The association between periprocedural myocardial infarction (PMI) and mortality after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main disease was presented in the European Heart Journal recently. In this study, the authors have analysed data from the EXCEL trial and concluded that PMI was strongly associated with increased 3-year mortality. Creatine kinase-MB levels were used to quantify myocardial injury and are presented in five strata normalized to the upper reference level (URL), the upper being >_10 URL. The mortality-plots in Figure 4 demonstrate the risk of death following PCI or CABG in four strata of creatine kinase-MB. Logically, myocardial injury leading to early post-operative death would be associated with higher creatine kinase-MB levels than 10 URL. The distribution of creatine kinase-MB levels is not reported, and we are unable to find shared data. The combined endpoint of death, stroke, or myocardial infarction (MI) (both PMI and subsequent spontaneous or procedural MI) was in the EXCEL trial not significantly different at 5 years. All-cause mortality at 5 years, however, was higher in the PCI group. Periprocedural myocardial infarction was higher in the CABG group and contributes as a component of the combined endpoint to the conflicting results between all-cause mortality and the combined endpoint. Hence, the definition and implications of PMI are important for the interpretation of the EXCEL trial. In the EXCEL trial, the authors discuss that the definition of MI used is at odds with both the prior and current universal definitions of MI and the authors state that PMI ‘was independently predictive of late death’. Although this seems to be true for PCI (Figure 4b), for CABG this association is due to early mortality (Figure 4c). To better understand the implications and long-term prognostic value of PMI following CABG, we encourage the authors to share data, in particular the distribution of creatine kinase-MB levels and the values associated with CABG, PCI, early and late mortality, respectively.

中文翻译：

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EXCEL 试验中的围手术期心肌损伤

最近，欧洲心脏杂志报道了围手术期心肌梗死 (PMI) 与左主干病变经皮冠状动脉介入治疗 (PCI) 和冠状动脉旁路移植术 (CABG) 后死亡率之间的关联。在这项研究中，作者分析了 EXCEL 试验的数据并得出结论，PMI 与 3 年死亡率增加密切相关。肌酸激酶-MB 水平用于量化心肌损伤，并以标准化为参考水平上限 (URL) 的五个层次呈现，上层为 >_10 URL。图 4 中的死亡率图显示了肌酸激酶-MB 的四个层次中 PCI 或 CABG 后的死亡风险。从逻辑上讲，导致术后早期死亡的心肌损伤与肌酸激酶-MB 水平高于 10 URL 相关。未报告肌酸激酶-MB 水平的分布，我们无法找到共享数据。在 EXCEL 试验中，死亡、中风或心肌梗死 (MI)（PMI 和随后的自发性或程序性 MI）的综合终点在 5 年时没有显着差异。然而，PCI 组的 5 年全因死亡率更高。CABG 组围手术期心肌梗死的发生率较高，并且作为联合终点的一个组成部分，导致全因死亡率和联合终点之间的结果相互矛盾。因此，PMI 的定义和含义对于解释 EXCEL 试验很重要。在EXCEL考试中，作者讨论了所使用的 MI 定义与之前和当前 MI 的通用定义不一致，作者指出 PMI“独立预测晚期死亡”。尽管这对于 PCI 来说似乎是正确的（图 4b），但对于 CABG，这种关联是由于早期死亡率（图 4c）。为了更好地理解 CABG 后 PMI 的影响和长期预后价值，我们鼓励作者分享数据，特别是肌酸激酶-MB 水平的分布以及分别与 CABG、PCI、早期和晚期死亡率相关的值。