Percutaneous coronary intervention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Percutaneous coronary intervention (PCI), commonly known as coronary angioplasty, is an invasive cardiologic therapeutic procedure to treat the stenotic (narrowed) coronary arteries of the heart. These stenotic segments are due to the build up of cholesterol-laden plaques that form due to atherosclerosis in coronary heart disease. PCI is usually performed by an interventional cardiologist. Percutaneous coronary intervention can be performed to reduce or eliminate the symptoms of coronary artery disease, including angina (chest pain), dyspnea (shortness of breath) on exertion, and congestive heart failure. PCI is also used to abort an acute myocardial infarction, and in some specific cases it may reduce mortality.

There are several risk assessment scores which can help in determining a patient’s risk for death, myocardial infarction and recurrent cardiac events.

There are several steps involved in preparing the patient for PCI, which include the use of premedications and the use of a Heart Team approach. Attention should be given to possible adverse reactions to contrast, possible anaphylactoid reactions, the use of statins, bleeding risk in the patient, and the presence of on-site surgical back-up services.

Diagnostic catheters used for coronary arteriography are usually constructed from polyethylene or polyurethane with a fine wire braid within the wall to allow advancement and directional control (torquability) and to prevent kinking. The outer diameter size of the catheters ranges from 4 to 8F, but 5 and 6F catheters are used most commonly for diagnostic arteriography.

Angioplasty guidewires are small, soft, flexible, lubricated, wires that act as a rail over which equipment such as an angioplasty balloon, a stent, or an intravascular ultrasound device can be delivered over into the coronary artery. Angioplasty guide wires were introduced in 1982 by doctors Simpson and Roberts. The introduction of coronary guidewires was a major advance as it allowed the angioplasty balloon to be a traumatically steered to the proper location.

2011 AHA guidelines recommend the use of antiplatelet therapy aspirin (Level of Evidence: B) and P2Y12 receptor inhibitor (clopidogrel, prasugrel and ticagrelor) (Level of Evidence: A) to support PCI in patients with ACS. Few randomised trials have been conducted showing comparison of clopidogrel with aspirin and other P2Y12 inhibitors (prasugrel and ticagrelor) in terms of clinical benefit and risk of bleeding when given in patients undergoing PCI. However, there is limited data comparing new P2Y12 receptor inhibitors (prasugrel and ticagrelor) for downstream and upstream therapy in patients undergoing PCI with non ST elevation MI in terms of clinical benefit and adverse effects. Hence, a new large scale randomised open label trial called DUBIUS is in process in Italy comparing two new P2Y12 inhibitors prasugrel and ticagrelor for pretreatment in patients with non ST elevation MI undergoing PCI.

At the very heart of any successful endovascular procedure is successful arterial entry and exit. The first successful cardiac catheterization, according to Andre Cournand, was performed on an equine patient in 1844 utilizing a retrograde approach through both the jugular vein and carotid artery. Human retrograde left heart catheterization was first reported by Zimmerman and Limon-Lason in 1950. Shortly thereafter in 1953, Seldinger developed the percutaneous technique and this technique was quickly adapted to left heart cardiac catheterizations. With the growth of Interventional Cardiology in the years following Grüntzig’s introduction of coronary angioplasty in 1977, the percutaneous approach became, and today remains, by far the most common method of performing catheterization, angiography and endovascular intervention. Within the realm of percutaneous approaches, the majority of the procedures are performed from the femoral approach, with a minority being done from a radial approach. Brachial and axillary are also used in a minority of procedures. Reasons for the continued preference of the femoral route for access includes the vessel size, operator training and equipment, radiation exposure (operator), and the advent of vascular closure devices. Studies have suggested that between 8-10% of all patients selected for a transradial approach will convert to a transfemoral route

Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation(Level of Evidence: B-NR). When noncardiac surgery is required in patients currently taking a P2Y12 inhibitor, a consensus decision among treating clinicians as to the relative risks of surgery and discontinuation or continuation of antiplatelet therapy can be useful.(Level of Evidence: C-EO)“. Elective noncardiac surgery after DES implantation in patients for whom P2Y12 inhibitor therapy will need to be discontinued may be considered after 3 months if the risk of further delay of surgery is greater than the expected risks of stent thrombosis(Level of Evidence: C-EO)“. ” Prasugrel should not be administered to patients with a prior history of stroke or TIA(Level of Evidence: B-R)

