When is percutaneous coronary intervention (PCI) not used in patients with coronary artery disease?

When PCI is Not Used in Coronary Artery Disease

PCI should not be performed in stable patients without objective evidence of ischemia, those with insignificant stenosis (<50%), patients with only small areas of myocardium at risk, or when lesion morphology suggests low likelihood of success. 1

Absolute Contraindications (Class III - Do Not Perform)

In Stable Coronary Disease

• No objective evidence of ischemia on noninvasive testing - PCI provides no benefit when ischemia cannot be documented, regardless of angiographic appearance 1
• Insignificant disease (<50% coronary stenosis) - These lesions do not warrant intervention 1
• Only small area of viable myocardium at risk - The procedural risk outweighs any potential benefit 1
• Lesions with low likelihood of successful dilatation - Unfavorable morphology predicts poor outcomes 1
• High risk of procedure-related morbidity or mortality - When procedural risks exceed potential benefits 1
• Significant left main disease (>50% stenosis) when patient is a CABG candidate - CABG provides superior outcomes in this population 1
• Mild symptoms unlikely due to myocardial ischemia - PCI will not relieve non-ischemic chest pain 1

In STEMI Patients

• Totally occluded infarct artery >24 hours after STEMI in asymptomatic, hemodynamically stable patients with 1- or 2-vessel disease and no severe ischemia - Multiple trials demonstrate no benefit beyond optimal medical therapy 1
• Noninfarct artery PCI at time of primary PCI in hemodynamically stable patients - This approach causes harm and worsens clinical outcomes unless the patient is in cardiogenic shock 1

Before Noncardiac Surgery

• Routine prophylactic coronary revascularization in stable CAD patients - This strategy does not improve perioperative outcomes 1

Clinical Scenarios Where PCI Should Be Avoided

Asymptomatic or Minimal Symptoms

PCI is not recommended for asymptomatic ischemia or CCS Class I-II angina unless specific high-risk criteria are met 1:

• Non-proximal LAD disease with only small myocardial territory at risk
• Absence of documented ischemia on stress testing
• Patients who have not attempted medical therapy optimization

The ACC/AHA guidelines explicitly state that for patients with 1- or 2-vessel CAD without significant proximal LAD involvement, PCI provides no mortality or MI benefit and should not be performed without symptoms or objective ischemia 1, 2

Stable Multivessel Disease Considerations

Three-vessel disease with significant left main stenosis requires CABG, not PCI 1, 3. The survival benefit of CABG is particularly pronounced in patients with:

• Abnormal LV function (LVEF <0.50) 1, 3
• Diabetes mellitus 3
• Complex anatomy (SYNTAX score >22) 3

Post-MI Late Presentation

Do not open chronically occluded infarct arteries in stable post-MI patients 1. The "late open artery hypothesis" lacks supporting evidence - trials consistently show no benefit in:

• LV function preservation
• Prevention of subsequent cardiovascular events
• Mortality reduction

This applies specifically to patients who are asymptomatic, hemodynamically stable, electrically stable, and lack severe inducible ischemia 1

Timing Contraindications

STEMI Time Windows

Hospitals unable to achieve first medical contact-to-device time of ≤120 minutes for transfer patients should use fibrinolytic therapy instead of PCI 1. While the goal remains <90 minutes for direct admissions, systems that cannot meet these benchmarks have worse outcomes with delayed PCI 1

Perioperative Period

Elective noncardiac surgery must not be performed within specific timeframes after PCI 1:

• 4-6 weeks after balloon angioplasty or bare metal stent
• 12 months after drug-eluting stent implantation

These restrictions exist because premature discontinuation of dual antiplatelet therapy dramatically increases stent thrombosis risk, which carries catastrophic consequences including MI and death 1

Special Populations

Patients Requiring Anticoagulation or with High Bleeding Risk

Balloon angioplasty or bare metal stents should be used instead of drug-eluting stents when 1:

• High bleeding risk exists
• Patient cannot comply with 12 months of dual antiplatelet therapy
• Anticipated invasive or surgical procedures within 12 months will require DAPT interruption

Patients with Prior GI Bleeding

While not an absolute contraindication to PCI, extreme caution is warranted 4. If PCI is necessary:

• Shorten DAPT duration to 1-3 months with drug-eluting stents 4
• Use clopidogrel rather than ticagrelor or prasugrel 4
• Mandatory PPI co-prescription 4

Common Clinical Pitfalls

Never assume angiographic stenosis severity alone justifies PCI - The presence of a stenosis does not prove it causes the patient's symptoms 5, 6. Objective ischemia documentation is mandatory 1

Avoid PCI in diabetic patients with three-vessel disease unless absolutely not CABG candidates - CABG provides superior survival benefit in this population 3

Do not perform multivessel PCI during primary STEMI intervention in stable patients - This increases mortality; treat only the culprit vessel unless cardiogenic shock is present 1

Never proceed without discussing DAPT duration and compliance before DES implantation - Premature DAPT discontinuation causes stent thrombosis with potentially fatal consequences 1

Evidence Strength Considerations

The prohibition against PCI in stable patients without objective ischemia is supported by multiple randomized trials showing no mortality or MI reduction compared to optimal medical therapy alone 7, 5, 6. The COURAGE trial and subsequent analyses demonstrate that PCI's primary benefit in stable CAD is symptom relief, not prognostic improvement 7, 5

For late opening of occluded infarct arteries, the evidence is particularly strong - trials specifically designed to test this strategy (OAT trial) showed no benefit in preserving LV function or preventing cardiovascular events when performed 1-28 days post-MI in stable patients 1