Troponisms, necrosettes, enzyme leaks, creatinine phosphokinase bumps, and infarctlets: what's behind this new lexicon and what does it add?

Dramatic improvements in angioplasty technology have allowed initial patient and lesion selection criteria to expand and to include the treatment of complex lesions in critically ill patients. Most recent estimates indicate that 900 000 patients were treated with a percutaneous approach in the United States in 2000 and 1.7 million patients were treated with one worldwide. As the technology has become more complex with the introduction of a variety of stents, atherectomy devices, capture devices, and filters, among others, interventionists have learned more about the procedures and the patients undergoing them. See p 642 In the early years of balloon angioplasty, success rates were low. In the initial National Heart, Lung and Blood Percutaneous Transluminal Coronary Angioplasty Registry from 1977 and 1981, clinical success, which was defined as a reduction in luminal diameter stenosis by ≥20% and no death, infarction, or coronary bypass surgery, was achieved in 61% of patients.1,2 Failures were often the result of dissection or refractory acute closure, emergency coronary bypass graft surgery (often required), and Q-wave myocardial infarction (often resulted). Nonfatal Q-wave myocardial infarction occurred in 4.9% of patients and death, nonfatal Q-wave myocardial infarction, or emergency surgery occurred in 8.8%.1–3 There was often nothing subtle about an angioplasty complication at that time. As operator experience has improved and improvements in technology have become available, these morbid complications have decreased markedly. The need for emergency surgery has declined from 5.8% (initial registry) to ≈0.5% (today). Satisfaction from these advances has been tempered by the recognition of just how frequently enzyme elevations result from even successful percutaneous revascularization procedures. The issue of cardiac enzyme elevation (or “biomarker” elevation, in the case of the troponins, which are not enzymes) has become increasingly important for 2 reasons.4–10 (1) The definition of acute infarction has changed, and …