PROTECTION AGAINST MYOCARDIAL DAMAGE DURING CORONARY INTERVENTION. THE ARMYDA (ATORVASTATIN FOR REDUCTION OF MYOCARDIAL DAMAGE DURING ANGIOPLASTY) TRIAL IN PERSPECTIVE

Abstract
Small myocardial necrosis frequently occurs during coronary interventions and are associated with higher risk of cardiac events during follow-up. Several possible treatments have been proposed to address this issue, but at present the only effective preventive measure used in clinical practice is IIb/IIIa inhibitors. In a recent prospective and randomised study (the ARMYDA trial) published on Circulation, we confirmed the hypothesis that statin treatment before coronary intervention may have a protective effect. The ARMYDA trial included 153 patients with stable angina who, irrespective of cholesterol levels, were randomized to atorvastatin 40 mg/day or placebo 7 days before coronary interventions. Atorvastatin treatment significantly reduced the incidence of myocardial infarction after coronary intervention (5% vs. 18% in atorvastatin and placebo group, respectively, p = 0.025). Post-procedural peak levels of creatine kinase-MB (2.9 ± 3 vs. 7.5 ± 18 ng/ml, p = 0.007) and troponin-I (0.09 ± 0.2 vs. 0.47 ± 1.3 ng/ml, p < 0.001) were also significantly lower in the atorvastatin group. The results of the ARMYDA trial demonstrate that pre-treatment with atorvastatin 40 mg/day for 7 days significantly reduces the occurrence of procedural myocardial injury in patients with stable angina undergoing elective coronary intervention. Thus, all patients with suspected coronary disease should start a statin treatment before undergoing coronary angiography with possible interventions.

Key words
Coronary intervention, myocardial necrosis, statins, therapy

Bibliografía del artículo

1. Klein LW, Kramer BL, Howard E, et al. Incidence and clinical significance of transient creatine kinase elevations and the diagnosis of non-Q wave myocardial infarction associated with coronary angioplasty. J Am Coll Cardiol 1991; 17:621-6.
2. Abdelmeguid AE, Topol EJ, Whitlow PL, et al. Significance of mild transient release of creatine-kinase MB fraction after percutaneous coronary interventions. Circulation 1996; 94:1528-36.
3. Brener SJ, Ellis SG, Schneider J, et al. Frequency and long-term impact of myonecrosis after coronary stenting. Eur Heart J 2002; 23: 869-76.
4. Nallamothu BK, Bates ER. Periprocedural myocardial infarction and mortality. Causality versus association. J Am Coll Cardiol 2003; 42: 1412-14.
5. Ricciardi MJ, Wu E, Davidson CJ, et al. Visualization of discrete microinfarction after percutaneous coronary intervention associated with mild creatine kinase-MB elevation. Circulation 2001; 103: 2780-83.
6. Ioannidis JPA, Karvouni E, Katritis DG. Mortality risk conferred by small elevations of creatine-kinase MB isoenzyme after percutaneous intervention. J Am Coll Cardiol 2003; 42: 1406-11.
7. Kurz DJ, Naegeli B, Bertel O. A double-blind, randomized study of the effect of immediate intravenous nitroglycerin on the incidence of post-procedural chest pain and minor myocardial necrosis after elective coronary stenting. Am Heart J 2000; 139: 35-43.
8. Ellis SG, Brener SJ, Lincoff AM, et al. Beta-blockers before percutaneous coronary intervention do not attenuate postprocedural creatine kinase isoenzyme rise. Circulation 2001;104: 2685-90.
9. Wang FW, Osman A, Otero J, et al. Distal myocardial protection during percutaneous coronary intervention with an intracoronary beta-blocker. Circulation 2003; 107: 2914-19.
10. The EPISTENT Investigators. Randomized placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein IIb/IIIa blockade. Lancet 1998; 352: 87-92.
11. Desmet W, Dens J, Coussement P, et al. Does adenosine prevent myocardial micronecrosis following percutaneous coronary intervention The ADELINE pilot trial. Heart 2002; 88: 293-5.
12. Herrmann J, Lerman A, Baumgart D, et al. Preprocedural statin medication reduces the extent of periprocedural non-Q-wave myocardial infarction. Circulation 2002; 106: 2180-3.
13. Chan AW, Bhatt DL, Chew DP, et al. Early and sustained survival benefit associated with statin therapy at the time of percutaneous coronary intervention. Circulation 2002; 105: 691-96.
14. Ellis SG, Chew D, Chan A, et al. Death following creatine kinase-MB elevation after coronary intervention. Identification of an early risk period: importance of creatine-kinase-MB level, completeness of revascularization, ventricular function, and probable benefit of statin therapy. Circulation 2002; 106:1205-10.
15. Pasceri V, Patti G, Nusca A, et al. Randomized trial of atovrastatin for reduction of myocardial damage during coronary intervention. Results from the ARMYDA study. Circulation 2004; 110: 674-8.
16. Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction redefined – a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000; 36: 959-69.
17. Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Sinvastatin Survival Study (4S). Lancet 1994; 344: 1383-89.
18. Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia: West of Scotland Coronary Prevention Study Group. N Engl J Med 1995; 333: 1301-7.
19. Serruys PW, De Feyter P, Macaya C, et al. Fluvastatin for prevention of cardiac events following successful first percutaneous coronary intervention: a randomized controlled trial. JAMA 2002; 287: 3215-22.
20. Schwartz GG, Olsson AG, Ezekowitz MD, et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA 2001; 285: 1711-18.
21. Chan AW, Bhatt DL, Chew DP, et al. Relation of inflammation and benefit of statins after percutaneous coronary interventions. Circulation 2003; 107: 1750-56.
22. Wassmann S, Faul A, Hennen B, et al. Rapid effect of 3-hydroxy-3-methylglutaryl coenzyme a reductase inhibition on coronary endothelial function. Circ Res 2003; 93: e98-103.