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percutaneous coronary intervention (PCI)

An invasive procedure to enlarge the lumen of a narrowed coronary artery by balloon compression. The angioplasty catheter is inserted into a coronary artery, & the cylindrical balloon is inflated at the site of an obstructing atheroma. Indications: 1) primary therapy for unstable angina with ST segment elevation* (see CAPITAL AMI study, STEMI) [17] 2) rescue therapy a) *following failed thrombolysis b) *persistent hemodynamic instability or arrhythmia c) *60-90 minutes* after initiation of thrombolytic therapy 3) unstable angina - *patient not eligible for thrombolytic therapy 4) myocardial infarction - *complicated by cardiogenic shock or CHF [14] - *failure of medical management following initial stabilization 5) *restenosis of previous coronary artery bypass graft 6) elective revascularization for ischemic heart disease due to coronary artery disease a) *impaired left ventricular function - *2 or more vessels with > 50% stenosis - CABG preferred for multivessel disease with reduced LV ejection fraction [2] - *viable left ventricular myocardium with abnormal wall motion b) *normal left ventricular function with left main, 3-vessel or severe 2-vessel disease c) proximal left anterior descending artery disease - common clinical practice, improves quality of life [2] - exception to the single vessel contraindication (MKSAP18) [2] 7) new onset acute heart failure or cardiogenic shock [2] * may be better than thrombolysis for primary therapy [9] see 'PTCA vs thrombolysis for acute MI * 3-24 hours after thrombolytic therapy in asymptomatic patients [61] # PCI for STEMI in patients with diabetes mellitus #CABG for failed PCI or thrombolytic therapy after STEMI [2] #CABG in with diabetes mellitus otherwise be eligible for PCI (better 5 year survival, 80% vs 65%) Contraindications: 1) elective PCI for one vessel disease or chronic stable angina* does not: a) reduce future risk of myocardial infarction b) improve resting left ventricular function c) increase survival d) either PCI or CABG reasonable for left main coronary artery disease [87] 2) routine thrombectomy with PCI of no benefit (see thrombectomy) 3) late PCI to restore perfusion of infarcted myocardium of no benefit. [18] 4) preventive PCI in stable coronary disease of no benefit [19] 5) PCI for stable occluded coronary artery disease of little to no benefit [23] 6) late PCI for totally occluded coronary artery after myocardial infarction of no benefit [25] 7) PCI no better than medical therapy for stable coronary artery disease with proven myocardial ischemia [42,43,44,58,66] 8) acute coronary syndrome or NSTEMI [49] 9) patients without hemodynamically significant coronary artery stenosis have favorable long-term prognosis with medical therapy alone [68] * for some patients with chronic stable angina & coronary ischemia, elective PCI can provide meaningful symptomatic relief & functional benefits [90] Benefit/risk: - PCI for acute coronary syndrome or NSTEMI [49] - no mortality benefit - risk for MI higher for PCI than medical management - number needed to treat (NNT) to reduce severity of angina pectoris = 9 [49] Procedure: - radial artery vs femoral artery access exposes patients to a bit more but operators to a lot more radiation (77 vs 41 microsieverts at the level of the chest) [62] - still radial artery access recommended for PCI [82,93] - loading dose of clopidogrel 600 mg, followed by 150 mg/day for 6 days, then 75 mg/day - add aspirin 81 mg QD if coronary stenting - systemic anticoagulation - bivalirudin anticoagulation [32] - heparin 70 U/kg is superior to bivalirudin [45] - bivalirudin vs unfractionated heparin at the time of PCI roughly equivalent [55,64] - IV nitroglycerin for management of angina - intravascular imaging vs coronary angiography for visualizing coronary artery anatomy [86] - eptifibatide (Integrilin) for 12 hours after PTCA - coronary stenting may reduce the rate of restenosis [7] - treatment with abciximab with PTCA & coronary stenting may further reduce the rate of restenosis (10% at 6 months [7]) - facilitated PCI with reteplase plus abciximab or abciximab alone started early before PCI did improve outcomes, compared with primary PCI in STEMI patients [21] - intracoronary abciximab (0.25 mg/kg), delivered into the thrombus region with an infusion catheter [32] - manual aspiration thrombectomy with the Export catheter in patients with as large thrombus [32] - routine thrombus aspiration before PCI in patients with STEMI of no benefit [46] - routine thrombectomy of no benefit [48] & may result in an increased 30 day risk of stroke (0.7% vs 0.3%) - fractional flow reserve (FFR) guidance should be standard of care for most patients with multivessel disease [54,68] - single vessel fractional flow reserve (FFR) guidance of benefit [76] - complete multivessel revascularization at the time of PCI in patients with acute myocardial infarction who present with cardiogenic shock [75] - fewer early complications & lower mortality with culprit vessel only revascularization [75,82] - culprit vessel only revascularization associated with lower 1-year mortality if culprit lesion located in the left main coronary artery or proximal left anterior descending artery but not other coronary arteries [78] - in patients with STEMI & multivessel CAD, complete revascularization increases likelihood of freedom from angina vs culprit-lesion only strategy [85] - complete revascularization reduces death, MI, stroke, or repeat revascularization within 1 year vs culprit vessel only for STEMI or NSTEMI (RR=0.73, NNT=20) [88] Laboratory: - reperfusion is associated with higher peak serum CK-MB than persistent occlusion - platelet-function testing may be clinically relevant for a small proportion of patients [40] - high platelet reactivity confers risk of stent thrombosis Complications: 1) contrast nephropathy [12] 2) 30-45% restenosis within 6 months (20% in [7]) 3) patients with atrial fibrillation requiring warfarin plus clopidogrel plus aspirin at high risk of hemorrhage [36] 4) pseudoaneurysm or arteriovenous fistula at the site of catheter insertion [2,39] - duplex ultrasound to distinguish 5) stent thrombosis may occur in patients with high platelet reactivity [40] 6) accelerated idioventricular rhythm (ventricular tachycardia) is common following coronary reperfusion & does not require intervention when it occurs within the 1st 24 hours [2] - heart rate < 120/min, usually < 100/min 7) device approved for treatment of acute coronary artery perforations during PCI [70] Management: - PCI should be performed ASAP (as soon as possible) [27] - PCI should be performed within 90 minutes of medical contact - symptom onset to procedure time more important than door to procedure time (door to balloon time) [35] - PCI within 2 hours of symptom onset leads to better outcomes [35] - revascularization of non-infarct-related arteries in STEMI results in improved outcomes [41] - revascularization on non-infarct-related arteries after STEMI determined by fractional flow reserve associated with diminished need for revascularization (6.1% vs 17.5%) but not all-cause mortality (1.4% vs 1.7%) [63] - complete revascularization vs culprit artery only PCI in patients with multivessel disease reduces cardiovascular death & myocardial infarction - benefits of revascularization during same procedure vs shortly after not established - antiplatelet therapy - clopidogrel 600 mg prior to procedure or cangrelor 30 ug/kg bolus & 4 ug/kg infusion followed by 600 mg of clopidogrel at termination of infusion [37] - pretreatment with P2Y12 inhibitor (clopidogrel, ticagrelor) - prasugrel for STEMI prior to PCI but deferred until after PCI for NSTEMI & other acute coronary syndromes (superior to routine ticagrelor) [91] - 16% reduction in major cardiovascular events - 32% increase in major bleeding - no change in mortality [47] - dual anti-platelet therapy (DAPT) after PCI - 1-3 months sufficient [72,92] - lower bleeding risk with 3 months DAPT than 6 months in elderly without difference in major cardiovascular events [92] - 1 month of DAPT after PCI for acute coronary syndrome inadequate [81] - 1 month of DAPT after PCI with biodegradable-polymer sirolimus-eluting coronary stent may be sufficient in high-risk patients [83] - aspirin 81 mg PO QD + clopidogrel 75 mg daily PO QD [38] - addition of aspirin 81 mg to ticagrelor for 1-12 months after PCI for acute coronary syndrome of no benefit [74] - continue P2Y12 inhibitor for 6-12 months [72] - clopidogrel superior to aspirin or ticagrelor for long-term monotherapy [80] - MKSAP19 disagrees, aspirin indicated vs clopidogrel [2] - higher cost of prasugrel & ticagrelor vs clopidogrel associated with