Percutaneous coronary intervention (PCI): Difference between revisions

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that do not provide onsite cardiac surgery. (Level of
that do not provide onsite cardiac surgery. (Level of
Evidence: C)*
Evidence: C)*
==CAD Revascularization: Recommendations [http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf]==
===Heart Team Approach to Revascularization Decisions===
{{cquote|
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]====
'''1.''' A Heart Team approach to revascularization is recommended in patients with [[PCI in the unprotected left main patient|unprotected left main]] or [[CAD|complex CAD]].<ref name="pmid10859284">Feit F, Brooks MM, Sopko G, Keller NM, Rosen A, Krone R et al. (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10859284 Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators.] ''Circulation'' 101 (24):2795-802. PMID: [http://pubmed.gov/10859284 10859284]</ref><ref name="pmid9185632">King SB, Barnhart HX, Kosinski AS, Weintraub WS, Lembo NJ, Petersen JY et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9185632 Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes. Emory Angioplasty versus Surgery Trial Investigators.] ''Am J Cardiol'' 79 (11):1453-9. PMID: [http://pubmed.gov/9185632 9185632]</ref><ref name="pmid19228612">Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19228612 Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.] ''N Engl J Med'' 360 (10):961-72. [http://dx.doi.org/10.1056/NEJMoa0804626 DOI:10.1056/NEJMoa0804626] PMID: [http://pubmed.gov/19228612 19228612]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]====
'''1.''' Calculation of the Society of Thoracic Surgeons and [[SYNTAX]] ([[SYNTAX|Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery]]) scores is reasonable in patients with [[PCI in the unprotected left main patient|unprotected left main]] and [[CAD|complex CAD]].<ref name="pmid19228612">Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19228612 Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.] ''N Engl J Med'' 360 (10):961-72. [http://dx.doi.org/10.1056/NEJMoa0804626 DOI:10.1056/NEJMoa0804626] PMID: [http://pubmed.gov/19228612 19228612]</ref><ref name="pmid21256999">Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21256999 Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.] ''Am J Cardiol'' 107 (3):360-6. [http://dx.doi.org/10.1016/j.amjcard.2010.09.029 DOI:10.1016/j.amjcard.2010.09.029] PMID: [http://pubmed.gov/21256999 21256999]</ref><ref name="pmid11573040">Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson TB, Dziuban SW et al. (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11573040 A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases.] ''Ann Surg'' 234 (4):464-72; discussion 472-4. PMID: [http://pubmed.gov/11573040 11573040]</ref><ref name="pmid20630454">Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20630454 Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization.] ''JACC Cardiovasc Interv'' 3 (6):612-23. [http://dx.doi.org/10.1016/j.jcin.2010.04.004 DOI:10.1016/j.jcin.2010.04.004] PMID: [http://pubmed.gov/20630454 20630454]</ref><ref name="pmid20530001">Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20530001 Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial.] ''Circulation'' 121 (24):2645-53. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.899211 DOI:10.1161/CIRCULATIONAHA.109.899211] PMID: [http://pubmed.gov/20530001 20530001]</ref><ref name="pmid19559822">Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19559822 The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery.] ''Ann Thorac Surg'' 88 (1 Suppl):S2-22. [http://dx.doi.org/10.1016/j.athoracsur.2009.05.053 DOI:10.1016/j.athoracsur.2009.05.053] PMID: [http://pubmed.gov/19559822 19559822]</ref><ref name="pmid20022608">Shahian DM, O'Brien SM, Normand SL, Peterson ED, Edwards FH (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20022608 Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score.] ''J Thorac Cardiovasc Surg'' 139 (2):273-82. [http://dx.doi.org/10.1016/j.jtcvs.2009.09.007 DOI:10.1016/j.jtcvs.2009.09.007] PMID: [http://pubmed.gov/20022608 20022608]</ref><ref name="pmid17954059">Welke KF, Peterson ED, Vaughan-Sarrazin MS, O'Brien SM, Rosenthal GE, Shook GJ et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17954059 Comparison of cardiac surgery volumes and mortality rates between the Society of Thoracic Surgeons and Medicare databases from 1993 through 2001.] ''Ann Thorac Surg'' 84 (5):1538-46. [http://dx.doi.org/10.1016/j.athoracsur.2007.06.022 DOI:10.1016/j.athoracsur.2007.06.022] PMID: [http://pubmed.gov/17954059 17954059]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''}}


==Procedural Considerations: Recommendations [http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf]==
==Procedural Considerations: Recommendations [http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf]==
===Vascular Access===
===Vascular Access===
{{cquote|
{{cquote|

Revision as of 15:32, 1 December 2011

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Epidemiology and Demographics

  • Approximately 850,000 PCIs are performed each year in the United States.