After PCI, use of aspirin should be continued indefinitely. In patients receiving a stent (bare metal stent (BMS) or drug eluting stent (DES)) during PCI for ACS, P2Y12 inhibitor therapy should be given for at least 12 months. Options include clopidogrel 75 mg daily, prasugrel 10 mg daily , and ticagrelor 90 mg twice daily. (Level of Evidence: B). In patients receiving drug eluting stent (DES) for a non-ACS indication, clopidogrel 75 mg daily should be given for at least 12 months if the patient is not at high risk of bleeding. Continuation of clopidogrel, prasugrel or ticagrelor beyond 12 months may be considered in patients undergoing placement of drug eluting stent (DES). (Level of Evidence: C)“. Proton pump inhibitors should be used in patients with a history of prior gastrointestinal bleeding who require dual antiplatelet therapy (DAPT). When a patient predisposed to inadequate platelet inhibition with clopidogrel is identified by genetic testing, treatment with an alternate P2Y12 inhibitor (e.g., prasugrel or ticagrelor) might be considered. Routine periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed. Medically supervised exercise programs (cardiac rehabilitation) should be recommended to patients after PCI, particularly for moderate- to high-risk patients for whom supervised exercise training is warranted.

Status of tobacco use should be asked about at every visit (Level of Evidence: B). Every tobacco user and family members who smoke should be advised to quit at every visit. (Level of Evidence: B). The tobacco user should be assisted by counseling and developing a plan for quitting. (Level of Evidence: B)”. Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological treatment) should be arranged. (Level of Evidence: B)“. Blood pressure goal is less than 140/90 mm Hg or less than 130/80 mm Hg if patient has diabetes or chronic kidney disease. Starting dietary therapy is recommended. Reduce intake of saturated fats (to less than 7% of total calories), trans fatty acids, and cholesterol (to less than 200 mg per day) (Level of Evidence: B)“. LDL-C should be less than 100 mg per dL. (Level of Evidence: B). If triglycerides are greater than or equal to 150 mg per dL or HDL-C is less than 40 mg per dL, weight management, physical activity, and smoking cessation should be emphasized. (Level of Evidence: B). Adding plant stanol/sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower LDL-C. (Level of Evidence: A)“. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated. It may be reasonable to encourage increased consumption of omega-3 fatty acids in the form of fish or in capsules (1 g per day) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. (Level of Evidence: B)“. Physical activity goal is 30 minutes 5 days per week; optimal daily. Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure) is recommended. (Level of Evidence: B)“. For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription. (Level of Evidence: B)“. For all patients, encouraging 30 to 60 minutes of moderate-intensity aerobic activity is recommended, such as brisk walking on most—preferably all—days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work). (Level of Evidence: B)”

According to AHA guidelines, routine periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed. However, there has been a conflicting evidence on benefits of coronary angiography versus clinical follow up to detect major complications such as restenosis and its impact on survival outcome. In the recent ReACT trial 2016, it is demonstrated that there is no difference in clinical benefit when coronary angiography is compared to regular clinical follow up after PCI. Study results demonstrated that there was increased incidence of coronary revascularization with the corornary angiography after one year following PCI but there was no difference in the primary endpoint which included composite of death, MI, stroke, or emergency hospitalizations for acute coronary syndrome or heart failure when compared to regular clinical follow up after 5 years.

Hybrid coronary bypass is a relatively new procedure and alternative to traditional bypass surgery that is defined by the performance of coronary bypass surgery and coronary stenting during the same operation. A much smaller incision (made through the rib cage as opposed to cutting the sternum and opening the rib cage) than with traditional bypass surgery.

Complications of PCI include , vessel perforation, dissection, distal embolization, no-reflow, coronary vasospasm, abrupt closure, access site complications, peri-procedure bleeding, restenosis, renal failure, thrombocytopenia, late acquired stent malapposition and loss of side branch.

Factors associated with complications can be taken into account using various risk score systems. These systems take into account clinical variables, age, cardiovascular history, comorbities, anatomical variables. Mayo clinic risk score and the CADILLAC risk score are two common examples.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Xin Yang, MA(Cantab), MB BChir, MRCP(Lond) Anahita Deylamsalehi, M.D.[2]

There are several risk assessment scores which can help in determining a patient’s risk for death, myocardial infarction and recurrent cardiac events.

