Journal MI, mortality and Quality of Life.pptx

Correlation Between Periprocedural Myocardial Infarction, Mortality, and Quality of Life in Coronary Revascularization Trials: A Meta-analysis by Mario et al

1. C orrelation Between Periprocedural Myocardial Infarction, Mortality, and Quality of Life in Coronary Revascularization Trials: A Meta-analysis Presented by : Natalia Wara , MD Supervised by : Victor G.X. Rooroh , MD, FIHA Gaudino M, Franco A, Dimagli A, et al. Journal of the Society for Cardiovascular Angiography & Interventions 2 (2023) 100591

2. Myocardial Infarction (MI)  - Related to CAD - Associated with an adverse prognosis in observational studies of patient with CAD Controversy over the definition and prognostic importance of nonfatal MI and of periprocedural MI ( pMI ) - Association of pMIs with mortality was weaker than non pMIs . - Smaller MI can affect survival and quality of Life (QoL)  controversial Introduction

3. To assess whether pMI correlates with subsequent all cause mortality or cardiac mortality and Quality of Life in coronary revascularization trials 01 To assess the potential modifier effect of pMI definition and other key clinical and procedural variables 02 Aim of this study

4. Databases : Ovid MEDLINE, Ovid EMBASE, the Cochrane Library (Wiley) January 2022 S tudy years, number of participating centers, location, patient number, patients characteristic, procedural characteristic, details of medical therapy, follow up time and definition of pMI Extracted Variables All RCTs comparing PCI vs CABG, reported data for pMI and mortality, included measurement of patient QoL Inclusion Criteria A ll cause mortality, cardiac mortality, pMI , QoL Qol  the SAQ-AF and the SF-PC Questionnaire Extracted Outcomes Methods Statistical analysis were performed in R version 4.1.1 with threshold for validating was set at 0.7

5. Result Records identified from: Databases (n =7177) -Ovid MEDLINE: 2078 -Ovid EMBASE: 4658 -Cochrane (Wiley): 441   Registers (n = 0) Records removed before screening : Duplicate records removed (n = 1744) Records screened (n = 5433) Records excluded (n = 5389) Reports sought for retrieval (n = 44) Reports not retrieved (n = 0) Reports assessed for eligibility (n = 44) Reports excluded: Non-randomized trial (n = 7) Comparing balloon angioplasty versus CABG (n = 5) Later follow-up available (n = 5) Not original study (n = 2) Not reporting data on periprocedural MI (n = 13  Studies included in review (n = 12) Reports of included studies (n = 12) Identification of studies via databases and registers Identification Screening   Included

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8. Result For pMI diagnosis : 8 Trials  CKMB 1 trial  Troponin F or definition of PMI : 5 trials  rise in cardiac biomarker >5 times URL 4 trials  lower biomarker threshold (<5) 3 trials  didn’t provide details of biomarker Number of patients in individual trials : 130 – 1905 patients Mean age : 61 – 67.5 yo . Prevalence of women : 1% - 35.9% Prevalence of Diabetic patients : 15% - 100%

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12. Result Analysis Studies Patients Slope (95%CI) R 2 (95%CI) Multivessel coronary disease         pMI and all-cause mortality 5 5929 2.16 (0.69 – 3.64) 0.88 (0.05 – 0.94) pMI and cardiac mortality 4 5427 0.59 (0.19 – 1.00) 0.95 (0.01 – 0.98) Left main disease         pMI and all-cause mortality 4 5090 -1.47 (-6.56 – 3.62) 0.43 (0.002 – 0.74) pMI and cardiac mortality 3 4889 1.02 (-16.35 – 18.39) 0.36 (0.004 – 0.72) Drug-eluting stents         pMI and all-cause mortality 10 9508 1.95 (1.01 – 2.90) 0.74 (0.22 – 0.86) pMI and cardiac mortality 7 8615 0.34 (-0.36 – 1.05) 0.24 (0.001 – 0.61) Study year: after year 2000         pMI and all-cause mortality 10 9508 1.95 (1.01 – 2.90) 0.74 (0.22 – 0.86) pMI and cardiac mortality 7 8615 0.34 (-0.36 – 1.05) 0.24 (0.001 – 0.61) Follow up >1 year         pMI & All-cause mortality 8 9157 1.86 (1.31 – 2.40) 0.92 (0.58 – 0.96) pMI & Cardiac mortality 8 9157 0.43 (-0.20 – 1.06) 0.31 (0.002 – 0.64) Follow up ≤1 year pMI & All-cause mortality 4 2392 3.37 (-1.41 – 8.15) 0.82 (0.004 – 0.91) pMI & Cardiac mortality 1 1500 NA NA Follow up ≤4 years         pMI & All-cause mortality 5 2590 3.13 (2.60 – 3.67) 0.99 (0.82 – 1.00) pMI & Cardiac mortality 2 1698 NA NA