Imaging Studies During PCI

Intravascular Ultrasound Imaging:

  • Class IIa

IVUS is reasonable for the following: a. Assessment of the adequacy of deployment of coronary stents, including the extent of stent apposition and determination of the minimum luminal diameter within the stent. (Level of Evidence: B) b. Determination of the mechanism of stent restenosis (inadequate expansion versus neointimal proliferation) and to enable selection of appropriate therapy (vascular brachytherapy versus repeat balloon expansion). (Level of Evidence: B) c. Evaluation of coronary obstruction at a location difficult to image by angiography in a patient with a suspected flow-limiting stenosis. (Level of Evidence: C) d. Assessment of a suboptimal angiographic result after PCI. (Level of Evidence: C) e. Establishment of the presence and distribution of coronary calcium in patients for whom adjunctive rotational atherectomy is contemplated. (Level of Evidence: C) f. Determination of plaque location and circumferential distribution for guidance of directional coronary atherectomy. (Level of Evidence: B)

  • Class IIb

IVUS may be considered for the following: a. Determination of the extent of atherosclerosis in patients with characteristic anginal symptoms and a positive functional study with no focal stenoses or mild CAD on angiography. (Level of Evidence: C) b. Preinterventional assessment of lesional characteristics and vessel dimensions as a means to select an optimal revascularization device. (Level of Evidence: C) c. Diagnosis of coronary disease after cardiac transplantation. (Level of Evidence: C)

  • Class III

IVUS is not recommended when the angiographic diagnosis is clear and no interventional treatment is planned. (Level of Evidence: C)

Coronary Artery Pressure and Flow: Use of Fractional Flow Reserve and Coronary Vasodilatory Reserve[1]:

  • Class IIa

Coronary pressure (fractional flow reserve [FFR]) or Doppler velocimetry can be useful to determine whether PCI of a specific coronary lesion is warranted. FFR or Doppler velocimetry can also be useful as an alternative to performing noninvasive functional testing (e.g., when the functional study is absent or ambiguous) to determine whether an intervention is warranted. It is reasonable to use intracoronary physiological measurements (coronary pressure (FFR) (Level of Evidence: A) or Doppler velocimetry (Level of Evidence: C)) in the assessment of the effects of intermediate coronary stenoses (30% to 70% luminal narrowing) in patients with anginal symptoms.

  • Class IIb

1. Intracoronary physiologic measurements may be considered for the evaluation of the success of PCI in restoring flow reserve and to predict the risk of restenosis. (Level of Evidence: C) 2. Intracoronary physiologic measurements may be considered for the evaluation of patients with anginal symptoms without an apparent angiographic culprit lesion. (Level of Evidence: C)

  • Class III

Routine assessment with intracoronary physiological measurements such as coronary pressure (FFR) or Doppler ultrasound to assess the severity of angiographic disease in concordant vascular distribution in patients with angina and a positive, unequivocal noninvasive functional study is not recommended. (Level of Evidence: C)

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention [3]

Classification of Recommendations:

“
  • Class I: Benefit >>> Risk
  • Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.
  • Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
  • Class IIa: Benefit >> Risk
  • Weight of evidence/opinion is in favor of usefulness/efficacy.
  • Class IIb: Benefit ≥ Risk
  • Usefulness/efficacy is less well established by evidence/opinion.
  • Class III: Risk ≥ Benefit
  • Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.
 ”

Level of Evidence:

“
  • Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.
  • Level of Evidence B: Data derived from a single randomized trial, or nonrandomized studies.
  • Level of Evidence C: Only consensus opinion of experts,case studies, or standard-of-care.
 ”

Institutional and Operator Competency

Quality Assurance

  • Class I

1. An institution that performs PCI should establish an ongoing mechanism for valid peer review of its quality and outcomes. Review should be conducted both at the level of the entire program and at the level of the individual practitioner. Quality-assessment reviews should take risk adjustment, statistical power, and national benchmark statistics into consideration. Quality-assessment reviews should include both tabulation of adverse event rates for comparison with benchmark values and case review of complicated procedures and some uncomplicated procedures. (Level of Evidence: C) 2. An institution that performs PCI should participate in a recognized PCI data registry for the purpose of benchmarking its outcomes against current national norms. (Level of Evidence: C)

Operator and Institutional Volume

  • Class I

1. Elective PCI should be performed by operators with acceptable annual volume (at least 75 procedures) at high-volume centers (more than 400 procedures) with onsite cardiac surgery (310,312). (Level of Evidence: B) 2. Elective PCI should be performed by operators and institutions whose historical and current risk-adjusted outcomes statistics are comparable to those reported in contemporary national data registries. (Level of Evidence: C) 3. Primary PCI for STEMI should be performed by experienced operators who perform more than 75 elective PCI procedures per year and, ideally, at least 11 PCI procedures for STEMI per year. Ideally, these procedures should be performed in institutions that perform more than 400 elective PCIs per year and more than 36 primary PCI procedures for STEMI per year. (Level of Evidence B)