Studies demonstrated that rescue PCI after failed fibrinolytic therapy is related to a lower risk of cardiovascular events when compared to repeated fibrinolytic therapy or conservative managements.^[1][2][3][4]

• However, rates of complications such as stroke and bleeding were higher in the rescue PCI group.^[1][2]
• On the other hand, the fact that those studies have been done in the era of femoral artery access and limited antiplatelet and anticoagulant therapies may explain the higher rates of stroke and bleeding.^[4]
• Half-dose tenecteplase in patients older than 75 years old reduces the risk of stroke.^[5]
• Furthermore, radial artery access instead of femoral artery or avoiding routine use of glycoprotein IIb/IIIa inhibitors could be used to decrease the risk of bleeding.^[6]

Template:WikiDoc Sources

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

• Due to angiography limitations, intra-coronary imaging can be used to guide coronary stent implantation, especially in patients with left main coronary artery involvement or complex lesions.^[1]
• Intravascular ultrasound (IVUS) and optical coherence tomography (OCT are two imaging methods that can be used to assess vasculature conditions before and after PCI.
• Both imaging methods can assist in evaluating the need for lesion preparation, stent sizing, diminishing geographic-related errors, confirming stent expansion, identifying complications, and causes of stent failure.^[2]

Class 2a Recommendation, Level of Evidence: B-R[1]

1.Intravascular ultrasound (IVUS) can be used as a procedural guidance in patients undergoing coronary stent implantation, particularly in those with left main or complex coronary artery stenting in order to diminish ischemic events. 2.Optical coherence tomography (OCT is a reasonable alternative to IVUS as an procedural guidance in patients undergoing coronary stent implantation, except in those with ostial left main disease.

Class 2a Recommendation, Level of Evidence: C-LD[1]

If stent failure occurs, both IVUS and OCT can be used to determine the mechanism of stent failure.

• Multiple meta-analyses have shown that intravascular ultrasound-guided PCI is more successful in reducing major adverse cardiovascular events (MACE) compared to angiographic-guided PCI.^{[3][4][5][6][7]}
• Furthermore, based on a trial named ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in “All-Comers” Coronary Lesions), intravascular ultrasound-guided PCI is more successful in reducing target-vessel failure compared to angiographic-guided PCI.^[8]
• The following are the list of pre-PCI evaluations that can be done with intravascular ultrasound:^[9][10]
  • Full-thickness evaluation of the vessel wall
  • Plaque burden
  • Calcification extent
  • Length of lesion
  • External elastic lamina diameter for stent sizing
• The following are the list of post-PCI evaluations that can be done with intravascular ultrasound:^[9][10]
  • Assessment of stent area
  • Stent malposition
  • Stent underexpansion
  • Tissue protrusion
  • Edge disease and dissection

• Optical coherence tomography (OCT) is capable of generating high-resolution images of vessel walls by using infrared light. This imaging method has particular advantages in the evaluation of the following:^[2]
  • Calcium thickness
  • Lipid, thrombus, fibroatheroma, and plaque rupture
  • Stent strut neointimal thickness
  • Stent malposition
  • Edge dissections
• The following are some of the limitations of optical coherence tomography (OCT):^[1]
  • Limited depth of imaging
  • Usage of OCT is limited in ostial left main disease since blood clearance through the use of contrast injection is necessary for performing OCT

Template:Cardiac surgery procedures

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [7] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[8]

There are several steps involved in preparing patients for PCI, which include the use of premedications and the use of a Heart Team approach. Attention should be given to possible adverse reactions to contrast, possible anaphylactoid reactions, use of statins, bleeding risk in patients, and the presence of on-site surgical backup services.

1. Aspirin
2. Clopidogrel

Class I

“1. In patients with ACS undergoing PCI, a radial approach is indicated in preference to a femoral approach to reduce the risk of death, vascular complications, or bleeding. (Level of Evidence: A)”

“2. In patients with SIHD undergoing PCI, the radial approach is recommended to reduce access site bleeding and vascular complications(Level of Evidence: A)”

Class I

“1. In patients undergoing PCI, DES should be used in preference to BMS to prevent restenosis, MI, or acute stent thrombosis (Level of Evidence: A)”

^[1]

Class IIa

” 1. In patients undergoing coronary stent implantation, IVUS can be useful for procedural guidance, particularly in cases of left main or complex coronary artery stenting, to reduce ischemic events. (Level of Evidence B-R)”.

