What is the workup for Percutaneous Coronary Interventions (PCI)?

Workup for Percutaneous Coronary Interventions (PCI)

The comprehensive workup for PCI should include patient risk stratification, anatomical assessment, and evaluation of procedural feasibility to optimize outcomes and minimize complications. 1

Initial Patient Assessment

• Medical History:

  • Cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking)
  • Previous cardiac events (MI, prior revascularization)
  • Comorbidities that increase procedural risk:
    • Chronic kidney disease
    • Chronic obstructive pulmonary disease
    • Peripheral vascular disease
    • Bleeding disorders 1

• Clinical Presentation:

  • Stable ischemic heart disease vs. acute coronary syndrome
  • STEMI requires immediate coronary angiography with intent to perform PCI 1
  • Cardiogenic shock requires emergency PCI with consideration for complete revascularization 1

Diagnostic Testing

1. Non-invasive Testing:

   • Stress testing to document ischemia (especially important for stable CAD)
   • Revascularization strongly indicated if ≥10% of myocardium shows ischemia 2
   • Medical therapy may be more appropriate if <6.25% ischemic burden 2

2. Laboratory Assessment:

   • Complete blood count
   • Renal function tests (crucial for contrast administration)
   • Coagulation profile
   • Cardiac biomarkers (troponin, CK-MB)

3. Coronary Angiography:

   • Gold standard for defining coronary anatomy
   • Determines lesion characteristics:
     • Location (left main, proximal LAD, bifurcation)
     • Complexity (calcification, tortuosity, length)
     • Chronic total occlusion assessment 2
   • TIMI flow grading

4. Advanced Imaging:

   • Intravascular ultrasound (IVUS) - recommended to determine mechanism of stent restenosis 1
   • Fractional Flow Reserve (FFR) - for assessment of lesion significance
   • Optical coherence tomography - for detailed plaque characterization

Risk Stratification

1. Patient Risk Assessment:

   • High-risk features 1:
     • Decompensated heart failure (Killip Class 3)
     • LVEF ≤25%
     • Left main stenosis (≥50% diameter) or 3-vessel disease
     • Single target lesion jeopardizing ≥50% of viable myocardium

2. Lesion Risk Assessment:

   • Increased risk features 1:
     • Diffuse disease (>2 cm) with proximal tortuosity
     • Moderate-severe calcification
     • Extreme angulation (>90°)
     • Inability to protect major side branches
     • Degenerated vein grafts with friable lesions
     • Substantial thrombus

3. Procedural Risk Calculators:

   • SYNTAX score for complex CAD
   • J-CTO score for chronic total occlusions 2
   • STS score to predict surgical risk (for comparison with CABG) 1

Heart Team Approach

For complex cases, a Heart Team approach is recommended 1:

• Collaboration between interventional cardiologist and cardiac surgeon
• Review of patient's medical condition and coronary anatomy
• Determination of technical feasibility
• Discussion of revascularization options with the patient

Operator and Institutional Considerations

• Elective/urgent PCI should be performed by operators with adequate annual volume (>75 procedures) at high-volume centers (>400 procedures/year) with on-site cardiac surgery 1
• Primary PCI for STEMI should be performed by experienced operators who perform >75 elective PCI procedures per year and ideally at least 11 PCI procedures for STEMI annually 1
• Institutions should perform >400 elective PCIs per year and >36 primary PCI procedures for STEMI annually 1

Special Considerations

1. Chronic Total Occlusions (CTOs):

   • Requires specialized expertise and techniques 2
   • Four crossing strategies: antegrade wire escalation, antegrade dissection/reentry, retrograde wire escalation, retrograde dissection/reentry
   • Dual coronary angiography essential for visualization from both sides of occlusion

2. Left Main Disease:

   • Heart Team approach mandatory
   • SYNTAX score calculation essential
   • Consider CABG for complex anatomy (SYNTAX score >33) 1

3. Multivessel Disease:

   • Complete revascularization generally preferred
   • Consider CABG for patients with diabetes and multivessel disease 1

Quality Assurance

Every PCI program should operate a quality improvement program that 1:

1. Reviews quality and outcomes of the entire program
2. Reviews results of individual operators
3. Includes risk adjustment
4. Provides peer review of difficult cases
5. Performs random case reviews

Common Pitfalls to Avoid

• Oculostenotic reflex: Intervening on all visible stenoses without considering clinical relevance 3
• Inadequate lesion preparation: Especially in calcified lesions
• Underestimating contrast volume: Particularly in patients with renal impairment
• Ignoring dual antiplatelet therapy compliance: Critical for stent thrombosis prevention
• Neglecting post-PCI risk factor modification: One-third of patients still have multiple modifiable risk factors 12-18 months after PCI 4

The workup for PCI requires meticulous attention to patient selection, procedural planning, and risk assessment to ensure optimal outcomes and minimize complications.