  • Class IIa

1. It is reasonable that operators with acceptable volume (at least 75 PCI procedures per year) perform PCI at low-volume centers (200 to 400 PCI procedures per year) with onsite cardiac surgery (310,312). (Level of Evidence: B) 2. It is reasonable that low-volume operators (fewer than 75 PCI procedures per year) perform PCI at high-volume centers (more than 400 PCI procedures per year) with onsite cardiac surgery (310,312). Ideally, operators with an annual procedure volume less than 75 should only work at institutions with an activity level of more than 600 procedures per year. Operators who perform fewer than 75 procedures per year should develop a defined mentoring relationship with a highly experienced operator who has an annual procedural volume of at least 150 procedures per year. (Level of Evidence: B)

  • Class IIb

The benefit of primary PCI for STEMI patients eligible for fibrinolysis when performed by an operator who performs fewer than 75 procedures per year (or fewer than 11 PCIs for STEMI per year) is not well established. (Level of Evidence: C)

  • Class III

It is not recommended that elective PCI be performed by low-volume operators (fewer than 75 procedures per year) at low-volume centers (200 to 400) with or without onsite cardiac surgery (310,312). An institution with a volume of fewer than 200 procedures per year, unless in a region that is underserved because of geography, should carefully consider whether it should continue to offer this service. (Level of Evidence: B)

Role of Onsite Surgical Backup

  • Class I

1. Elective PCI should be performed by operators with acceptable annual volume (at least 75 procedures per year) at high-volume centers (more than 400 procedures annually) that provide immediately available onsite emergency cardiac surgical services. (Level of Evidence: B) 2. Primary PCI for patients with STEMI should be performed in facilities with onsite cardiac surgery. (Level of Evidence: B)

  • Class III

Elective PCI should not be performed at institutions that do not provide onsite cardiac surgery. (Level of Evidence: C)*

Primary PCI for STEMI Without Onsite Cardiac Surgery

  • Class IIb

Primary PCI for patients with STEMI might be considered in hospitals without onsite cardiac surgery, provided that appropriate planning for program development has been accomplished, including appropriately experienced physician operators (more than 75 total PCIs and, ideally, at least 11 primary PCIs per year for STEMI), an experienced catheterization team on a 24 hours per day, 7 days per week call schedule, and a well-equipped catheterization laboratory with digital imaging equipment, a full array of interventional equipment, and intra-aortic balloon pump capability, and provided that there is a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital with appropriate hemodynamic support capability for transfer. The procedure should be limited to patients with STEMI or MI with new or presumably new left bundle-branch block on ECG and should be performed in a timely fashion (goal of balloon inflation within 90 minutes of presentation) by persons skilled in the procedure (at least 75 PCIs per year) and at hospitals performing a minimum of 36 primary PCI procedures per year. (Level of Evidence: B)

  • Class III

Primary PCI should not be performed in hospitals without onsite cardiac surgery and without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capability for transfer. (Level of Evidence: C)

Elective PCI Without Onsite Surgery

  • Class III

Elective PCI should not be performed at institutions that do not provide onsite cardiac surgery. (Level of Evidence: C)*

CAD Revascularization: Recommendations [4]

Heart Team Approach to Revascularization Decisions

“

Class I

1. A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD.[2][3][4] (Level of Evidence: C)

Class IIa

1. Calculation of the Society of Thoracic Surgeons and SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores is reasonable in patients with unprotected left main and complex CAD.[4][5][6][7][8][9][10][11] (Level of Evidence: B)

”

Procedural Considerations: Recommendations [5]

Vascular Access

“

Class IIa

1. The use of radial artery access can be useful to decrease access site complications.[12][13][14][15][16][17][18][19][20] (Level of Evidence: A)

”

Patients With Asymptomatic Ischemia or CCS Class I or II Angina

  • Class IIa

1. PCI is reasonable in patients with asymptomatic ischemia or CCS class I or II angina and with 1 or more significant lesions in 1 or 2 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The vessels to be dilated must subtend a moderate to large area of viable myocardium or be associated with a moderate to severe degree of ischemia on noninvasive testing. (Level of Evidence: B) 2. PCI is reasonable for patients with asymptomatic ischemia or CCS class I or II angina, and recurrent stenosis after PCI with a large area of viable myocardium or high-risk criteria on noninvasive testing. (Level of Evidence: C) 3. Use of PCI is reasonable in patients with asymptomatic ischemia or CCS class I or II angina with significant left main CAD (greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG. (Level of Evidence: B)

  • Class IIb

1. The effectiveness of PCI for patients with asymptomatic ischemia or CCS class I or II angina who have 2- or 3-vessel disease with significant proximal LAD CAD who are otherwise eligible for CABG with 1 arterial conduit and who have treated diabetes or abnormal LV function is not well established. (Level of Evidence: B) 2. PCI might be considered for patients with asymptomatic ischemia or CCS class I or II angina with nonproximal LAD CAD that subtends a moderate area of viable myocardium and demonstrates ischemia on noninvasive testing. (Level of Evidence: C)