” 2. In patients undergoing coronary stent implantation, OCT is a reasonable alternative to IVUS for procedural guidance, except in the ostial left main disease.(Level of Evidence B-R)”

”3. In patients with stent failure, IVUS or OCT is reasonable to determine the mechanism of stent failure.(Level of Evidence C-LD)”

^[1]

Class III (No Benefit)

“1. In patients with STEMI, routine aspiration thrombectomy before primary PCI is not useful. (Level of Evidence:A) ”

Class IIa

” 1. In patients with fibrotic or heavily calcified lesions, plaque modification with rotational atherectomy can be useful to improve procedural success (Level of Evidence B-R)”.

^[1]

Class IIb

” 2. In patients with fibrotic or heavily calcified lesions, plaque modification with orbital ather-ectomy, balloon atherotomy, laser angioplasty, or intracoronary lithotripsy may be considered to improve procedural success. (Level of Evidence B-NR)”.

^[1]

Class IIa

” 1. In select patients with previous CABG undergoing PCI of an SVG, the use of an embolic protection device, when technically feasible, is reasonable to decrease the risk of distal embolization (Level of Evidence B-R)”.

” 2. In patients with previous CABG, if PCI of a diseased native coronary artery is feasible, then it is reasonable to choose PCI of the native coronary artery over PCI of the severely diseased SVG(Level of Evidence B-NR)”

^[1]

Class III (No Benefit)

“1. In patients with a chronic occlusion of an SVG, percutaneous revascularization of the SVG should not be performed (Level of Evidence:C-LD) ”

^[1]

Class IIb

” 1. In patients with suitable anatomy who have refractory angina on medical therapy, after treatment of non-CTO lesions, the benefit of PCI of a CTO to improve symptoms is uncertain. (Level of Evidence B-R)”.

^[1]

Class I

“1. In patients who develop clinical in-stent restenosis (ISR) for whom repeat PCI is planned, a DES should be used to improve outcomes if anatomic factors are appropriate and the patient is able to comply with DAPT (Level of Evidence: A)”

^[1]

Class IIa

” 2. In patients with symptomatic recurrent diffuse ISR with an indication for revascularization, CABG can be useful over repeat PCI to reduce recurrent events. (Level of Evidence C-EO)”.

^[1]

Class IIb

” 1. In patients who develop recurrent ISR, brachytherapy may be considered to improve symptoms. (Level of Evidence B-NR)”.

Class IIb

” 1. In selected high-risk patients, elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable to prevent hemodynamic compromise during PCI(Level of Evidence B-R)”.

^[1]

Class I

“1. A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD. [4][5][6] (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. [6][7][8][9][10][11][12][13] (Level of Evidence: B)”

Class I

“1. Patients should be assessed for risk of contrast-induced acute kidney injury before PCI.[14][15] (Level of Evidence: C)”

“2. Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration.[16][17][18][19] (Level of Evidence: B)”

“3. In patients with chronic kidney disease (CKD) (creatinine clearance ≤60 mL/min), the volume of contrast media should be minimized.[20][21][22] (Level of Evidence: B)”

Class III (No Benefit)

“1. Administration of N-acetyl-L-cysteine is not useful for the prevention of contrast-induced acute kidney injury.[23][24] [25][26][27] (Level of Evidence: A)”

Class I

“1. Patients with prior evidence of an anaphylactoid reaction to contrast media should receive appropriate steroid and antihistamine prophylaxis before repeat contrast administration. [28][29][30][31](Level of Evidence: B)”

Class III (No Benefit)

“1. In patients with a prior history of allergic reactions to shellfish or seafood, anaphylactoid prophylaxis for contrast reaction is not beneficial. [32][33][34](Level of Evidence: C)”

Class IIa

“1. Administration of a high-dose statin is reasonable before PCI to reduce the risk of peri-procedural myocardial infarction. (Level of Evidence: A forstatin-naïve patients) [35][36][37][38][39][40][41];(Level of Evidence: B for those on chronic statin therapy) [42]”

Class I

“1. All patients should be evaluated for risk of bleeding before PCI. (Level of Evidence: C)”

Class III (Harm)

“1. Primary or elective PCI should not be performed in hospitals without on-site cardiac surgery capabilities 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)”

Class IIa

“1. Primary PCI is reasonable in hospitals without on-site cardiac surgery, provided that appropriate planning for program development has been accomplished.[43][44] (Level of Evidence: B)”

Class IIb

“1. Elective PCI might be considered in hospitals without on-site cardiac surgery, provided that appropriate planning for program development has been accomplished and rigorous clinical and angiographic criteria are used for proper patient selection.[44][45][46] (Level of Evidence: B)”

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

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

Class III (No Benefit)[47]

Routine aspiration thrombectomy is not useful before primary PCI in patients with ST elevation myocardial infarction.

