:405-11.nLehrke S, Henning S, Sievers HH, et al. 2004. Cardiac troponin T for prediction of short- and long-term morbidity and mortality after elective open heart surgery. Clin Chem 50:1560-7.nHannes W, Keilich M, Koester W, Seitelberger R, Fasol R. 1994. Shed blood autotransfusion influences ischemia-sensitive laboratory parameters after coronary operations. Ann Thorac Surg 57:1289-94.nKini AS, Lee P, Marmur JD, et al. 2004. Correlation of percutaneous coronary intervention creatine kinase-MB and troponin I elevation in predicting mid-term mortality. Am J Cardiol 93:18-23.nSaadeddin SM, Habbab MA, Soloki SH, Ferns GA. 2002. Biochemical detection of minor myocardial injury after elective, uncomplicated, successful percutaneous coronary interventions in patients with stable angina: clinical outcome. Ann Clin Biochem 39:392-7.nSinha MK, Gaze DC, Tippins JR, Collinson PO, Kaski JC. 2003. Ischemia modified albumin is a sensitive marker of myocardial ischemia after percutaneous coronary interventions. Circulation 107:2403-5.nSuleiman MS, Lucchetti V, Caputo M, Angelini GD. 1999. Short periods of regional ischemia and reperfusion provoke release of troponin I from human hearts. Clin Chim Acta 284:25-30.nBonatti J, Hangler H, Hörmann Ch, Mair J, Falkensammer J, Mair P. 1998. Myocardial damage after minimally invasive coronary artery bypass grafting on the beating heart. Ann Thorac Surg 66:1093-6.nBonnefoy E, Filley S, Kirkorian G, et al. 1998. Troponin I, Troponin T, or creatine kinase-MB to detect perioperative myocardial damage after coronary artery bypass surgery. Chest 114:482-6.nCarrier M, Pellerin M, Perrault LP, Solymoss BC, Pelletier CL. 2000. Troponin levels in patients with myocardial infarction after coronary artery bypass grafting. Ann Thorac Surg 69:435-40.nGarrido IP, Roy D, Calvino R, Vazquez-Rodriguez JM, Aldama G, Cosin-Sales J. 2004. Comparison of ischemia-modified albumin levels in patients undergoing percutaneous coronary intervention for unstable angina pectoris with versus without coronary collaterals. Am J Cardiol 93:88-90.nQuiles J, Roy D, Gaze D, et al. 2003. Relation of ischemia modified albumin (IMA) levels following elective angioplasty for stable angina pectoris to duration of balloon-induced myocardial ischemia. Am J Cardiol 92:322-4.nApple FS, Wu AHB, Mair J, et al. 2005. Future biomarkers for the detection of ischemia and risk stratification in acute coronary syndromes. Clin Chem 51, in press.nAscione R, Lloyd CT, Gomes WJ, Caputo M, Bryan AJ, Angelini GD. 1999. Beating versus arrested heart revascularization: evaluation of myocardial function in a prospective randomized study. Eur J Cardiothorac Surg 15:685-90.nBar-Or D, Lau E, Winkler JV. 2000. A novel assay for cobalt-albumin binding and its potential as a marker for myocardial ischemia - a preliminary report. J Emerg Med 19:311-5.nBar-Or D, Curtis G, Rao N, Bampos N, Lau E. 2001. Characterization of the Co(2+) and Ni(2+) binding amino-acid residues of the N-terminus of human albumin. An insight into the mechanism of a new assay for myocardial ischemia. Eur J Biochem 268:42-7.nBarron JT. 1998. Cardiac troponin I and non-Q-wave myocardial infarction: How useful is it after coronary artery bypass surgery? Crit Care Med 26:1936-7.nBraun SL, Barankay A, Mazzitelli D. 2000. Plasma troponin T and troponin I after minimally invasive coronary bypass surgery. Clin Chem 46:279-81.nFuchs S, Kornowski R, Mehran R, et al. 2000. Prognostic value of cardiac troponin I levels following catheter-based coronary interventions. Am J Cardiol 85:1077-82.nGalianes M. 1998. In search of a reliable marker of tissue injury during heart surgery. Heart 80:317-8.nKoh TW, Carr-White GS, DeSouza AC, et al. 1999. Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass. Heart 81:495-500.nApple FS, Wu AHB, Jaffe AS. 2002. European Society of Cardiology and American College of Cardiology guidelines for redefinition of myocardial infarction: how to use existing assays clinically and for clinical trials. Am Heart J 144:981-6.n