  • Class III

PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II angina who do not meet the criteria as listed under the class II recommendations or who have 1 or more of the following: a. Only a small area of viable myocardium at risk (Level of Evidence: C) b. No objective evidence of ischemia. (Level of Evidence: C) c. Lesions that have a low likelihood of successful dilatation. (Level of Evidence: C) d. Mild symptoms that are unlikely to be due to myocardial ischemia. (Level of Evidence: C) e. Factors associated with increased risk of morbidity or mortality. (Level of Evidence: C) f. Left main disease and eligibility for CABG. (Level of Evidence: C) g. Insignificant disease (less than 50% coronary stenosis). (Level of Evidence: C)

Patients With CCS Class III Angina

  • Class IIa

1. It is reasonable that PCI be performed in patients with CCS class III angina and single-vessel or multivessel CAD who are undergoing medical therapy and who have 1 or more significant lesions in 1 or more coronary arteries suitable for PCI with a high likelihood of success and low risk of morbidity or mortality. (Level of Evidence: B) 2. It is reasonable that PCI be performed in patients with CCS class III angina with single-vessel or multivessel CAD who are undergoing medical therapy with focal saphenous vein graft lesions or multiple stenoses who are poor candidates for reoperative surgery. (Level of Evidence: C) 3. Use of PCI is reasonable in patients with CCS class III angina with significant left main CAD (greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG. (Level of Evidence: B)

  • Class IIb

1. PCI may be considered in patients with CCS class III angina with single-vessel or multivessel CAD who are undergoing medical therapy and who have 1 or more lesions to be dilated with a reduced likelihood of success. (Level of Evidence: B) 2. PCI may be considered in patients with CCS class III angina and no evidence of ischemia on noninvasive testing or who are undergoing medical therapy and have 2- or 3-vessel CAD with significant proximal LAD CAD and treated diabetes or abnormal LV function. (Level of Evidence: B)

  • Class III

PCI is not recommended for patients with CCS class III angina with single-vessel or multivessel CAD, no evidence of myocardial injury or ischemia on objective testing, and no trial of medical therapy, or who have 1 of the following: a. Only a small area of myocardium at risk. (Level of Evidence: C) b. All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success. (Level of Evidence: C) c. Ahigh risk of procedure-related morbidity or mortality. (Level of Evidence: C) d. Insignificant disease (less than 50% coronary stenosis). (Level of Evidence: C) e. Significant left main CAD and candidacy for CABG. (Level of Evidence: C)

PCI in patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction

“

Class I

1. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures).[21][22][23] (Level of Evidence: B)

2. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events.[22][23][24][25] (Level of Evidence: A)

3. The selection of PCI or CABG as the means of revascularization in the patient with acute coronary syndrome (ACS) should generally be based on the same considerations as those without ACS.[26][23][27][28] (Level of Evidence: B)

Class III

1. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is not recommended in patients with extensive co-morbidities (e.g., liver or pulmonary failure, cancer) in whom:

a. The risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization, (Level of Evidence: C)
b. There is a low likelihood of ACS despite acute chest pain, or (Level of Evidence: C)
c. Consent to revascularization will not be granted regardless of the findings. (Level of Evidence: C)
 ”

Patients With STEMI: General and Specific Considerations

  • Class I

General considerations

1. If immediately available, primary PCI should be performed in patients with STEMI (including true posterior MI) or MI with new or presumably new left bundle- branch block who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation goal within 90 minutes of presentation) by persons skilled in the procedure (individuals who perform more than 75 PCI procedures per year, ideally at least 11 PCIs per year for STEMI). The procedure should be supported by experienced personnel in an appropriate laboratory environment (one that performs more than 200 PCI procedures per year, of which at least 36 are primary PCI for STEMI, and that has cardiac surgery capability). (Level of Evidence: A) Primary PCI should be performed as quickly as possible, with a goal of a medical contact-to-balloon or door-to-balloon time within 90 minutes. (Level of Evidence: B)

Specific Considerations

2. Primary PCI should be performed for patients less than 75 years old with ST elevation or presumably new left bundle-branch block who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. (Level of Evidence: A) 3. Primary PCI should be performed in patients with severe congestive heart failure and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours. The medical contact-to-balloon or door-to balloon time should be as short as possible (i.e., goal within 90 minutes). (Level of Evidence: B)

  • Class IIa

1. Primary PCI is reasonable for selected patients 75 years or older with ST elevation or left bundle-branch block or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who are suitable for revascularization and agree to invasive care may be selected for such an invasive strategy. (Level of Evidence: B) 2. It is reasonable to perform primary PCI for patients with onset of symptoms within the prior 12 to 24 hours and 1 or more of the following: a. Severe congestive heart failure (Level of Evidence: C) b. Hemodynamic or electrical instability (Level of Evidence: C) c. Evidence of persistent ischemia (Level of Evidence: C)

