What are the indications for percutaneous coronary intervention (PCI) in adults with coronary artery disease?

Indications for Percutaneous Coronary Intervention

PCI is indicated primarily to improve survival in ST-elevation myocardial infarction (STEMI), cardiogenic shock, and high-risk acute coronary syndromes, while in stable coronary artery disease, the primary indication is symptom relief rather than mortality reduction. 1

Acute Coronary Syndromes

ST-Elevation Myocardial Infarction (STEMI)

Primary PCI is the preferred reperfusion strategy for STEMI when it can be performed within appropriate time windows. 1

• Immediate PCI (Class I indication): Perform primary PCI in patients presenting within 12 hours of STEMI onset, with a goal of first medical contact to device time of ≤90 minutes at PCI-capable hospitals or ≤120 minutes when transfer is required 1

• Cardiogenic shock (Class I indication): Perform immediate PCI regardless of time delay in patients with severe heart failure or cardiogenic shock who are suitable revascularization candidates 1

• Contraindications to fibrinolysis (Class I indication): Perform primary PCI as soon as possible in patients with contraindications to thrombolytic therapy and ischemic symptoms <12 hours 1

• Failed fibrinolysis (Class IIa indication): Perform immediate PCI in patients with moderate-to-large area of myocardium at risk and evidence of failed fibrinolysis 1

• Post-fibrinolysis strategy (Class IIa indication): Perform angiography 3-24 hours after successful fibrinolysis in hemodynamically stable patients 1

Unstable Angina/Non-ST-Elevation Myocardial Infarction (UA/NSTEMI)

An early invasive strategy with intent to perform PCI is indicated for high-risk patients but not for low-risk stable patients. 1

• High-risk features requiring early invasive strategy (Class I indication): Refractory angina, hemodynamic instability, electrical instability, or elevated risk scores in initially stabilized patients 1

• Timing: Early angiography (≤48 hours) benefits high-risk groups; deferral of intervention does not improve outcomes 1

• Contraindication (Class III): Do not perform early invasive strategy in patients with extensive comorbidities (liver failure, pulmonary failure, cancer) where risks outweigh benefits 1

Stable Ischemic Heart Disease

In stable coronary artery disease, PCI is indicated primarily for symptom relief, not survival benefit, except in specific high-risk anatomic subsets. 1, 2

Revascularization for Survival Benefit

• Unprotected left main disease (Class I for CABG): CABG is preferred over PCI for survival benefit 1

  • PCI Class IIa: Reasonable for left main disease when SYNTAX score ≤22 (low complexity) AND surgical risk is high (STS-predicted mortality ≥5%) 1
  • PCI Class IIb: Uncertain benefit when SYNTAX score ≤33 (low-intermediate complexity) AND moderate surgical risk (STS-predicted mortality ≥2%) 1
  • PCI Class III (Harm): Do not perform PCI for left main disease with unfavorable anatomy in good surgical candidates 1

• Three-vessel disease with or without proximal LAD (Class I for CABG): CABG improves survival 1

  • CABG Class IIa over PCI: Choose CABG in patients with complex 3-vessel disease (SYNTAX score >22) who are good surgical candidates 1
  • PCI Class IIb: Uncertain survival benefit 1

• Two-vessel disease with proximal LAD (Class I for CABG): CABG improves survival 1

  • PCI Class IIb: Uncertain survival benefit 1

• Single-vessel proximal LAD disease:

  • CABG with LIMA Class IIa: Reasonable for long-term benefit 1
  • PCI Class IIb: Uncertain survival benefit 1

• Left ventricular dysfunction:

  • CABG Class IIa: Reasonable when LVEF 35-50% 1
  • CABG Class IIb: Uncertain benefit when LVEF <35% without significant left main disease 1

Revascularization for Symptom Relief

PCI is reasonable for symptom relief in stable patients with significant ischemia on objective testing. 1, 3

• Prerequisite: Document objective evidence of large ischemia (>10% of myocardium) through stress testing, FFR ≤0.80, or iFR ≤0.89 4, 3

• Symptomatic patients: PCI is appropriate for moderate-to-severe angina (CCS Class II-IV) despite optimal medical therapy with documented ischemia 4

• Asymptomatic patients (Class III - Harm): Do not perform PCI without anatomic or physiologic criteria for revascularization 1

Chronic Total Occlusions

The principal indication for CTO-PCI is symptom improvement, not survival benefit. 1

• Perform CTO-PCI in symptomatic patients with objective evidence of ischemia in the territory of the occluded vessel 1

• CTO-PCI may be considered for secondary prevention in patients with prior ventricular arrhythmias, though randomized data are lacking 1

Special Populations

Diabetic Patients with Multivessel Disease

CABG with LIMA is preferred over PCI in diabetic patients with multivessel disease for survival benefit. 1

Surgical Risk Stratification

Patient and lesion risk must be assessed before PCI, particularly at centers without on-site cardiac surgery. 1

• High patient risk: LVEF <25%, left main stenosis ≥50%, 3-vessel disease unprotected by prior bypass, or single lesion jeopardizing >50% of viable myocardium 1

• High lesion risk: Diffuse disease >2 cm, heavy calcification, extreme angulation >90°, degenerated vein grafts with friable lesions, or substantial thrombus 1

• Avoid non-emergency PCI without on-site surgery: High-risk patients with high-risk lesions should not undergo non-emergency PCI at facilities without on-site cardiac surgery 1

Common Pitfalls

• Do not perform PCI in stable patients without documented ischemia - multiple trials show no mortality benefit and potential harm 1, 2

• Do not choose PCI over CABG in diabetics with complex multivessel disease - CABG provides superior long-term outcomes 1

• Do not delay primary PCI for STEMI to achieve "door-to-balloon" times - transfer for primary PCI is superior to on-site fibrinolysis even with transport delays up to 120 minutes 1

• Do not perform PCI on non-culprit lesions during primary PCI for STEMI unless they are flow-limiting in patients with hemodynamic instability 1