What are the indications for coronary stenting?

Indications for Coronary Stenting

Coronary stenting is indicated for patients with acute coronary syndromes (both STEMI and NSTE-ACS), stable coronary artery disease with objective evidence of significant ischemia, and selected cases of unprotected left main disease when surgery carries prohibitive risk.

Acute Coronary Syndromes

ST-Elevation Myocardial Infarction (STEMI)

• Primary PCI with stenting is the preferred reperfusion strategy for STEMI when performed by experienced operators with short door-to-balloon times 1
• Stenting should be directed only at the culprit vessel during the acute phase; decisions about non-culprit lesions should be guided by objective evidence of residual ischemia at later follow-up 1
• Primary PCI is superior to thrombolysis beyond 3 hours from symptom onset for myocardial salvage and stroke prevention 1
• Within the first 3 hours, thrombolysis remains a viable alternative if PCI cannot be performed rapidly, though PCI is preferred for stroke prevention 1

Non-ST-Elevation Acute Coronary Syndromes (NSTE-ACS)

High-risk patients with NSTE-ACS (unstable angina or NSTEMI) should undergo coronary angiography within 48 hours with routine stenting of culprit lesions 1

High-risk features requiring early invasive strategy include 1:

• Recurrent resting angina despite medical therapy

• Dynamic ST-segment changes (≥0.1 mV depression or transient elevation)

• Elevated troponin levels

• Hemodynamic instability

• Major ventricular arrhythmias

• Early post-infarction unstable angina

• Diabetes mellitus

• Routine stenting is recommended in de novo lesions of high-risk NSTE-ACS patients based on predictability of results and immediate safety 1

• Deferral of intervention does not improve outcomes in high-risk NSTE-ACS 1

• Combined antiplatelet therapy (aspirin plus P2Y12 inhibitor) is superior to anticoagulation alone for preventing stent thrombosis 2, 3

Stable Coronary Artery Disease

PCI with stenting is indicated for stable CAD patients with objective evidence of large ischemia on noninvasive testing, particularly when:

• Significant left ventricular dysfunction is present (ejection fraction <0.40) 1
• Large anterior or multiple perfusion defects exist 1
• High-risk Duke treadmill score (≤-11) 1
• Symptoms persist despite optimal medical therapy 1

Stenting provides superior outcomes compared to balloon angioplasty alone, with reduced restenosis rates and lower need for repeat revascularization 1, 4

Anatomic Considerations

Left Main Coronary Artery Disease

• Unprotected left main stenting should be considered only when CABG carries very high perioperative risk (e.g., EuroSCORE >10) 1
• In NSTE-ACS patients, PCI of culprit unprotected left main lesions is an option if the patient is not a CABG candidate 1
• Drug-eluting stents show promising results in left main disease 1
• Stenting can be performed safely via transradial approach with mechanical support (IABP) for critical patients 5

Multivessel Disease

• In diabetic patients with multivessel disease, CABG should be preferred over PCI when feasible 1
• For NSTE-ACS, culprit lesion-only PCI is generally recommended, though multivessel PCI may be reasonable in selected cases 1
• Decisions about treating non-culprit lesions should be based on fractional flow reserve or objective ischemia testing 6

Post-Stenting Management

Dual antiplatelet therapy (DAPT) is mandatory following stent implantation 1:

• Aspirin 75-100 mg daily indefinitely 1
• Clopidogrel 75 mg daily for minimum 6 months after stenting, regardless of stent type 1
• Shorter DAPT duration (1-3 months) may be indicated if life-threatening bleeding risk exists 1
• Ticagrelor or prasugrel are reasonable alternatives to clopidogrel in ACS patients 1

For patients requiring oral anticoagulation:

• Triple therapy (aspirin + clopidogrel + OAC) should be kept as short as possible, typically 1 month 1
• Dual therapy (clopidogrel + OAC) should be considered after 1 month if bleeding risk outweighs ischemic risk 1
• NOACs are preferred over warfarin when not contraindicated 1
• Proton pump inhibitors are recommended for gastrointestinal bleeding prophylaxis 1

Common Pitfalls

• Avoid routine multivessel PCI during primary PCI for STEMI—treat only the culprit vessel acutely 1
• Do not use thrombolytic therapy in NSTE-ACS—it increases mortality compared to conservative or invasive strategies 1
• Avoid prasugrel or ticagrelor in triple antithrombotic therapy—use clopidogrel as the P2Y12 inhibitor of choice 1
• Anticoagulation therapy after stenting is inferior to dual antiplatelet therapy and increases stent thrombosis risk 2, 3