13. Result Analysis Studies Patients Slope (95%CI) R 2 (95%CI) Multivessel coronary disease         pMI and all-cause mortality 5 5929 2.16 (0.69 – 3.64) 0.88 (0.05 – 0.94) pMI and cardiac mortality 4 5427 0.59 (0.19 – 1.00) 0.95 (0.01 – 0.98) Left main disease         pMI and all-cause mortality 4 5090 -1.47 (-6.56 – 3.62) 0.43 (0.002 – 0.74) pMI and cardiac mortality 3 4889 1.02 (-16.35 – 18.39) 0.36 (0.004 – 0.72) Drug-eluting stents         pMI and all-cause mortality 10 9508 1.95 (1.01 – 2.90) 0.74 (0.22 – 0.86) pMI and cardiac mortality 7 8615 0.34 (-0.36 – 1.05) 0.24 (0.001 – 0.61) Study year: after year 2000         pMI and all-cause mortality 10 9508 1.95 (1.01 – 2.90) 0.74 (0.22 – 0.86) pMI and cardiac mortality 7 8615 0.34 (-0.36 – 1.05) 0.24 (0.001 – 0.61) Follow up >1 year         pMI & All-cause mortality 8 9157 1.86 (1.31 – 2.40) 0.92 (0.58 – 0.96) pMI & Cardiac mortality 8 9157 0.43 (-0.20 – 1.06) 0.31 (0.002 – 0.64) Follow up ≤1 year pMI & All-cause mortality 4 2392 3.37 (-1.41 – 8.15) 0.82 (0.004 – 0.91) pMI & Cardiac mortality 1 1500 NA NA Follow up ≤4 years         pMI & All-cause mortality 5 2590 3.13 (2.60 – 3.67) 0.99 (0.82 – 1.00) pMI & Cardiac mortality 2 1698 NA NA

14. In this Meta-analysis pMI was correlated with all cause mortality pMI that defined by large biomarker elevation  pMI events were associated with cardiac mortality There was a cor r elation between pMI and the physical component of QoL assessments Discussion Previous Reports ( O’Fee K, Deych E, Ciani O et al, 2021) Failed to show a correlation between nonfatal MI and all cause mortality or cardiovascular mortality Heterogenous interventions, sub analysis based on timing of MI was not presented, and its likely that survivor bias for nonprocedural MI and time of follow up may have been too short

15. Discussion Navarese EP, et al (2021)  metaanalysis of 25 RCTs with clinically stable CAD  revascularization + medical therapy vs medical therapy alone  pMI was not significantly corelated with absolute difference in cardiac mortality Silavin , et al (2021)  pooled analysis of CCS patients undergoing PCI  significant association between post PCI troponin elevation and 1 year mortality, >3fold increase troponin above URL increase mortality until 25-fold elevation, and major pMI (>5times troponin rise) significantly associated with 1 year mortality This study  pMI defined by larger biomarker elevation after PCI and CABG are associated with subsequent mortality and reduce QoL

16. Heterogenous population, difference of follow up duration and outcome assessment 02 03 01 Limitation No more granular data on ischemia effect except biomarker increase and cannot assess risk of pMI in those who don’t have post procedural biomarker data Surrogacy threshold of 0.7 was not formally validated and different cut off have with others

17. Conclusion pMI was associated with mortality and reduced quality of Life, especially extensive myocardial necrosis as define by a CKMB elevation >5 times URL pMI define by larger biomarker elevations as an outcome measure in coronary revascularization trials

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