• Routine rheolytic thrombectomy did not show any benefit based on trials done on patients with ST elevation myocardial infarction undergoing primary PCI even in the presence of thrombotic occlusion.^{[48][49][50][51][52][53]}

Template:WikiDoc Sources

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Class 1 Recommendation, Level of Evidence: ‌B-R[1][2][3][4][5][6][7][8][9][10][11][12][13][14]

1. A loading dose of aspirin, followed by daily dosing is recommended to reduce ischemic events in patients who are undergoing PCI. 2. A loading dose of P2Y12 inhibitor, followed by daily dosing is recommended to reduce ischemic events in patients with ACS who are undergoing PCI.

Class 1 Recommendation, Level of Evidence: C-LD [1][5][8][11][14][15][16][17]

1. A loading dose of clopidogrel, followed by daily dosing is recommended to reduce ischemic events in patients with stable ischemic heart disease (SIHD) who are undergoing PCI. 2. A loading dose of 300 mg of clopidogrel, followed by daily dosing is recommended to reduce ischemic events in patients undergoing PCI within 24 hours after fibrinolytic therapy.

Class IIa, Level of Evidence: ‌C-LD[1][18][19]

Intravenous glycoprotein IIb/IIIa inhibitors are a reasonable choice in order to improve procedural success in patients with ACS who are undergoing PCI and have a large thrombus burden, no-reflow, or slow flow.

Class 2b Recommendation, Level of Evidence: B-R [1][6][13][20][21][22][23]

1. Using ticagrelor or prasugrel is preferred to clopidogrel in order to decrease ischemic events (including stent thrombosis) in ACS patients undergoing PCI. 2. Intravenous cangrelor is recommended in order to reduce periprocedural ischemic events among P2Y12 inhibitor naïve patients who are undergoing PCI.

Class 2b Recommendation, Level of Evidence: B-R[1]

Ticagrelor could be a reasonable alternative over clopidogrel in order to decrease ischemic events in patients older than 75 years old who are undergoing PCI within 24 hours after fibrinolytic therapy.

Class 3 Recommendation: HARM, Level of Evidence: B-R[1][24][25][26]

1. Prasugrel should not be administered in patients with a history of stroke or transient ischemic attack who are undergoing PCI. 2. The routine use of an intravenous glycoprotein IIb/IIIa inhibitor is not recommended in patients with stable ischemic heart disease undergoing PCI.

Class I

“1.In patients with ACS treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months(Level of Evidence: B-R)”

“2.In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended(Level of Evidence: B-NR)”

Class IIa

“1.In patients with ACS treated with DAPT after coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy(Level of Evidence: B-R)”

“2.In patients with ACS treated with DAPT after coronary stent implantation, who are not at high risk for bleeding complications and who do not have a history of stroke or TIA, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy ((Level of Evidence: B-R)”

Class IIb

“1.In patients with ACS treated with coronary stent implantation who have tolerated DAPT without bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use) continuation of DAPT for longer than 12 months may be reasonable(Level of Evidence: A SR)”

“2.In patients with ACS treated with DAPT after DES implantation who develop a high risk of bleeding (e.g., treatment with oral anticoagulant therapy), are at high risk of severe bleeding complication (e.g., major intracranial surgery), or develop significant overt bleeding, discontinuation of P2Y12 therapy after 6 months may be reasonable(Level of Evidence: C-LD)”

Class III (No Benefit)

“1.Prasugrel should not be administered to patients with a prior history of stroke or TIA(Level of Evidence: B-R) ”

Class 1 Recommendation, Level of Evidence: C-EO[1]

Administration of intravenous unfractionated heparin (UFH) is useful in reducing ischemia events in patients undergoing PCI.

Class 1 Recommendation, Level of Evidence: C-LD[1][28][29]

Bivalirudin or argatroban should be used instead of UFH in patients with heparin-induced thrombocytopenia who are undergoing PCI.

Class 2b Recommendation, Level of Evidence: A[1][30][31][32][33][34][35][36][37][38][39]

Bivalirudin could be used as a reasonable alternative to UFH in order to reduce bleeding in patients undergoing PCI.

Class 2b Recommendation, Level of Evidence: B-BR[1][40][41][42][43][44]

In patients who have been treated with upstream subcutaneous enoxaparin for either unstable angina or NSTE-ACS, intravenous enoxaparin could be considered at the time of PCI in order to reduce ischemic events.

