Vora Keyur P, Kalra Ankur, Shah Chirag D, Bhatt Kinjal, Kumar Andreas, Pandya Tejas, Poptani Vishal, Chan Shing Fai, Singh Dhirendra, Jambunathan Nithya, Subramanian Ramesh, Youssef Khalid, Kanakasabai Saravanan, Finney Robert, Desai Ankit, Kreutz Rolf P, Kovacs Richard J, Raman Subha V, Bhatt Deepak L, Dharmakumar Rohan
Indiana University School of Medicine, Indianapolis.
Synergy Cardiovascular Research Center, Synergy Superspecialty Hospital, Rajkot, India.
NEJM Evid. 2025 Sep;4(9):EVIDoa2400294. doi: 10.1056/EVIDoa2400294. Epub 2025 Aug 26.
Advances in acute ST-elevation myocardial infarction (STEMI) care have substantially decreased in-hospital mortality; however, in absolute terms, in-hospital mortality still remains high. Reperfusion injury, particularly intramyocardial hemorrhage following primary percutaneous coronary intervention (PCI), is a major predictor of adverse cardiovascular outcomes in the long term, but whether it contributes to in-hospital mortality is not known.
We performed a multicenter study to investigate the use of post-PCI high-sensitivity cardiac troponin I (hs-cTn-I) as a diagnostic tool to identify hemorrhagic myocardial infarction (MI) by determining hourly hs-cTn-I thresholds (every hour up to 12 hours, and at 16, 20, 24, and 48 hours post-PCI). We then investigated the relationship between patients classified as having hemorrhagic MI based on post-PCI hs-cTn-I cutoff values and in-hospital mortality using STEMI registries containing information about 6180 patients across seven hospitals in a single large health system in the United States.
We enrolled 154 patients in a discovery cohort and 53 patients in a validation cohort. Hemorrhagic MI was diagnosed by cardiac magnetic resonance imaging. Post-PCI hs-cTn-I cutoff values for the determination of hemorrhagic MI were time dependent, with a sensitivity greater than 0.91, a specificity greater than 0.86, and an area under the curve (AUC) greater than 0.92 over the first 10 hours post-PCI, decreasing to a sensitivity greater than>0.84, a specificity greater than 0.80, and an AUC greater than 0.84 thereafter. The STEMI registry analysis demonstrated that patients classified as having hemorrhagic MI based on hs-cTn-I cutoff values had a 2.81-fold greater risk for in-hospital mortality than those classified as having had nonhemorrhagic MI (adjusted odds ratio, 2.81; 95% confidence interval, 2.17 to 3.64).
Post-PCI troponin kinetics may have the potential to diagnose hemorrhagic MI, which was associated with in-hospital mortality. (Funded by the National Institutes of Health National Heart, Lung, and Blood Institute (grant numbers HL133407, HL136578, and HL147133) and others; ClinicalTrials.gov ID, NCT05872308).
急性ST段抬高型心肌梗死（STEMI）治疗方面的进展已大幅降低了住院死亡率；然而，从绝对数值来看，住院死亡率仍然很高。再灌注损伤，尤其是直接经皮冠状动脉介入治疗（PCI）后的心肌内出血，是长期不良心血管结局的主要预测因素，但它是否会导致住院死亡率尚不清楚。
我们进行了一项多中心研究，以调查PCI后高敏心肌肌钙蛋白I（hs-cTn-I）作为诊断工具，通过确定每小时hs-cTn-I阈值（PCI后每小时直至12小时，以及在16、20、24和48小时）来识别出血性心肌梗死（MI）。然后，我们使用包含美国一个大型医疗系统中七家医院6180名患者信息的STEMI登记册，研究根据PCI后hs-cTn-I临界值分类为出血性MI的患者与住院死亡率之间的关系。
我们在一个发现队列中纳入了154名患者，在一个验证队列中纳入了53名患者。出血性MI通过心脏磁共振成像诊断。用于确定出血性MI的PCI后hs-cTn-I临界值是时间依赖性的，在PCI后的前10小时内，敏感性大于0.91，特异性大于0.86，曲线下面积（AUC）大于0.92，此后敏感性降至大于0.84，特异性大于0.80，AUC大于0.84。STEMI登记册分析表明，根据hs-cTn-I临界值分类为出血性MI的患者，其住院死亡率比分类为非出血性MI的患者高2.81倍（调整后的优势比，2.81；95%置信区间，2.17至3.64）。
PCI后肌钙蛋白动力学可能有诊断出血性MI的潜力，出血性MI与住院死亡率相关。（由美国国立卫生研究院国家心脏、肺和血液研究所资助（拨款编号HL133407、HL136578和HL147133）及其他机构；ClinicalTrials.gov标识符，NCT05872308）