  • Class IIb

The benefit of primary PCI for STEMI patients eligible for fibrinolysis when performed by an operator who performs fewer than 75 PCI procedures per year (or fewer than 11 PCIs for STEMI per year) is not well established. (Level of Evidence: C)

  • Class III

1. Elective PCI should not be performed in a noninfarct- related artery at the time of primary PCI of the infarct related artery in patients without hemodynamic compromise. (Level of Evidence: C) 2. Primary PCI should not be performed in asymptomatic patients more than 12 hours after onset of STEMI who are hemodynamically and electrically stable. (Level of Evidence: C)

PCI in Fibrinolytic-Ineligible Patients

  • Class I

Primary PCI should be performed in fibrinolytic-ineligible patients who present with STEMI within 12 hours of symptom onset. (Level of Evidence: C)

  • Class IIa

It is reasonable to perform primary PCI for fibrinolytic- ineligible patients with onset of symptoms within the prior 12 to 24 hours and 1 or more of the following: a. Severe congestive heart failure. (Level of Evidence: C) b. Hemodynamic or electrical instability. (Level of Evidence: C) c. Evidence of persistent ischemia. (Level of Evidence: C)

Facilitated PCI

  • Class IIb

Facilitated PCI might be performed as a reperfusion strategy in higher-risk patients when PCI is not immediately available and bleeding risk is low. (Level of Evidence: B)

PCI After Failed Fibrinolysis (Rescue PCI)

  • Class I

1. Rescue PCI should be performed in patients less than 75 years old with ST elevation or left bundle-branch block who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless further support is futile because of the patient’s wishes or contraindications/ unsuitability for further invasive care. (Level of Evidence: B) 2. Rescue PCI should be performed in patients with severe congestive heart failure and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours. (Level of Evidence: B)

  • Class IIa

1. Rescue PCI is reasonable for selected patients 75 years or older with ST elevation or left bundle-branch block or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who are suitable for revascularization and agree to invasive care may be selected for such an invasive strategy. (Level of Evidence: B) 2. It is reasonable to perform rescue PCI for patients with 1 or more of the following: a. Hemodynamic or electrical instability. (Level of Evidence: C) b. Evidence of persistent ischemia. (Level of Evidence: C)

  • Class III

Rescue PCI in the absence of 1 or more of the above class I or IIa indications is not recommended. (Level of Evidence: C)

PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion

  • Class I

1. In patients whose anatomy is suitable, PCI should be performed when there is objective evidence of recurrent MI. (Level of Evidence: C) 2. In patients whose anatomy is suitable, PCI should be performed for moderate or severe spontaneous or provocable myocardial ischemia during recovery from STEMI. (Level of Evidence: B) 3. In patients whose anatomy is suitable, PCI should be performed for cardiogenic shock or hemodynamic instability. (Level of Evidence: B)

  • Class IIa

1. It is reasonable to perform routine PCI in patients with LV ejection fraction less than or equal to 0.40, HF, or serious ventricular arrhythmias. (Level of Evidence: C) 2. It is reasonable to perform PCI when there is documented clinical heart failure during the acute episode, even though subsequent evaluation shows preserved LV function (LV ejection fraction greater than 0.40). (Level of Evidence: C)

  • Class IIb

PCI might be considered as part of an invasive strategy after fibrinolytic therapy. (Level of Evidence: C)

PCI in patients with Cardiogenic Shock

“

Class I

1. PCI is recommended for patients with acute myocardial infarction who develop cardiogenic shock and are suitable candidates.[29][30][31][32] (Level of Evidence: B)

2. A hemodynamic support device is recommended for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological therapy.[29][33][34][35][36] (Level of Evidence: B)

”

Percutaneous Intervention in Patients With Prior Coronary Bypass Surgery

  • Class I

1. When technically feasible, PCI should be performed in patients with early ischemia (usually within 30 days) after CABG. (Level of Evidence: B) 2. It is recommended that distal embolic protection devices be used when technically feasible in patients undergoing PCI to saphenous vein grafts. (Level of Evidence: B)

  • Class IIa

1. PCI is reasonable in patients with ischemia that occurs 1 to 3 years after CABG and who have preserved LV function with discrete lesions in graft conduits. (Level of Evidence: B) 2. PCI is reasonable in patients with disabling angina secondary to new disease in a native coronary circulation after CABG. (If angina is not typical, objective evidence of ischemia should be obtained.) (Level of Evidence: B) 3. PCI is reasonable in patients with diseased vein grafts more than 3 years after CABG. (Level of Evidence: B) 4. PCI is reasonable when technically feasible in patients with a patent left internal mammary artery graft who have clinically significant obstructions in other vessels. (Level of Evidence: C)

