Korean Circ J.  2013 Oct;43(10):664-673. 10.4070/kcj.2013.43.10.664.

The Impact of Ischemic Time on the Predictive Value of High-Sensitivity C-Reactive Protein in ST-Segment Elevation Myocardial Infarction Patients Treated by Primary Percutaneous Coronary Intervention

• Kim KH
• Kim W
• Kang WY
• Hwang SH
• Cho SC
• Kim W
• Jeong MH
• Other Korean Working Group in Myocardial Infarction Investigators

• KMID: 1826557
• DOI: http://doi.org/10.4070/kcj.2013.43.10.664

Abstract

BACKGROUND AND OBJECTIVES
The high-sensitivity C-reactive protein (hs-CRP), a marker of inflammation, has been known to be elevated in patients with coronary artery disease. However, there is controversy about the predictive value of hs-CRP after acute myocardial infarction (MI). Therefore, we evaluated the impact of ischemic time on the predictive value of hs-CRP in ST-segment elevation myocardial infarction (STEMI) patients who were treated by primary percutaneous coronary intervention (PCI).
SUBJECTS AND METHODS
We enrolled 5123 STEMI patients treated by primary PCI from the Korean Working Group in Myocardial Infarction and divided enrolled patients into four groups by symptom-to-balloon time (SBT) and level of hs-CRP (Group I: SBT <6 hours and hs-CRP <3 mg/L, Group II: SBT <6 hours and hs-CRP > or =3 mg/L, Group III: SBT > or =6 hours and hs-CRP <3 mg/L, and Group IV: SBT > or =6 hours and hs-CRP > or =3 mg/L). To evaluate the impact of ischemic time on the predictive value of hs-CRP in STEMI patients, we compared the cumulative cardiac event-free survival rate between these four groups.
RESULTS
The sum of the cumulative incidence of all-cause mortality and recurrence of MI was higher in Group IV than in the other groups. However, there was no significant difference among Group I, Group II, and Group III. The Cox-regression analyses showed that an elevated level of hs-CRP (> or =3 mg/L) was an independent predictor of long-term cardiovascular outcomes only among late-presenting STEMI patients (p=0.017, hazard ratio=2.462).
CONCLUSION
For STEMI patients with a long ischemic time (> or =6 hours), an elevated level of hs-CRP is a poor prognostic factor of long-term cardiovascular outcomes.

Keyword

C-reactive protein; Myocardial infarction; Myocardial reperfusion

MeSH Terms

Coronary Artery Disease
Disease-Free Survival
Humans
Incidence
Inflammation
Myocardial Infarction*
Myocardial Reperfusion
Percutaneous Coronary Intervention*
Recurrence

Figure

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  Fig. 1 Comparison of the sum of the cumulative incidence of all-cause mortality and myocardial infarction in total STEMI patients treated by primary PCI (A) and Cox regression multivariate regression analysis showed that a high level of hs-CRP is an independent predictor of the sum of all-cause mortality and myocardial infarction in total STEMI patients treated by primary PCI (B). STEMI: ST-segment elevation myocardial infarction, DM: diabetes mellitus, HTN: hypertension, TIMI: Thrombolysis in Myocardial Infarction, LVEF: left ventricular ejection fraction, hs-CRP: high-sensitivity C-reactive protein, RAAS: rennin-angiotensin-aldosterone system blockers, PCI: percutaneous coronary intervention, HR: hazard ratio.

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  Fig. 2 Comparison of the sum of the cumulative incidence of all-cause mortality and myocardial infarction among the four groups, which were divided by SBT and blood level of the hs-CRP (Group I: SBT <6 hours and hs-CRP <3 mg/L, Group II: SBT <6 hours and hs-CRP ≥3 mg/L, Group III: SBT ≥6 hours and hs-CRP <3 mg/L, and Group IV: SBT ≥6 hours and hs-CRP ≥3 mg/L). SBT: symptom-to-balloon time, hs-CRP: high-sensitivity C-reactive protein.

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  Fig. 3 Comparison of detailed cardiovascular outcomes (A: cardiac death, B: non-cardiac death, C: myocardial infarction, D: repetition of PCI) among the four groups, which were divided by SBT and the blood level of the hs-CRP (Group I: SBT <6 hours and hs-CRP <3 mg/L, Group II: SBT <6 hours and hs-CRP ≥3 mg/L, Group III: SBT ≥6 hours and hs-CRP <3 mg/L, and Group IV: SBT ≥6 hours and hs-CRP ≥3 mg/L). PCI: percutaneous coronary intervention, SBT: symptom-to-balloon time, hs-CRP: high-sensitivity C-reactive protein.

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  Fig. 4 Comparison of the sum of the cumulative incidence of all-cause mortality and myocardial infarction in early-presenting STEMI patients (SBT <6 hours) (A) and Cox regression multivariate regression analysis showed that a high level of hs-CRP is not an independent predictor of the sum of all-cause mortality and myocardial infarction in early-presenting STEMI patients treated by primary PCI (B). STEMI: ST-segment elevation myocardial infarction, DM: diabetes mellitus, HTN: hypertension, TIMI: Thrombolysis in Myocardial Infarction, LVEF: left ventricular ejection fraction, hs-CRP: high-sensitivity C-reactive protein, RAAS: rennin-angiotensin-aldosterone system blockers, SBT: symptom-to-balloon time, HR: hazard ratio.

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  Fig. 5 Comparison of the sum of the cumulative incidence of all-cause mortality and myocardial infarction in late-presenting STEMI patients (SBT ≥6 hours) (A) and Cox regression multivariate regression analysis showed that a high level of hs-CRP is an independent predictor of the sum of all-cause mortality and myocardial infarction in late-presenting STEMI patients treated by primary PCI (B). STEMI: ST-segment elevation myocardial infarction, DM: diabetes mellitus, HTN: hypertension, TIMI: Thrombolysis in Myocardial Infarction, LVEF: left ventricular ejection fraction, hs-CRP: high-sensitivity C-reactive protein, RAAS: rennin-angiotensin-aldosterone system blockers, SBT: symptom-to-balloon time, PCI: percutaneous coronary intervention, HR: hazard ratio.

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