What are the indications for coronary artery stenting?

Indications for Coronary Artery Stenting

Coronary artery stenting is indicated for patients with acute coronary syndromes, significant coronary artery disease causing symptoms or ischemia, and specific high-risk anatomical features that warrant revascularization to reduce mortality, morbidity, and improve quality of life. 1

Acute Coronary Syndromes

ST-Elevation Myocardial Infarction (STEMI)

• Primary PCI with stenting within 12 hours of symptom onset is a Class I recommendation 1
• Additional indications include:
  • Patients presenting to PCI-capable hospitals within 90 minutes of first medical contact 1
  • Patients presenting to non-PCI hospitals when transfer can be completed within 120 minutes 1
  • Patients with severe heart failure or cardiogenic shock regardless of time delay 1
  • Patients with contraindications to fibrinolytic therapy with ischemic symptoms <12 hours 1
  • Patients with clinical/ECG evidence of ongoing ischemia between 12-24 hours after symptom onset 1

Non-ST-Elevation ACS (NSTE-ACS)

• Early invasive strategy with stenting is indicated for high-risk NSTE-ACS patients 1
• High-risk features warranting early intervention include:
  • Elevated cardiac biomarkers (troponin)
  • Dynamic ST-segment changes
  • Recurrent angina/ischemia despite medical therapy
  • Hemodynamic instability
  • Major arrhythmias
  • Early post-infarction unstable angina
  • Diabetes mellitus 1

Stable Coronary Artery Disease

Stenting is indicated in stable coronary artery disease when:

1. Significant symptoms persist despite optimal medical therapy 1
2. Large area of myocardium at risk demonstrated by:
   • Significant ischemia on non-invasive testing
   • Proximal LAD disease with evidence of ischemia
   • Multivessel disease with reduced left ventricular function 2

Specific Anatomical Considerations

• Left main coronary artery disease: Traditionally managed with CABG, but PCI with stenting is now considered for selected patients, particularly those with high surgical risk 1
• Multivessel disease: Stenting can be considered based on anatomical complexity, comorbidities, and patient preference 1
• Saphenous vein bypass grafts: Stenting shows benefit over balloon angioplasty alone 1
• Small coronary arteries: Stenting provides better outcomes than balloon angioplasty 1

Contraindications and Cautions

Stenting is not recommended in:

• Asymptomatic patients with non-significant stenoses and no evidence of ischemia 2
• Totally occluded infarct artery >24 hours after STEMI in hemodynamically stable, asymptomatic patients 1
• Non-infarct artery during primary PCI in patients without hemodynamic compromise 1

Clinical Outcomes and Benefits

Stenting provides several advantages over balloon angioplasty alone:

• Lower rates of restenosis 3
• Reduced need for target vessel revascularization 3, 4
• Better immediate procedural success rates 3
• Larger immediate increase in luminal diameter 3

Drug-eluting stents have shown additional benefits in STEMI patients compared to bare-metal stents:

• Reduced major adverse cardiac events
• Lower rates of target vessel revascularization
• Reduced in-stent restenosis 5

Post-Stenting Management

After stent placement:

• Dual antiplatelet therapy (DAPT) is required:
  • Aspirin 75-100 mg daily indefinitely 1
  • P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) for a duration based on stent type and clinical scenario 1, 6
• For patients also requiring oral anticoagulation, careful consideration of bleeding risk is essential 1

Conclusion

The decision for coronary stenting should be based on clinical presentation, coronary anatomy, evidence of ischemia, and patient risk factors. In acute coronary syndromes, early intervention with stenting has demonstrated clear mortality and morbidity benefits, while in stable coronary disease, symptom relief and evidence of ischemia are the primary drivers for intervention.