What are the latest guidelines for cardiac intervention?

Latest Guidelines for Cardiac Intervention

Primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy for patients with ST-elevation myocardial infarction (STEMI) when performed by an experienced team within 120 minutes of first medical contact. 1

Acute Coronary Syndrome Management

Reperfusion Strategy

• For STEMI patients:
  • Primary PCI is preferred when available within 120 minutes of first medical contact
  • If primary PCI cannot be performed within this timeframe, fibrinolysis should be administered within 30 minutes of hospital arrival 1
  • After fibrinolysis, patients should be transferred to a PCI-capable center for routine early angiography (within 2-24 hours) 1

Antiplatelet Therapy

• Dual antiplatelet therapy (DAPT) is essential after ACS:
  • Aspirin loading dose (150-300mg) followed by maintenance dose (75-100mg daily) indefinitely 1
  • P2Y12 inhibitor for 12 months in addition to aspirin 1, 2:
    • Ticagrelor (180mg loading, 90mg twice daily) is recommended for moderate-to-high risk patients 1, 2
    • Prasugrel (60mg loading, 10mg daily) is recommended for patients proceeding to PCI without contraindications 1, 2
    • Clopidogrel (300-600mg loading, 75mg daily) for patients who cannot receive ticagrelor or prasugrel 1, 2

Anticoagulant Therapy

• Unfractionated heparin (70-100 IU/kg IV) is standard during primary PCI 1
• For patients requiring oral anticoagulation plus DAPT (triple therapy):
  • Consider shorter duration of triple therapy (1-6 months) based on bleeding risk
  • After triple therapy, continue oral anticoagulation plus single antiplatelet therapy for up to 12 months 1

Post-ACS Pharmacotherapy

Lipid Management

• High-intensity statin therapy should be started as early as possible and continued indefinitely 1
• For patients with LDL-C ≥1.8 mmol/L (70 mg/dL) despite maximum tolerated statin dose, additional lipid-lowering therapy should be considered 1

Renin-Angiotensin-Aldosterone System Blockers

• ACE inhibitors are recommended within 24 hours of STEMI for patients with:
  • Heart failure
  • Left ventricular systolic dysfunction
  • Diabetes
  • Anterior infarct 1
• ACE inhibitors should be considered in all patients without contraindications 1
• Angiotensin receptor blockers (ARBs), preferably valsartan, are alternatives for ACE inhibitor-intolerant patients 1
• Mineralocorticoid receptor antagonists (MRAs) are recommended for patients with:
  • LVEF <40% and heart failure or diabetes
  • Already receiving ACE inhibitor and beta-blocker
  • No renal failure or hyperkalemia 1

Specific Interventional Procedures

Coronary Stenting

• Drug-eluting stents (DES) are preferred over bare-metal stents for primary PCI 1
• Radial access is preferred over femoral access to reduce bleeding risk 1, 2

Multivessel Disease

• In STEMI patients with multivessel disease:
  • Complete revascularization should be considered before hospital discharge (either immediate or staged) 1
  • The Heart Team approach is crucial for complex cases or when considering surgical revascularization 3

Structural Heart Disease Interventions

• Transcatheter aortic valve implantation (TAVI) is established for severe aortic stenosis in high-risk patients 4, 5
• MitraClip may be considered for severe mitral regurgitation in patients at high surgical risk 4, 5
• Left atrial appendage closure can be considered for stroke prevention in patients with atrial fibrillation who cannot take oral anticoagulants 4

Cardiac Rehabilitation

• Cardiac rehabilitation should be offered to all ACS patients 1, 6
• Home-based exercise training with wireless monitoring has shown benefits in exercise capacity and quality of life for ACS patients after PCI 6

Common Pitfalls and Caveats

• Bleeding risk assessment is crucial before initiating DAPT or triple therapy
• P2Y12 inhibitor selection should consider both ischemic and bleeding risks
• Prasugrel should not be administered when coronary anatomy is unknown 1
• Avoid routine intra-aortic balloon pumping in cardiogenic shock 1
• Radial access is preferred over femoral access to reduce vascular complications 1, 2
• Careful monitoring of renal function is essential when using contrast media, especially in elderly patients and those with pre-existing renal impairment 1

The field of cardiac intervention continues to evolve rapidly, with increasing options for percutaneous treatment of both coronary and structural heart disease. A multidisciplinary Heart Team approach is essential to provide optimal patient-centered care, particularly for complex cases.