  • Class III

1. PCI is not recommended in patients with prior CABG for chronic total vein graft occlusions. (Level of Evidence: B) 2. PCI is not recommended in patients who have multiple target lesions with prior CABGand who have multivessel disease, failure of multiple SVGs, and impaired LV function unless repeat CABG poses excessive risk due to severe comorbid conditions. (Level of Evidence: B)

Antiplatelet and Antithrombotic Adjunctive Therapies for PCI

Oral Antiplatelet Therapy

Guidelines (DO NOT EDIT)

  • Class I

1. Patients already taking daily chronic aspirin therapy should take 75 to 325 mg of aspirin before the PCI procedure is performed. (Level of Evidence: A) 2. Patients not already taking daily chronic aspirin therapy should be given 300 to 325 mg of aspirin at least 2 hours and preferably 24 hours before the PCI procedure is performed. (Level of Evidence: C) 3. After the PCI procedure, in patients with neither aspirin resistance, allergy, nor increased risk of bleeding, aspirin 325 mg daily should be given for at least 1 month after bare-metal stent implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which daily chronic aspirin use should be continued indefinitely at a dose of 75 to 162 mg. (Level of Evidence: B) 4. A loading dose of clopidogrel should be administered before PCI is performed. (Level of Evidence: A) An oral loading dose of 300 mg, administered at least 6 hours before the procedure, has the best established evidence of efficacy. (Level of Evidence: B) 5. In patients who have undergone PCI, clopidogrel 75 mg daily should be given for at least 1 month after bare-metal stent implantation (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks), 3 months after sirolimus stent implantation, and 6 months after paclitaxel stent implantation, and ideally up to 12 months in patients who are not at high risk of bleeding. (Level of Evidence: B)

  • Class IIa

1. If clopidogrel is given at the time of procedure, supplementation with GP IIb/IIIa receptor antagonists can be beneficial to facilitate earlier platelet inhibition than with clopidogrel alone. (Level of Evidence: B) 2. For patients with an absolute contraindication to aspirin, it is reasonable to give a 300-mg loading dose of clopidogrel, administered at least 6 hours before PCI, and/or GP IIb/IIIa antagonists, administered at the time of PCI. (Level of Evidence: C) 3. When a loading dose of clopidogrel is administered, a regimen of greater than 300 mg is reasonable to achieve higher levels of antiplatelet activity more rapidly, but the efficacy and safety compared with a 300- mg loading dose are less established. (Level of Evidence: C) 4. It is reasonable that patients undergoing brachytherapy be given daily clopidogrel 75 mg indefinitely and daily aspirin 75 to 325 mg indefinitely unless there is significant risk for bleeding. (Level of Evidence: C)

  • Class IIb

In patients in whom subacute thrombosis may be catastrophic or lethal (unprotected left main, bifurcating left main, or last patent coronary vessel), platelet aggregation studies may be considered and the dose of clopidogrel increased to 150 mg per day if less than 50% inhibition of platelet aggregation is demonstrated. (Level of Evidence: C)

Glycoprotein IIb/IIIa Inhibitors

Guidelines (DO NOT EDIT)

  • Class I

In patients with UA/NSTEMI undergoing PCI without clopidogrel administration, a GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) should be administered. (Level of Evidence: A)*

  • Class IIa

1. In patients with UA/NSTEMI undergoing PCI with clopidogrel administration, it is reasonable to administer a GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban). (Level of Evidence: B)* 2. In patients with STEMI undergoing PCI, it is reasonable to administer abciximab as early as possible. (Level of Evidence: B) 3. In patients undergoing elective PCI with stent placement, it is reasonable to administer a GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban). (Level of Evidence: B)

  • Class IIb

In patients with STEMI undergoing PCI, treatment with eptifibatide or tirofiban may be considered. (Level of Evidence: C)

  • *It is acceptable to administer the GP IIb/IIIa inhibitor before performance

of the diagnostic angiogram (“upstream treatment”) or just before PCI (“in-lab treatment”).

Antithrombotic Therapy: Unfractionated Heparin, LowMolecular Weight Heparin, and Bivalirudin

Guidelines (DO NOT EDIT)

  • Class I

1. Unfractionated heparin should be administered to patients undergoing PCI. (Level of Evidence: C) 2. For patients with heparin-induced thrombocytopenia, it is recommended that bivalirudin or argatroban be used to replace heparin. (Level of Evidence: B)

  • Class IIa

1. It is reasonable to use bivalirudin as an alternative to unfractionated heparin and glycoprotein IIb/IIIa antagonists in low-risk patients undergoing elective PCI. (Level of Evidence: B) 2. Low-molecular-weight heparin is a reasonable alternative to unfractionated heparin in patients with UA/NSTEMI undergoing PCI. (Level of Evidence: B)

