Statin administration before percutaneous coronary intervention: Impact on periprocedural myocardial infarction

Interventional Cardiology

volved in the care of NSTE ACS patients and on improving the appropriate use of invasive cardiac procedures and other guideline-based recommendations for all high-risk patients. DM

Abstracts Utilization of Early Invasive Management Strategies for High-Risk Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: Results From the CRUSADE Quality Improvement Initiative

Statin Administration Before Percutaneous Coronary Intervention: Impact on Periprocedural Myocardial Infarction

Bhatt DL, Roe MT, Peterson ED et al. for the CRUSADE Investigators. JAMA 2004;292:1839 – 44.

Briguori C, Colombo A, Airoldi F, et al. Eur Heart J 2004;25: 1822– 8.

Study Question: The objective of this study was to determine the use and predictors of early invasive management strategies (cardiac catheterization ⬍48 h following presentation) in high-risk patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS) and to examine the association of early invasive management with mortality. Methods: The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) quality improvement initiative evaluated care patterns and outcomes for 17,926 high-risk NSTE ACS patients (positive cardiac markers and/or ischemic electrocardiographic [ECG] changes) based on ACC/AHA guideline recommendations at 248 U.S. hospitals with catheterization and revascularization facilities between March 2000 and September 2002. The primary outcome measure was the use of early invasive management within 48 h of presentation, predictors of early invasive management, and in-hospital mortality. Results: Of the 17,926 patients analyzed, 8037 (44.8%) underwent early cardiac catheterization less than 48 h following presentation. Predictors of early invasive management included cardiology care, younger age, lack of prior or current congestive heart failure, lack of renal insufficiency, ischemic ECG changes, positive cardiac markers, white race, and male gender. Patients treated with early invasive management were more likely to be given medications and interventions recommended by the ACC/AHA guidelines and had a lower risk of in-hospital mortality after adjusting for differences in clinical characteristics and after comparing propensity-matched pairs (2.5% vs. 3.7%; p⬍0.001). Conclusions: The investigators concluded that an early invasive management strategy is not utilized in the majority of high-risk patients with NSTE ACS. Perspective: An early invasive management strategy appears to be associated with lower in-hospital mortality in NSTE ACS patients treated in routine clinical practice. This strategy, already validated in randomized clinical trials, is utilized in a minority of high-risk NSTE ACS patients and appears to be preferentially reserved for younger patients without comorbidities who were cared for by cardiologists. Therefore, quality improvement efforts should focus on educational interventions that target noncardiologists in-

Study Question: Investigators assessed whether pre-procedural statin administration is effective in preventing release of biomarkers of myocardial injury after elective coronary stent implantation. Methods: Four hundred and fifty-one patients scheduled for elective percutaneous coronary intervention (PCI) and not on statins were randomly assigned to either no treatment or to statin treatment. Statin administration was started at least 3 days before the procedure. Incidence of periprocedural myocardial injury was assessed by analysis of creatinine kinase–myocardial isoenzyme (CK-MB: upper limit of normal [ULN] 3.5 ng/mL) and cardiac troponin I (cTn I, ULN 0.10 ng/mL) before, 6 and 12 h after the intervention. A large non-Q-wave myocardial infarction (MI) was defined as a CK-MB elevation ⬎5 times ULN alone or associated with chest pain or ST-segment or T-wave abnormalities. Results: Median CK-MB peak after PCI was 1.70 (interquartile ranges 1.10 –3.70) ng/mL in the statin group and 2.20 (1.30 –5.60) ng/mL in the control group (p⫽0.015). Median peak cTnI after PCI was 0.13 (0.05– 0.45) ng/mL in the statin group and 0.21 (0.06 – 0.85) ng/mL in the control group (p⫽0.033). The incidence of a large non-Q-wave MI was 8.0% in the statin group and 15.6% in the control group (p⫽0.012; OR, 0.47; 95% CI 0.26 – 0.86). The incidence of cTnI elevation ⬎5 times ULN was 23.5% in the statin group and 32% in the control group (p⫽0.043; OR, 0.65; 95% CI 0.42– 0.98). By logistic regression analysis, the independent predictors of CK-MB elevation ⬎5 times ULN after PCI were intraprocedural angiographic complications (OR, 9.36; 95% CI 3.06 –28.64; p⬍0.001), statin pretreatment (OR, 0.33; 95% CI 0.13– 0.86; p⫽0.023) and age ⬎65 years (OR, 2.58; 95% CI 1.09 – 6.11; p⫽0.031). Conclusions: The investigators concluded that pre-procedural statin therapy reduces the incidence of large non-Qwave MI after PCI. Perspective: Consistent with earlier studies, this randomized trial confirms the cardioprotective effects of statin pretreatment in patients undergoing elective stent implantation. The incidence of large periprocedural non-Q-wave MI (i.e., CK-MB elevation ⬎5 times ULN) was significantly lower in patients pretreated with statins. When feasible, pre-procedural statin therapy should be considered in all patients undergoing PCI. DM

ACC CURRENT JOURNAL REVIEW February 2005

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