What is the role of Percutaneous Coronary Intervention (PCI) in treating coronary artery disease?

Role of Percutaneous Coronary Intervention (PCI) in Treating Coronary Artery Disease

PCI is a valuable treatment option for coronary artery disease that improves symptoms in patients with significant coronary stenosis but has limited impact on mortality except in specific high-risk scenarios. 1

Indications for PCI

Stable Coronary Artery Disease

• PCI can be considered a valuable initial mode of revascularization in patients with stable CAD who have objective evidence of large ischemia in the presence of almost any lesion subset, except chronic total occlusions that cannot be crossed 1
• PCI is beneficial for symptom improvement in patients with one or more significant (>70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite guideline-directed medical therapy 1
• PCI is reasonable for symptom relief in patients with significant stenoses and unacceptable angina when medical therapy cannot be implemented due to contraindications, adverse effects, or patient preferences 1

Acute Coronary Syndromes

• In patients with non-ST-elevation acute coronary syndromes (NSTE-ACS), early angiography (≤48 hours) and, when needed, PCI shows clear benefit only in high-risk groups 1
• For ST-elevation myocardial infarction (STEMI), primary PCI is the treatment of choice in patients presenting to hospitals with PCI facilities and experienced teams 1
• Primary PCI is superior to thrombolysis for STEMI treatment, with better outcomes including lower rates of death, non-fatal reinfarction, stroke, and recurrent ischemia 1

Comparison with CABG

• CABG is reasonable over PCI to improve survival in patients with complex 3-vessel CAD (e.g., SYNTAX score >22) with or without involvement of the proximal LAD artery 1
• CABG is generally preferred over PCI for patients with multivessel CAD and diabetes mellitus, particularly if a left internal mammary artery graft can be anastomosed to the LAD artery 1
• PCI should not be performed in patients with significant left main coronary artery disease who are candidates for CABG 1
• Recent long-term results from trials like SYNTAX, ASCERT, and FREEDOM showed significantly better survival rates after CABG than after PCI, especially in patients with diabetes and/or complex left main or three-vessel disease 1

Outcomes and Benefits of PCI

Symptom Relief

• The main purpose of PCI in stable CAD is to relieve angina symptoms 2
• In the COURAGE trial, patients randomized to PCI had small but significant benefits in terms of less angina frequency, better physical functional status, and better quality of life over 6-24 months after randomization, though health status outcomes were equivalent at 36 months 1

Mortality and Morbidity

• PCI does not reduce mortality in stable CAD patients 2, 3
• In patients with chronic coronary syndrome, a recent propensity score-matched analysis from the Swedish Coronary Angiography and Angioplasty Registry showed that PCI was associated with lower rates of myocardial infarction, urgent revascularization, and cardiovascular mortality compared to medical therapy alone, though no difference was observed for all-cause mortality 4
• The relationship between ACC/AHA guideline-recommended indications for PCI and outcomes has been demonstrated, with clinical success declining across indication classes (Class I: 92.8%, Class IIa: 91.7%, Class IIb: 89%, and Class III: 85.5%) 1

Special Considerations

Post-Thrombolysis Management

• After successful thrombolysis, routine coronary angiography within 24 hours and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischemia to improve outcomes 1

Procedural Aspects

• PCI should not be performed if the patient is not likely to tolerate and comply with dual antiplatelet therapy for the appropriate duration based on the type of stent implanted 1
• For primary PCI, a higher level of experience and patient volume is required than for PCI in patients with stable CAD 1
• In patients with multi-vessel disease, primary PCI should be directed only at the infarct-related coronary artery (culprit vessel), with decisions about PCI of non-culprit lesions guided by objective evidence of residual ischemia at later follow-up 1

Limitations and Caveats

• PCI should not be performed in patients who do not meet anatomic (>50% left main or >70% non-left main stenosis) or physiological criteria for revascularization 1
• For stenotic lesions without evidence of ischemia, the benefit of revascularization is less clear, and medical therapy alone may be equally effective 5
• The usefulness of PCI to improve survival is uncertain in patients with 2- or 3-vessel CAD (with or without involvement of the proximal LAD artery) or 1-vessel proximal LAD disease 1
• Patients undergoing PCI require careful management before, during, and after the procedure, including appropriate antiplatelet therapy and monitoring for complications such as contrast nephropathy, groin complications, and restenosis 6