Percutaneous coronary intervention (PCI): Difference between revisions
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== Other Diagnostic Studies == | == Other Diagnostic Studies == | ||
'''Coronary Artery Pressure and Flow: Use of Fractional Flow Reserve and Coronary Vasodilatory Reserve''' | '''Coronary Artery Pressure and Flow: Use of Fractional Flow Reserve and Coronary Vasodilatory Reserve'''<ref>[http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.10.015]</ref> | ||
* ''Class IIa'' | * ''Class IIa'' | ||
Coronary pressure (fractional flow reserve [FFR]) or Doppler | |||
velocimetry can be useful to determine whether PCI of a | |||
reserve) | specific coronary lesion is warranted. FFR or Doppler | ||
coronary | 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 | |||
an alternative to performing noninvasive functional | whether an intervention is warranted. It is reasonable to | ||
testing (e.g., when the functional study is absent or | use intracoronary physiological measurements (coronary | ||
ambiguous) to determine whether an intervention is | pressure (FFR) (Level of Evidence: A) or | ||
warranted. (Level of Evidence: | 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'' | * ''Class IIb'' | ||
1. Intracoronary physiologic measurements may be considered | 1. Intracoronary physiologic measurements may be considered | ||
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lesion. (Level of Evidence: C) | lesion. (Level of Evidence: C) | ||
* ''Class III'' | * ''Class III'' | ||
Routine assessment with intracoronary | Routine assessment with intracoronary physiological | ||
measurements such as Doppler ultrasound | 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 | |||
noninvasive functional study is not recommended. | a positive, unequivocal noninvasive functional study is not | ||
(Level of Evidence: C) | recommended. (Level of Evidence: C) | ||
== Treatment == | == Treatment == | ||
Revision as of 15:42, 20 November 2009
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]
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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)
Other Diagnostic Studies
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)
Treatment
Any recommendations found on these pages are for education use only. wiki doc is not a substitute for a licensed healthcare provider. Please see the disclaimers page for important information regarding limitations of the information found here. In recommending therapies, wiki doc suggests that the following classification scheme be used. This is the classification scheme used by the ACC / AHA Guidelines Committee. Use the Class designation to indicate whether the therapy is recommended or not and the certainty surrounding that recommendation. Use the Level of Evidence designation to indicate the strength of the data associated with that recommendation.
Classification of Recommendations
- Class I: 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: Weight of evidence/opinion is in favor of usefulness/efficacy.
- Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
- Class III: 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.
wiki doc cites here the ACC / AHA Guidelines Based Therapy for ST Elevation MI. DO NOT EDIT THESE GUIDELINES. You can make comments regarding the guidelines in the discussion section.
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)*
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)
Patients With UA/NSTEMI
- Class I
An early invasive PCI strategy is indicated for patients with UA/NSTEMI who have no serious comorbidity and coronary lesions amenable to PCI. Patients must have any of the following high-risk features: a. Recurrent ischemia despite intensive anti-ischemic therapy. (Level of Evidence: A) b. Elevated troponin level. (Level of Evidence: A) c. New ST-segment depression. (Level of Evidence: A) d. HF symptoms or new or worsening MR. (Level of Evidence: A) e. Depressed LV systolic function. (Level of Evidence: A) f. Hemodynamic instability. (Level of Evidence: A) g. Sustained ventricular tachycardia. (Level of Evidence: A) h. PCI within 6 months. (Level of Evidence: A) i. Prior CABG. (Level of Evidence: A)
- Class IIa
1. It is reasonable that PCI be performed in patients with UA/NSTEMI and 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) 2. In the absence of high-risk features associated with UA/NSTEMI, it is reasonable to perform PCI in patients with amenable lesions and no contraindication for PCI with either an early invasive or early conservative strategy. (Level of Evidence: B) 3. Use of PCI is reasonable in patients with UA/NSTEMI 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. In the absence of high-risk features associated with UA/NSTEMI, PCI may be considered in patients with single-vessel or multivessel CAD who are undergoing medical therapy and who have 1 or more lesions to be dilated with reduced likelihood of success. (Level of Evidence: B) 2. PCI may be considered in patients with UA/NSTEMI who are undergoing medical therapy who have 2- or 3-vessel disease, significant proximal LAD CAD, and treated diabetes or abnormal LV function. (Level of Evidence: B)
- Class III
In the absence of high-risk features associated with UA/NSTEMI, PCI is not recommended for patients with UA/NSTEMI who have single-vessel or multivessel CAD and no trial of medical therapy, or who have 1 or more 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. A high 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: B)
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 for Cardiogenic Shock
- Class I
Primary PCI is recommended for 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: A)
- Class IIa
Primary PCI is reasonable for selected patients 75 years or older 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. 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)
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)
Pharmacotherapy
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, Low-Molecular- 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[2]
- 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)
References
Acknowledgements
WikiDoc would like to acknowledge that the verbiage in guidelines recommendations comes from the ACC/AHA guidelines statements.