What are the recommendations for patients undergoing Percutaneous Coronary Intervention (PCI)?

Recommendations for Percutaneous Coronary Intervention (PCI)

Primary Indications by Clinical Presentation

ST-Elevation Myocardial Infarction (STEMI)

Primary PCI is the preferred reperfusion strategy for STEMI patients when performed by an experienced team with door-to-balloon time ≤90 minutes. 1

Timing-Based Strategy:

• Within 3 hours of symptom onset: Primary PCI is preferred over thrombolysis primarily to prevent stroke, though both strategies show similar efficacy for reducing infarct size and mortality 1
• 3-12 hours after symptom onset: Primary PCI is strongly superior to thrombolysis for myocardial salvage and stroke prevention 1
• Beyond 12 hours: Primary PCI remains beneficial even with longer delays 1

Absolute Class I Indications for Immediate PCI:

• Candidates for primary PCI presenting with STEMI 1
• Cardiogenic shock or severe heart failure if suitable for revascularization 1
• Contraindications to thrombolysis 1

Post-Thrombolysis Management:

• Rescue PCI is recommended if thrombolysis fails within 45-60 minutes 1
• Routine coronary angiography within 3-24 hours after successful thrombolysis is reasonable, even in asymptomatic patients without demonstrable ischemia 1

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

Early invasive strategy with angiography ≤48 hours and PCI when appropriate shows clear benefit only in high-risk patients. 1, 2

High-risk features warranting early PCI include:

• Elevated cardiac biomarkers 1
• Hemodynamic instability 1
• Recurrent ischemia despite medical therapy 1
• Serious ventricular arrhythmias 1

Stable Coronary Artery Disease

For CCS Class III angina (marked limitation of ordinary physical activity), PCI is reasonable when:

• Single-vessel or multivessel disease with ≥1 significant lesions (>70% stenosis) suitable for PCI with high likelihood of success and low risk 1
• Focal saphenous vein graft lesions in poor surgical candidates 1
• Significant left main disease (>50% stenosis) in patients ineligible for CABG 1

For asymptomatic ischemia or CCS Class I-II angina, PCI may be considered when:

• Objective evidence of large ischemia is present 2
• Unacceptable angina persists despite guideline-directed medical therapy 2
• Medical therapy cannot be implemented due to contraindications, adverse effects, or patient preferences 2

Critical Contraindications and Limitations

PCI should NOT be performed in the following scenarios:

• Patients with significant left main disease who are candidates for CABG 1, 2
• Complex 3-vessel disease (SYNTAX score >22) with or without proximal LAD involvement—CABG improves survival 2
• Multivessel disease with diabetes mellitus (CABG generally preferred, especially with LIMA to LAD) 2
• Insignificant disease (<50% left main or <70% non-left main stenosis) 2
• Only small area of viable myocardium at risk 1
• No objective evidence of ischemia 1
• Risks of revascularization outweigh benefits 1
• Patient unable to tolerate or comply with dual antiplatelet therapy for appropriate duration 2

Risk Stratification for Surgical Backup

High-risk patients (any of the following): 1

• LVEF ≤25%
• Left main stenosis ≥50% or unprotected 3-vessel disease (≥70% proximal stenoses)
• Single lesion jeopardizing ≥50% of remaining viable myocardium
• Decompensated CHF (Killip Class 3), recent CVA, advanced malignancy, or clotting disorders

High-risk lesions (any of the following): 1

• Diffuse disease (≥2 cm length) with excessive proximal tortuosity
• More than moderate calcification
• Extremely angulated segments (≥90°)
• Inability to protect major side branches
• Degenerated vein grafts with friable lesions
• Substantial thrombus present

Surgical backup requirements: 1

• High-risk patients with high-risk lesions should NOT undergo nonemergency PCI at facilities without on-site surgery
• High-risk patients with non-high-risk lesions require immediate availability of cardiac surgeon and operating room
• Non-high-risk patients require no additional precautions regardless of lesion complexity

Essential Procedural Considerations

Stenting approach:

• Routine stenting is recommended during primary PCI for STEMI 1
• In multivessel disease during primary PCI, target only the culprit vessel; decisions about non-culprit lesions should be guided by objective evidence of residual ischemia at follow-up 1, 2

Adjunctive pharmacotherapy:

• All patients with coronary stents require aspirin plus clopidogrel (dual antiplatelet therapy) 3
• Intracoronary nitroglycerin bolus is recommended to unmask vasospastic reactions 1
• For no-reflow phenomenon, adenosine, verapamil, or nitroprusside are reasonable options 1

Operator and facility requirements:

• Primary PCI requires higher experience levels and patient volumes than PCI for stable CAD 1, 2
• Experienced teams with established interventional programs should perform STEMI PCI 1

Common Pitfalls to Avoid

The most critical error is recommending PCI over CABG in patients with complex multivessel disease and diabetes—this directly impacts survival. 2 Studies demonstrate that catheterization laboratory cardiologists frequently over-recommend PCI and under-recommend CABG compared to guideline indications, particularly when PCI capability exists at their institution 4

Do not perform PCI without confirming:

• Patient can tolerate dual antiplatelet therapy for the required duration 2
• Anatomic (stenosis severity) or physiological criteria for revascularization are met 2
• Objective evidence of ischemia exists in stable patients 1, 2

Timing errors to avoid:

• Delaying primary PCI beyond 90 minutes from first medical contact when feasible 1
• Choosing thrombolysis over primary PCI when substantial PCI delays (>2-3 hours) are NOT anticipated 1
• Failing to perform rescue PCI when thrombolysis clearly fails within 45-60 minutes 1