In a homeless patient presenting with atrial fibrillation with rapid ventricular response, decompensated heart failure, low ejection fraction, and angiographically significant proximal right coronary artery disease, is it appropriate to defer urgent percutaneous coronary intervention to assess medication compliance, and what is the recommended management and documentation for such patients?

Management of Proximal RCA Disease in a Homeless Patient with Decompensated Heart Failure

Deferring PCI based solely on medication compliance concerns in a homeless patient with decompensated heart failure, reduced ejection fraction, and significant proximal RCA disease is not appropriate—revascularization should proceed based on clinical indications, not social circumstances.

Clinical Indications for PCI in This Patient

Your patient meets multiple Class I and Class IIa guideline criteria for proceeding with PCI:

• Class IIa recommendation: PCI is reasonable in patients with LV ejection fraction ≤0.40, heart failure, or serious ventricular arrhythmias 1
• Class IIa recommendation: PCI is reasonable when documented clinical heart failure occurred during the acute episode, even with preserved function 1
• Class I recommendation: In patients whose anatomy is suitable, PCI should be performed for cardiogenic shock or hemodynamic instability 1

The ACC/AHA guidelines explicitly state that patients with heart failure and reduced ejection fraction presenting with significant coronary disease should undergo coronary angiography and revascularization assessment, as this population derives mortality benefit from appropriate revascularization 2.

Why "Prove Compliance First" is Problematic

The staged approach to "prove compliance" creates several critical issues:

• Increased mortality risk: Delaying revascularization in a patient with decompensated heart failure and reduced EF exposes them to ongoing ischemia, progressive ventricular dysfunction, and risk of sudden cardiac death 1, 2
• Logistical impossibility: As you correctly identified, expecting a homeless patient to maintain outpatient medication compliance, attend follow-up appointments, and then return for elective PCI is unrealistic and sets up failure 3
• Guideline contradiction: The guidelines support proceeding with PCI in patients with suitable anatomy when heart failure and reduced EF are present—there is no recommendation to defer based on social circumstances 1

Recommended Management Approach

Immediate Revascularization Strategy

Proceed with PCI during the index hospitalization based on the following algorithm:

• Assess hemodynamic stability: If the patient has cardiogenic shock or hemodynamic instability, PCI is a Class I indication and should be performed urgently 1
• Evaluate ischemic burden: With decompensated heart failure, reduced EF, and proximal RCA disease, the patient has high-risk anatomy warranting revascularization 1, 2
• Consider complete revascularization: If multivessel disease is present, determine whether PCI or CABG is more appropriate based on SYNTAX score and surgical risk 1

Addressing the Homeless Population

Documentation and discharge planning should focus on realistic, harm-reduction strategies:

• Initiate guideline-directed medical therapy (GDMT) in-hospital: Start ACE inhibitor/ARB, beta-blocker, aldosterone antagonist, and diuretics before discharge 2
• Provide extended medication supply: Give 90-day prescriptions or arrange pharmacy delivery to shelters 2
• Coordinate with social services: Connect with homeless outreach programs, case management, and community health centers for follow-up 2
• Simplify antiplatelet regimen: After bare metal stent, clopidogrel is required for minimum 1 month; consider this when selecting stent type 1
• Document barriers to care: Note homelessness as a social determinant of health affecting follow-up, but do not use it to deny indicated treatment 3

Antiplatelet and Anticoagulation Management

Given the patient has atrial fibrillation with RVR:

• Triple therapy duration: If stenting is performed, use aspirin + clopidogrel + anticoagulation for limited time (1 month for bare metal stent) 1
• Transition to dual therapy: After 1 month, continue clopidogrel + anticoagulation (preferably NOAC over warfarin given compliance concerns) 1
• Long-term anticoagulation: Maintain anticoagulation lifelong for stroke prevention in atrial fibrillation 1
• Prefer radial access: Use radial artery access for PCI to reduce bleeding complications 1

Rate Control for AFib with RVR

Beta-blockers are preferred over calcium channel blockers in heart failure with reduced ejection fraction:

• Metoprolol is the preferred agent: IV metoprolol achieves similar rate control to diltiazem but with lower risk of worsening heart failure symptoms 4, 5
• Avoid diltiazem in HFrEF: Diltiazem has negative inotropic effects and is associated with increased oxygen requirements and need for inotropic support in HFrEF patients 5, 6
• Consider cardioversion: If hemodynamically unstable with AFib and RVR, immediate cardioversion is Class I recommendation 1

Common Pitfalls to Avoid

• Do not withhold indicated revascularization based on social circumstances: This constitutes a form of bias and denies evidence-based care 1, 3
• Do not assume non-compliance: Many homeless patients are highly motivated to improve their health when given appropriate support 3
• Do not use warfarin as first-line anticoagulation: NOACs have better safety profiles and do not require INR monitoring, making them more suitable for patients with limited healthcare access 1
• Do not delay ICD evaluation: If LVEF remains ≤35% after ≥3 months of optimal medical therapy, ICD placement should be considered 2

Evidence Quality Considerations

The recommendations prioritize ACC/AHA Class I and IIa guidelines from multiple consensus statements 1. The specific guidance on coronary angiography in ischemic cardiomyopathy from Praxis Medical Insights synthesizes these guidelines and emphasizes that immediate coronary angiography is recommended for patients with symptomatic heart failure with reduced ejection fraction and regional wall motion abnormality 2. While no randomized trials specifically address homeless populations, the consensus statement from SCAI on ad hoc PCI supports proceeding with intervention when clinically indicated rather than staging based on non-clinical factors 3.