Differences in high-sensitivity troponin assay and association with myocardial injury and periprocedural MI after PCI for de novo three-vessel disease: insights from Multivessel TALENT

Background High-sensitivity cardiac troponin (hs-cTn) is recommended by current guidelines as the standard biomarker for diagnosing acute coronary syndrome. The measurement of hs-cTn has also become increasingly common for diagnosing periprocedural myocardial infarction (PPMI), along with creatine kinase-MB (CK-MB). However, hs-cTn may contribute to the overdiagnosis of periprocedural myocardial infarction after PCI. Purpose We investigated whether the type of high-sensitivity cardiac troponin (hs-cTn) assay influenced the diagnosis and incidence of PPMI in patients with de novo three-vessel disease in a randomized PCI trial (Multivessel TALENT). Methods The Multivessel TALENT trial is a randomised, 1:1, multicentre (54 centres in Europe), open-label study comparing clinical outcomes between the Supraflex Cruz™ and SYNERGY™ in patients with de novo 3VD without left main disease. PPMI was assessed according to three different definitions, SCAI, ARC-2, and the Fourth Universal Definition of MI (4th UDMI), based on post-PCI cardiac enzymes (hs-cTnI, hs-cTnT, CK-MB). Results 1548 patients underwent 2334 PCI procedures (1548 index and 786 staged). As post-procedural cardiac enzymes, both troponin and CK-MB were measured in 973 procedures (41.7%), troponin alone in 1061 (45.5%), CK-MB alone in 56 (2.4%), and neither in 244 (10.5%) (Figure A). Among the 2034 procedures with post-procedure troponin available, hs-cTnI was used in 848 (41.7%) and hs-cTnT in 1186 (58.3%). In patients with normal baseline troponin (N=996; Figure B1), hs-cTnI demonstrated higher rates of post-PCI elevations than hs-cTnT at >5×, >35×, and >70× the upper limit of normal (ULN) (all P<0.001). In contrast, the rates above the CK-MB thresholds (>5× and >10×ULN) were comparable between hs-cTnI and hs-cTnT groups (P=0.514 and 1.000). In those with elevated baseline troponin (N=857; Figure B2), the proportions with ΔcTn >5×, >35×, and >70×ULN were significantly higher with hs-cTnT than with hs-cTnI. ΔCK-MB >5×, >10×ULN were similar between groups (P=0.191 and P=0.461). According to the SCAI and ARC-2 definitions, the frequency of PPMI was significantly higher for hs-cTnI than for hs-cTnT (SCAI: 10.1% vs. 1.3%, P < 0.001; ARC2: 5.4% vs. 2.2%, P < 0.001) (Figure B3). Based on 4th UDMI, a similar trend toward higher frequency was observed with hs-cTnI (12.6% vs. 9.9%, P = 0.070). Conclusions In the post-PCI setting, hs-cTnI showed a more sensitive increase than hs-cTnT, and PPMI was more frequent when assessed using hs-cTnI. These findings suggest that the validity of using hs-cTn assays to define PPMI may need to be reconsidered.