From the Guidelines
Percutaneous coronary intervention (PCI) is indicated for several conditions beyond ST-elevation myocardial infarctions (STEMIs), including non-ST-elevation acute coronary syndromes (NSTEMI and unstable angina), stable coronary artery disease, cardiogenic shock, mechanical complications of myocardial infarction, and cardiac arrest survivors with suspected coronary etiology. The decision to perform PCI in these non-STEMI scenarios typically involves consideration of symptom burden, anatomical complexity, comorbidities, and the patient's overall risk profile 1. Some key considerations for PCI include:
- High-risk patients with positive cardiac biomarkers, dynamic ECG changes, or ongoing symptoms despite medical therapy 1
- Patients with significant ischemia on noninvasive testing or those with a large area of viable myocardium 1
- Patients with multivessel coronary disease with suitable coronary anatomy, normal LV function, and without diabetes mellitus 1
- Patients with significant left main CAD (greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG or who require emergent intervention at angiography for hemodynamic instability 1 It is essential to weigh the benefits and risks of PCI, considering factors such as the patient's overall health, the severity of their condition, and the potential for improvement in quality of life 1. In general, PCI is recommended for patients with UA/NSTEMI who have no serious comorbidity and who have coronary lesions amenable to PCI and any of the high-risk features listed in Section 3.3 of the guidelines 1. However, PCI is not recommended for patients with 1- or 2-vessel CAD without significant proximal left anterior descending CAD with no current symptoms or symptoms that are unlikely to be due to myocardial ischemia and who have no ischemia on noninvasive testing 1. Ultimately, the decision to perform PCI should be individualized and based on a thorough evaluation of the patient's condition and the potential benefits and risks of the procedure 1.
From the Research
Reasons for PCI other than STEMIs
- Other reasons for PCI include:
- Stable ischemic heart disease, where PCI may be performed to relieve symptoms and improve quality of life, although its efficacy in reducing mortality or preventing myocardial infarction is uncertain 2
- Multivessel disease, where PCI may be performed on non-culprit lesions in addition to the culprit lesion, with the goal of reducing cardiovascular events and improving outcomes 3, 4
- High-risk non-STEMI patients, where PCI may be performed as an emergency procedure to reduce the risk of death or myocardial infarction 5
- Factors associated with ineligibility for PCI differ between inpatient and outpatient STEMIs, with inpatients being less likely to receive coronary angiography or PCI due to increased risks of bleeding, and outpatients being more likely to have complex coronary artery disease as a contraindication for PCI 6
Specific Indications for PCI
- PCI may be indicated for patients with stable ischemic heart disease who have:
- Significant ischemia or symptoms despite optimal medical therapy
- Complex coronary anatomy, such as bifurcation lesions or heavy calcification
- High-risk features, such as left ventricular dysfunction or diabetes
- PCI may also be indicated for patients with multivessel disease, where complete revascularization may be beneficial in reducing cardiovascular events and improving outcomes 3, 4
Controversies and Uncertainties
- The role of PCI in stable ischemic heart disease is still uncertain, with some studies suggesting that it may not reduce mortality or prevent myocardial infarction, while others suggest that it may improve quality of life and reduce symptoms 2
- The optimal approach to multivessel disease in the context of acute myocardial infarction is still debated, with some studies suggesting that complete revascularization may be beneficial, while others suggest that culprit-only PCI may be sufficient 3, 4