  • Class IIb

Low-molecular-weight heparin may be considered as an alternative to unfractionated heparin in patients with STEMI undergoing PCI. (Level of Evidence: B)


Surgery and Device Based Therapy

Acute Results

  • Class I

It is recommended that distal embolic protection devices be used when technically feasible in patients undergoing PCI to saphenous vein grafts. (Level of Evidence: B)

Drug-Eluting Stents[1]

  • Class I

A drug-eluting stent (DES) should be considered as an alternative to the bare-metal stent in subsets of patients in whom trial data suggest efficacy. (Level of Evidence: A)

  • Class IIa

It is reasonable to use a DES as an alternative to a BMS for primary PCI in STEMI. (Level of Evidence: B)

  • Class IIb

A DES may be considered for clinical and anatomic settings in which the efficacy/safety profile appears favorable. (Level of Evidence: B)

Thrombus Aspiration During PCI

  • Class IIa

Aspiration thrombectomy is reasonable for patients undergoing primary PCI .(Level of Evidence: B)

Guideline Resources

References

  1. ↑ 1.0 1.1 1.2 Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM et al. (2009) 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 54 (23):2205-41. DOI:10.1016/j.jacc.2009.10.015 PMID: 19942100
  2. ↑ Feit F, Brooks MM, Sopko G, Keller NM, Rosen A, Krone R et al. (2000) Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators. Circulation 101 (24):2795-802. PMID: 10859284
  3. ↑ King SB, Barnhart HX, Kosinski AS, Weintraub WS, Lembo NJ, Petersen JY et al. (1997) Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes. Emory Angioplasty versus Surgery Trial Investigators. Am J Cardiol 79 (11):1453-9. PMID: 9185632
  4. ↑ 4.0 4.1 Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ et al. (2009) Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 360 (10):961-72. DOI:10.1056/NEJMoa0804626 PMID: 19228612
  5. ↑ Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011) Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization. Am J Cardiol 107 (3):360-6. DOI:10.1016/j.amjcard.2010.09.029 PMID: 21256999
  6. ↑ Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson TB, Dziuban SW et al. (2001) A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases. Ann Surg 234 (4):464-72; discussion 472-4. PMID: 11573040
  7. ↑ Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010) Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization. JACC Cardiovasc Interv 3 (6):612-23. DOI:10.1016/j.jcin.2010.04.004 PMID: 20630454
  8. ↑ Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010) Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation 121 (24):2645-53. DOI:10.1161/CIRCULATIONAHA.109.899211 PMID: 20530001
  9. ↑ Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB et al. (2009) The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery. Ann Thorac Surg 88 (1 Suppl):S2-22. DOI:10.1016/j.athoracsur.2009.05.053 PMID: 19559822
  10. ↑ Shahian DM, O'Brien SM, Normand SL, Peterson ED, Edwards FH (2010) Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score. J Thorac Cardiovasc Surg 139 (2):273-82. DOI:10.1016/j.jtcvs.2009.09.007 PMID: 20022608
  11. ↑ Welke KF, Peterson ED, Vaughan-Sarrazin MS, O'Brien SM, Rosenthal GE, Shook GJ et al. (2007) Comparison of cardiac surgery volumes and mortality rates between the Society of Thoracic Surgeons and Medicare databases from 1993 through 2001. Ann Thorac Surg 84 (5):1538-46. DOI:10.1016/j.athoracsur.2007.06.022 PMID: 17954059
  12. ↑ Brueck M, Bandorski D, Kramer W, Wieczorek M, Höltgen R, Tillmanns H (2009) A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. JACC Cardiovasc Interv 2 (11):1047-54. DOI:10.1016/j.jcin.2009.07.016 PMID: 19926042
  13. ↑ Jaffe R, Hong T, Sharieff W, Chisholm RJ, Kutryk MJ, Charron T et al. (2007) Comparison of radial versus femoral approach for percutaneous coronary interventions in octogenarians. Catheter Cardiovasc Interv 69 (6):815-20. DOI:10.1002/ccd.21021 PMID: 17191214
  14. ↑ Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR (2009) Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 157 (1):132-40. DOI:10.1016/j.ahj.2008.08.023 PMID: 19081409
  15. ↑ Louvard Y, Benamer H, Garot P, Hildick-Smith D, Loubeyre C, Rigattieri S et al. (2004) Comparison of transradial and transfemoral approaches for coronary angiography and angioplasty in octogenarians (the OCTOPLUS study). Am J Cardiol 94 (9):1177-80. DOI:10.1016/j.amjcard.2004.07.089 PMID: 15518616
  16. ↑ Pristipino C, Trani C, Nazzaro MS, Berni A, Patti G, Patrizi R et al. (2009) Major improvement of percutaneous cardiovascular procedure outcomes with radial artery catheterisation: results from the PREVAIL study. Heart 95 (6):476-82. DOI:10.1136/hrt.2008.150714 PMID: 19036757