increased nonfilling of prescriptions [69] - prasugrel contraindicated in patients with history of stroke [2] - no benefit to glycoprotein inhibitors as adjunctive treatment to PCI for patients with STEMI [50] - P2Y12 inhibitor + direct oral anticoagulant if atrial fibrillation [73] - for older adults with atrial fibrillation & acute MI who undergo PCI, treatment with dual antiplatelet therapy (DAPT) plus warfarin (triple therapy) of no benefit over DAPT alone & may increase risk of bleeding [52,71] - ACC recommends P2Y12 inhibitor + direct oral anticoagulant (omit aspirin) if atrial fibrillation [79] - dabigatran 110 mg BID + clopidogrel or ticagrelor [65] (no aspirin) noninferior to triple therapy with respect to thromboembolic events with lower risk of bleeding - beta-blocker of no benefit in older patients without myocardial infarction [59] - ranolazine of no benefit for patients with incomplete revascularization after PCI - atorvastatin 80 mg before & 24 hours after PCI followed by 40 mg PO QD does not reduce major cardiovascular events at 30 days [67] - combination B vitamins for 6 months - folate 1 mg, vitamin B12 400 ug, vitamin B6 10 mg PO QD - reduces serum homocysteine - reduced combined endpoint: myocardial infarction, death, restenosis (revascularization) {15% vs 23%} [8] - in other settings, the combination of folate, vitamin B6, & vitamin B12 have not been foun to reduce cardiovascular mortality - intraluminal radiation, beta-radiation (18 Gy) or gamma-radiation may also reduce rate of restenosis, including those with restenosis after stenting [6] - cyclosporine prior to PCI of no benefit in patients with anterior wall STEMI [53] - delay placement of ICD until patient has recovered & medical therapy has been optimized [1] - same day discharge after PTCA appears safe [29] - delay non-cardiac surgery for 14 days (no coronary stent) [2,60] - cardiac stress testing (stress echocardiography) after PCI may be appropriate [33] - routine electrocardiogram, cardiac stress testing or angiography (invasive or CT angiography) in asymptomatic patients after successful PCI not indicated [2,84] - avoid smoking marijuana after PCI - increased risk of recurrent myocardial infarction or stroke [77] Notes: - angioplasty would appear superior to streptokinase thrombolysis in the treatment of myocardial infarction, but requires expertise not yet available at many hospitals [4] - elective PTCA for multivessel disease has a slightly higher mortality than CABG [11] - at 1 year (5% vs 4%) - at 5 years (16% vs 14%) - CABG is superior to PCI for a) severe coronary artery disease [24]; see Syntax trial b) patients with diabetes mellitus [26] c) patients > 65 years of age [26] d) left main coronary artery disease e) multivessel coronary artery disease with involvement of left anterior descending coronary artery (LAD) & reduced LV ejection fraction [2] - facilitated percutaneous intervention is the use of pharmaceutical agents before a planned intervention a) mixed results b) pretreatment with clopidogrel decreased combined incidence of sudden death, myocardial infarction & stroke associated with PTCA in patients with STEMI. (4% vs 6%) [15] c) offered no benefit, outcomes may be worse [16] d) would be to become standard of care [37] - combination of pretreatment with clopidogrel + treatment with abciximab + heparin (during or after procedure) may be of benefit in patient with non-STEMI (see ISAR-REACT 2 trial) - prasugrel in combination with aspirin may be an option for patients with a) stent thrombosis during clopidogrel treatment b) diabetes mellitus (NGC, NICE) - percutaneous coronary intervention at hospitals without on-site cardiac surgery are noninferior to those at hospitals with on-site surgery [31] - outcomes independent of procedure appropriateness [34] - public reporting of acute MI outcomes is associated with - lower PCI use, particularly in high-risk patients - higher overall in-hospital mortality, mostly in patients who do not undergo PCI [51]

Related

Bypass Angioplasty Revascularization Investivation (BARI) coronary stent/coronary stenting ISAR-REACT 2 trial percutaneous coronary intervention (PCI)/coronary stent vs CABG Syntax trial TIMI study

Specific

percutaneous transluminal coronary angioplasty (PTCA)

General

interventional radiology cardiac catheterization

References

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