Class 3 Recommendation (HARM), Level of Evidence: B-R[1][41][45][46]

UFH should be avoid in patients who are on therapeutic subcutaneous enoxaparin, and have received the last dose within 12 hours of PCI due to higher rate of bleeding.

Template:WH Template:WS

Editor-In-Chief: Michael S. Fenster, MD [1]

At the very heart of any successful endovascular procedure is successful arterial entry and exit. The first successful cardiac catheterization, according to Andre Cournand, was performed on an equine patient in 1844 utilizing a retrograde approach through both the jugular vein and carotid artery^[1]. Human retrograde left heart catheterization was first reported by Zimmerman^[2] and Limon-Lason^[3] in 1950. Shortly thereafter in 1953, Seldinger developed the percutaneous technique and this technique was quickly adapted to left heart cardiac catheterizations. With the growth of Interventional Cardiology in the years following Grüntzig’s introduction of coronary angioplasty in 1977^[4], the percutaneous approach became, and today remains, by far the most common method of performing catheterization, angiography and endovascular intervention.

Within the realm of percutaneous approaches, the majority of the procedures are performed from the femoral approach, with a minority being done from a radial approach. Brachial and axillary are also used in a minority of procedures^[5]. Reasons for the continued preference of the femoral route for access includes the vessel size, operator training and equipment, radiation exposure (operator), and the advent of vascular closure devices. Studies have suggested that between 8-10% of all patients selected for a transradial approach will convert to a transfemoral route.^{[6] [7] [8]}

• Require long learning curve
• Small vessel size (<4.0–5.0mm); a contraindication to use
• Non-common femoral artery ‘sticks’; a contraindication to use
• Peripheral vascular disease; a contraindication to use (very common problem)
• Significant endoluminal device components (prone to thrombosis)
• High costs
• Require bed rest post closure
• Impaired or delayed common femoral artery re-entry (re-access concerns)
• Non-inert, very reactive, permanent and absorbable device components (therefore may be prone to infection and common femoral artery scarring)
• Catastrophic complications (1–2%, but may be under-reported)
• Poorly compatible with anticoagulated patients (increased bleeding)

• After an incubation period of 2 to 29 days (average of 8 days) a vascular closure device infection can occur.
• Symptoms include local pain and fever. The pain may improve and then worsen.
• Blood cultures are positive
• Most common pathogen is staphylococcus aureus infecting a mycotic aneurysm
• Medical and surgical treatment are both required

Class I

“1. Patients considered for vascular closure devices should undergo a femoral angiogram to ensure their anatomic suitability for deployment. (Level of Evidence: C)”

Class III (No Benefit)

“1. The routine use of vascular closure devices is not recommended for the purpose of decreasing vascular complications, including bleeding.[10][11][12][13][14][15] (Level of Evidence: B)”

Class IIa

“1. The use of vascular closure devices is reasonable for the purposes of achieving faster hemostasis and earlier ambulation compared with the use of manual compression.[10][11][12][13](Level of Evidence: B)”

Template:WikiDoc Sources

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Class IIa

” 1. In selected patients undergoing PCI, shorter-duration DAPT (1–3 months) is reasonable, with subsequent transition to P2Y12 inhibitor monotherapy to reduce the risk of bleeding events (Level of Evidence A)”.

^[1]

Class III (No Benefit)

“1. In patients with SIHD and normal left ventricular function, the routine use of chronic oral beta-blockers is not beneficial to reduce cardiovascular events after complete revascularization.(Level of Evidence:C-LD ”

^[1]

Class I

“1. In patients with atrial fibrillation who are undergoing PCI and are taking oral anticoagulant therapy, it is recommended to discontinue aspirin treatment after 1 to 4 weeks while maintaining P2Y12 inhibitors in addition to a non–vitamin K oral anticoagulant (rivaroxaban, dabigatran, apixaban, or edoxaban) or warfarin to reduce the risk of bleeding (Level of Evidence: B-R)”

^[1]

Class IIa

” 2. In patients with atrial fibrillation who are undergoing PCI, are taking oral anticoagu-lant therapy, and are treated with DAPT or a P2Y12 inhibitor monotherapy, it is reasonable to choose a non–vitamin K oral anticoagulant over warfarin to reduce the risk of bleeding (Level of Evidence B-R)”.

