Nouveaux Concepts Johanne SILVAIN johanne.silvain@aphp.fr 1 - - PowerPoint PPT Presentation

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Nouveaux Concepts Johanne SILVAIN johanne.silvain@aphp.fr 1 - - PowerPoint PPT Presentation

Sep 16, 2023 149 likes •432 views

Dfinition de linfarctus du myocarde Nouveaux Concepts Johanne SILVAIN johanne.silvain@aphp.fr 1 Sorbonne Universit 2 ACTION Study Group 3 INSERM UMRS 1166 ICAN 4 Institut de Cardiologie (APHP) www.action- cur.org PITIE-SALPETRIERE

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Définition de l’infarctus du myocarde Nouveaux Concepts

Johanne SILVAIN johanne.silvain@aphp.fr

1 Sorbonne Université 2 ACTION Study Group 3 INSERM UMRS 1166 ICAN 4 Institut de Cardiologie (APHP)

www.action-cœur.org

PITIE-SALPETRIERE UNIVERSITY HOSPITAL

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DISCLOSURE STATEMENT OF FINANCIAL INTEREST Johanne SILVAIN MD, PhD Consulting fees, Speaker honorariums or Travel support from from Algorythm, Amed, Astra-Zeneca , Bayer, Boeringher Ingelheim, CLS Bering, Gilead Science, Sanofi-Aventis, Web MD Amgen, Astra-Zeneca and Saint-Jude Medical

Disclosures

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Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

Historical Evolution of the definition of Myocardial Infarction

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What’s new ?

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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What’s new ?

1/ Differentiation of MI from myocardial injury 2/ Highlighting periprocedural myocardial injury after cardiac procedures as distinct from MI.

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What’s new ?

1/ Differentiation of MI from myocardial injury

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Clinical Criteria of Myocardial Infarction

Acute Myocardial Injury Acute Myocardial Ischemia

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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Myocardial Injury

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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Biomarker

High-Sensitivity assay for detection of Cardiac troponin I (cTnI) and T (cTnT) Chronic myocardial injury = persistently elevated cTn levels

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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Mechanisms

Myocardial injury can be detected in clinical conditions associated with nonischemic mechanisms of myocardial injury as well

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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Conditions associated with Myocardial Injury

Atherosclerotic plaque disruption with thrombosis Oxygen supply/demand imbalance

Other causes myocardial Injury

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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Myocardial Ischemia

« Ischemia denotes signs and/or symptoms of clinical myocardial ischemia »

  • New ischemic ECG changes
  • Development of new

pathological Q waves

  • Ischemic symptoms

Or equivalent

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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Myocardial Infarction or Injury

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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What’s new ?

1/ Differentiation of MI from myocardial injury 2/ Highlighting periprocedural myocardial injury after cardiac procedures as distinct from MI.

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CORONARY PROCEDURE–RELATED Myocardial Injury and Infarction

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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Peri procedural (PCI) Myocardial

Rise of cTn values >20% of the baseline value

In patients with normal baseline values (≤ 99th percentile URL)

Increases of cTn values (>99th percentile URL)

In patients with positive values (> 99th percentile URL) stable (≤20% variation) or falling

Injury

Increases of cTn values > 5 times the ULN

Infarction*

+ absolute post PCI > 5 times the ULN

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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*additionnal criteria of Acute Myocardial Ischemia

  • New ischemic ECG changes
  • Development of new

pathological Q waves

  • Imaging evidence of new loss of viable

myocardium

  • New regional wall motion abnormality in a

pattern consistent with an ischemic etiology

  • Angiographic findings consistent

with a procedural flow-limiting complication :

  • coronary dissection
  • cclusion of a major epicardial artery or

a side branch

  • cclusion/thrombus
  • disruption of collateral flow
  • distal embolization

Thygesen et al. 2018 ESC/ACC/AHA/WHF Fourth Universal Definition of MI

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What is the rate of events ?

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Rate of MI type 4a and injury in post PCI

Authors Journal Years n MI Type 4a or myocardial injury (>3X 99th percentile) Collet al New Engl J Med 2012 2500 29% Novacket al Arch Intern Med 2012 4930 24% Pervaizet al Circulation CI 2012 3687 19% Porto et al Circulation CI 2012 50 42% Feldman et al Catheter Cardiovasc Inter 2011 22253 (MA) 26%/34% Lee et al Circ CVI 2011 131 24% Kim et al Int J Cardiol 2011 213 14% Mangiacapra et al JACC CardiovascInterv 2010 338 31% Locca et al JACC CardiovascInterv 2010 45 58% Hoole et al Coron Artery Dis 2010 243 27% Nienhuiset al Catheter Cardiovasc Inter 2008 15581 (MA) 33% Average 30%

MI Type 4a or myocardial injury rates (2nd universal definition) in the literature Silvain J et al. ALPHEUS Design paper

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Real life events rate

71.0 % 21.6 % 7.0 %

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Total number n=1390

No events (n=988) Myocardial Injury (n=301) Myocardial Infarction (n=97) 0.07% Death (n=1) 0.07% Stroke (n=1) 0.14% Stent thrombosis (MI 4b

n= 1390 Elective PCI (Troponin <0) at the Pitié-Salpêtrière Hospital in 2014-2015

Zeitouni M et al. Eur Heart J 2018

29% events at 48hours

  • frequent (28.6%) when considering PCI-

related myonecrosis/myocardial injury

  • rare (0.28%) but serious when considering

stent thrombosis, Q wave MI or stroke.

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Définition*

1/ peri-procedural Myocardial Infarction type 4a (Troponin Elevation X5 ULN + Ischemic Criteria) 7% 2/ myocardial injury at 48hours or earlier if discharge. = Silent elevation of Troponin > 5xULN

  • r

Ischemic Criteria + Troponin < 5xULN 21.8% 3/ No events (Troponin Elevation <5x ULN only 72.2% Zeitouni M et al. Eur Heart J 2018 *Third Universal definition

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What is the impact ?

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Impact on CV events

Event Free survival from ischemic events at one year Zeitouni M et al. Eur Heart J 2018

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Impact on mortality

Ndrepeppa et al. JACC 2016 N= 5626 patients undergoing elective PCI

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Next step ?

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Troponin evaluation post PCI Primary end-point : MI type 4a, 4b (stent thrombosis) or myocardial injury @ 48hours or discharge

N= 1900 troponin negative patients scheduled for PCI PCI procedure Ticagrelor 180 mg Clopidogrel LD* R

ALPHEUS Trial

*300 or 600mg at physicians discretion

Ticagrelor MD

90mg x2/day

Clopidogrel MD

75 mg /day

Follow up at 30days for secondary EP

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885 patients randomisés / 1900 Bravo à tous les centres participants !

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Johanne SILVAIN johanne.silvain@aphp.fr

1 Sorbonne Université 2 ACTION Study Group 3 INSERM UMRS 1166 ICAN 4 Institut de Cardiologie (APHP)

www.action-cœur.org

PITIE-SALPETRIERE UNIVERSITY HOSPITAL

Merci