The risk of death is heightened in patients meeting two or three evidence-supporting criteria for periprocedural myocardial infarction (MI), but not in those meeting 1 criterion, a new study finds. In the April 30th issue of the Journal of the American College of Cardiology, researchers recommend a re-evaluation of the fourth universal definition of myocardial infarction (UDMI) periprocedural MI criteria to improve their “clinical usefulness.” “Adopting a two- or three-criteria approach could harmonize UDMI criteria, which encompass biomarkers and clinical features, with purely biomarker-based definitions,” said the researchers. “This approach might also decrease the incidence of periprocedural MI by focusing on clinically significant events.” The fourth UDMI is distinguished by a higher incidence of periprocedural MI, along with a diminished prognostic impact in comparison with other criteria. At variance with the definitions based on increased cardiac troponin levels post PCI, periprocedural MI using the fourth UDMI requires the presence of ≥1 of specific criteria. These include electrocardiographic (ECG) ischemic changes, cardiac imaging abnormalities, or angiographic complications. Study findings The study, which was also published Monday online, found that out of 1010 patients enrolled onto the study, periprocedural MI defined by the fourth UDMI occurred in 174 patients (17.2%). Of these, 124 (71.3%) patients met one and two of the criteria with 50 (28.7%) meeting three of the criteria. Using a multivariable Cox regression analysis, patients with periprocedural MI had an increased risk of all-cause death at the one-year follow-up (12 of 174 [6.9%]) vs. patients without periprocedural MI (22 of 836 [2.6%]); adjusted hazard ratio [HR]: 2.47; 95% confidence interval [CI]: 1.19-5.12; P=0.015). ECG criteria (adjusted HR: 3.22; 95% CI:1.48-6.97; P=0.003), imaging criteria (adjusted HR: 3.45; 95% CI:1.26-9.46; P=0.016) and angiographic criteria (adjusted HR:3.21; 95% CI:1.27-8.09; P=0.013) were all associated with an increased risk of all-cause death. However, periprocedural MI with only one criterion did not increase the risk of death (5 of 124 [4.0%]; adjusted HR: 1.39; 95% CI: 0.52-3.75; P=0.514). Risk of death at one year On the other hand, periprocedural MI with two or three criteria was associated with an increased risk of all cause death at one year (7 of 50 [14.3%]; adjusted HR:5.38; 95% CI: 2.24-12.9; P=0.001). “The role of elective PCI in stable patients remains controversial and periprocedural MI plays a critical role in the risk-benefit ratio between medical therapy and myocardial revascularization,” said the research team. “Indeed, although elective PCI decreases the risk of spontaneous MI, it concurrently increases the risk of periprocedural ischemic events, resulting in a net neutral effect on the overall MI risk. “The optimal definition of periprocedural MI is far more contentious due to prognostic heterogeneity across existing definitions Yet, the fourth UDMI is the most frequent but carriers the least prognostic significance.” Limitations of the investigation The team, based at the University of Naples Federico II and CEINGE Advanced Biotechnologies in Naples, Italy, said the study data suggested that the fourth UDMI’s definition held “prognostic significance” predominantly when two or three criteria were fulfilled. However, the team also highlighted the limitations of the study that included the adjudication of periprocedural MI, which was based on the availability of source documents. They pointed out that, in a small subset of patients (n=77), post-PCI echocardiographic evaluations were not available and consequently, imaging criteria were absent. Despite the inclusion of several covariates in the study’s adjusted models, the team also considered the possibility that their study may not have been adequately powered to yield fully adjusted risk estimates. Sources: Piccolo R, Angellotti D, Simonetti F, et al. Evidence Supporting Criteria for Periprocedural Myocardial Infarction in Patients Undergoing Elective Percutaneous Coronary Intervention. J Am Coll Cardiol. 2023;83:1713–1715. Image Credit: Bangkok Click Studio - stock.adobe.com