^[1]

Class I

“1. After PCI, use of aspirin should be continued indefinitely.[3][4][5][6] (Level of Evidence: A)”

“2. The duration of P2Y12 inhibitor therapy after stent implantation should generally be as follows: a. In patients receiving a stent (bare metal stent (BMS) or drug eluting stent (DES)) during PCI for ACS, P2Y12 inhibitor therapy should be given for at least 12 months. Options include clopidogrel 75 mg daily [7], prasugrel 10 mg daily [8], and ticagrelor 90 mg twice daily.[9] (Level of Evidence: B) b. In patients receiving drug eluting stent (DES) for a non-ACS indication, clopidogrel 75 mg daily should be given for at least 12 months if the patient is not at high risk of bleeding.[10][11][12] (Level of Evidence: B) c. In patients receiving bare metal stent (BMS) for a non-ACS indication, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks).[13] (Level of Evidence: B)“

“3. Patients should be counseled on the importance of compliance with dual antiplatelet therapy (DAPT) and that therapy should not be discontinued before discussion with their cardiologist.[12] (Level of Evidence: C)”

Class IIa

“1. After PCI, it is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses.[14][15][16][17][18] (Level of Evidence: B)”

“2. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., less than 12 months) of P2Y12 inhibitor therapy is reasonable. (Level of Evidence: C)”

Class IIb

“1. Continuation of clopidogrel, prasugrel or ticagrelor beyond 12 months may be considered in patients undergoing placement of drug eluting stent (DES).[8][9] (Level of Evidence: C)”

Class I

“1. Proton pump inhibitors should be used in patients with a history of prior gastrointestinal bleeding who require dual antiplatelet therapy (DAPT).[19] (Level of Evidence: C)”

Class III (No Benefit)

“1. Routine use of a proton pump inhibitor is not recommended for patients at low risk of gastrointestinal bleeding, who have much less potential to benefit from prophylactic therapy.[19] (Level of Evidence: C)”

Class IIa

“1. Use of proton pump inhibitors is reasonable in patients with an increased risk of gastrointestinal bleeding (e.g., advanced age, concomitant use of warfarin, steroids, nonsteroidal antiinflammatory drugs, Helicobacter pylori infection) who require dual antiplatelet therapy (DAPT).[19] (Level of Evidence: C)”

Class III (No Benefit)

“1. The routine clinical use of genetic testing to screen patients treated with clopidogrel who are undergoing PCI is not recommended.[20] (Level of Evidence: C)”

Class IIb

“1. Genetic testing might be considered to identify whether a patient at high risk for poor clinical outcomes is predisposed to inadequate platelet inhibition with clopidogrel.[20] (Level of Evidence: C)”

“2. When a patient predisposed to inadequate platelet inhibition with clopidogrel is identified by genetic testing, treatment with an alternate P2Y12 inhibitor (e.g., prasugrel or ticagrelor) might be considered.[20] (Level of Evidence: C)”

Class III (No Benefit)

“1. The routine clinical use of platelet function testing to screen patients treated with clopidogrel who are undergoing PCI is not recommended.[20] (Level of Evidence: C)”

Class IIb

“1. Platelet function testing may be considered in patients at high risk for poor clinical outcomes.[20] (Level of Evidence: C)”

“2. In patients treated with clopidogrel with high platelet reactivity, alternative agents, such as prasugrel or ticagrelor, might be considered.[20] (Level of Evidence: C)”

Class III (No Benefit)

“1. Routine periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed.[21](Level of Evidence: C)”

Class IIa

“1. In patients entering a formal cardiac rehabilitation program after PCI, treadmill exercise testing is reasonable. (Level of Evidence: C)”

Class I

“1. Medically supervised exercise programs (cardiac rehabilitation) should be recommended to patients after PCI, particularly for moderate- to high-risk patients for whom supervised exercise training is warranted.[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47] (Level of Evidence: A)”

Template:WikiDoc Sources

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

“

Goal: Complete cessation, no exposure to environmental tobacco smoke

”

Class I

“1. Status of tobacco use should be asked about at every visit. (Level of Evidence: B)”

“2. Every tobacco user and family members who smoke should be advised to quit at every visit. (Level of Evidence: B)”

“3. The tobacco user’s willingness to quit should be assessed. (Level of Evidence: B)”

“4. The tobacco user should be assisted by counseling and developing a plan for quitting. (Level of Evidence: B)”

“5. Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological treatment) should be arranged. (Level of Evidence: B)”

“6. Exposure to environmental tobacco smoke at work and home should be avoided. (Level of Evidence: B)”