  17. ↑ Rao SV, Ou FS, Wang TY, Roe MT, Brindis R, Rumsfeld JS et al. (2008) Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv 1 (4):379-86. DOI:10.1016/j.jcin.2008.05.007 PMID: 19463333
  18. ↑ Rao SV, Cohen MG, Kandzari DE, Bertrand OF, Gilchrist IC (2010) The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol 55 (20):2187-95. DOI:10.1016/j.jacc.2010.01.039 PMID: 20466199
  19. ↑ Hamon M, Rasmussen LH, Manoukian SV, Cequier A, Lincoff MA, Rupprecht HJ et al. (2009) Choice of arterial access site and outcomes in patients with acute coronary syndromes managed with an early invasive strategy: the ACUITY trial. EuroIntervention 5 (1):115-20. PMID: 19577992
  20. ↑ Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P et al. (2011) Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 377 (9775):1409-20. DOI:10.1016/S0140-6736(11)60404-2 PMID: 21470671
  21. ↑ Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT (2006) Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 48 (7):1319-25. DOI:10.1016/j.jacc.2006.06.050 PMID: 17010789
  22. ↑ 22.0 22.1 Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N et al. (2001) Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 344 (25):1879-87. DOI:10.1056/NEJM200106213442501 PMID: 11419424
  23. ↑ 23.0 23.1 23.2 Fox KA, Clayton TC, Damman P, Pocock SJ, de Winter RJ, Tijssen JG et al. (2010) Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol 55 (22):2435-45. DOI:10.1016/j.jacc.2010.03.007 PMID: 20359842
  24. ↑ (1999) Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet 354 (9180):708-15. PMID: 10475181
  25. ↑ Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP, Faxon DP et al. (2009) Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med 360 (21):2165-75. DOI:10.1056/NEJMoa0807986 PMID: 19458363
  26. ↑ Jones RH, Kesler K, Phillips HR, Mark DB, Smith PK, Nelson CL et al. (1996) Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease. J Thorac Cardiovasc Surg 111 (5):1013-25. PMID: 8622299
  27. ↑ Rodriguez AE, Baldi J, Fernández Pereira C, Navia J, Rodriguez Alemparte M, Delacasa A et al. (2005) Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II). J Am Coll Cardiol 46 (4):582-8. DOI:10.1016/j.jacc.2004.12.081 PMID: 16098419
  28. ↑ Valgimigli M, Dawkins K, Macaya C, de Bruyne B, Teiger E, Fajadet J et al. (2007) Impact of stable versus unstable coronary artery disease on 1-year outcome in elective patients undergoing multivessel revascularization with sirolimus-eluting stents: a subanalysis of the ARTS II trial. J Am Coll Cardiol 49 (4):431-41. DOI:10.1016/j.jacc.2006.06.081 PMID: 17258088
  29. ↑ 29.0 29.1 Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD et al. (1999) Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med 341 (9):625-34. DOI:10.1056/NEJM199908263410901 PMID: 10460813
  30. ↑ Hochman JS, Sleeper LA, White HD, Dzavik V, Wong SC, Menon V et al. (2001) One-year survival following early revascularization for cardiogenic shock. JAMA 285 (2):190-2. PMID: 11176812
  31. ↑ Hochman JS, Sleeper LA, Webb JG, Dzavik V, Buller CE, Aylward P et al. (2006) Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA 295 (21):2511-5. DOI:10.1001/jama.295.21.2511 PMID: 16757723
  32. ↑ Urban P, Stauffer JC, Bleed D, Khatchatrian N, Amann W, Bertel O et al. (1999) A randomized evaluation of early revascularization to treat shock complicating acute myocardial infarction. The (Swiss) Multicenter Trial of Angioplasty for Shock-(S)MASH. Eur Heart J 20 (14):1030-8. DOI:10.1053/euhj.1998.1353 PMID: 10383377
  33. ↑ Sanborn TA, Sleeper LA, Bates ER, Jacobs AK, Boland J, French JK et al. (2000) Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? J Am Coll Cardiol 36 (3 Suppl A):1123-9. PMID: 10985715
  34. ↑ Chen EW, Canto JG, Parsons LS, Peterson ED, Littrell KA, Every NR et al. (2003) Relation between hospital intra-aortic balloon counterpulsation volume and mortality in acute myocardial infarction complicated by cardiogenic shock. Circulation 108 (8):951-7. DOI:10.1161/01.CIR.0000085068.59734.E4 PMID: 12912817
  35. ↑ Barron HV, Every NR, Parsons LS, Angeja B, Goldberg RJ, Gore JM et al. (2001) The use of intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2. Am Heart J 141 (6):933-9. DOI:10.1067/mhj.2001.115295 PMID: 11376306
  36. ↑ Reynolds HR, Hochman JS (2008) Cardiogenic shock: current concepts and improving outcomes. Circulation 117 (5):686-97. DOI:10.1161/CIRCULATIONAHA.106.613596 PMID: 18250279

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