“

Goal: Less than 140/90 mm Hg or less than 130/80 mm Hg if patient has diabetes or chronic kidney disease

”

Class I

“1. For patients with blood pressure greater than or equal to 140/90 mm Hg (or greater than or equal to 130/80 mm Hg for patients with diabetes or chronic kidney disease), it is recommended to initiate or maintain lifestyle modification— weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. (Level of Evidence: B)”

“2. For patients with blood pressure greater than or equal to 140/90 mm Hg (or greater than or equal to 130/80 mm Hg for patients with diabetes or chronic kidney disease), it is useful as tolerated, to add blood pressure medication, treating initially with beta blockers and/or ACE inhibitors, with the addition of other drugs such as thiazides as needed to achieve goal blood pressure. (Level of Evidence: A)”

“

Goal: LDL-C substantially less than 100 mg per dL (If triglycerides are greater than or equal to 200 mg per dL, non–HDL-C should be less than 130 mg per dL.)

”

Class I

“1. Starting dietary therapy is recommended. Reduce intake of saturated fats (to less than 7% of total calories), trans fatty acids, and cholesterol (to less than 200 mg per day). (Level of Evidence: B)”

“2. Promotion of daily physical activity and weight management is recommended. (Level of Evidence: B)”

“3. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated as recommended below before discharge according to the following schedule: ● LDL-C should be less than 100 mg per dL. (Level of Evidence: B) ● If baseline LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be initiated. (Level of Evidence: A) ● If on-treatment LDL-C is greater than or equal to 100 mg per dL, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination) is recommended. (Level of Evidence: A) ● If triglycerides are greater than or equal to 150 mg per dL or HDL-C is less than 40 mg per dL, weight management, physical activity, and smoking cessation should be emphasized. (Level of Evidence: B) ● If triglycerides are 200 to 499 mg per dL, non–HDL-C target should be less than 130 mg per dL. (Level of Evidence: B)“

“4. Therapeutic options to reduce non–HDL-C include: ● More intense LDL-C–lowering therapy is indicated. (Level of Evidence: B)“

“5. If triglycerides are greater than or equal to 500 mg per dL, therapeutic options indicated and useful to prevent pancreatitis are fibrate or niacin before LDL-lowering therapy, and treat LDL-C to goal after triglyceride-lowering therapy. Achieving a non–HDL-C of less than 130 mg per dL is recommended. (Level of Evidence: C)”

Class IIa

“1. Adding plant stanol/sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower LDL-C. (Level of Evidence: A)”

“2. Therapeutic options to reduce non–HDL-C include: ● Niacin (after LDL-C–lowering therapy) can be beneficial. (Level of Evidence: B) ● Fibrate therapy (after LDL-C–lowering therapy) can be beneficial. (Level of Evidence: B)“

“3. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated as recommended below before discharge according to the following schedule: ● If baseline LDL-C is 70 to 100 mg per dL, it is reasonable to treat to LDL-C less than 70 mg per dL. (Level of Evidence: B)“ ● Further reduction of LDL-C to less than 70 mg per dL is reasonable. (Level of Evidence: A)

Class IIa

“1. It may be reasonable to encourage increased consumption of omega-3 fatty acids in the form of fish or in capsules (1 g per day) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. (Level of Evidence: B)”

“2. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated as recommended below before discharge according to the following schedule: ● If triglycerides are 200 to 499 mg per dL, further reduction of non–HDL-C to less than 100 mg per dL is reasonable. (Level of Evidence: B)“

“

Goal: 30 minutes 5 days per week; optimal daily

”

Class I

“1. Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure) is recommended. (Level of Evidence: B)”

“2. For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription. (Level of Evidence: B)”

“3. For all patients, encouraging 30 to 60 minutes of moderate-intensity aerobic activity is recommended, such as brisk walking on most—preferably all—days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work). (Level of Evidence: B)”

Class IIb

“1. Encouraging resistance training 2 days per week may be reasonable. (Level of Evidence: C)”

“

Goal: BMI: 18.5 to 24.9 kg/m2 Waist circumference: men less than 40 inches (102 cm), women less than 35 inches (89 cm)

”

Class I

“1. It is useful to assess BMI and/or waist circumference on each visit and consistently encourage weight maintenance/ reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a BMI between 18.5 and 24.9 kg/m2. (Level of Evidence: B)”

“2. The initial goal of weight-loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. (Level of Evidence: B)”

“3. If waist circumference (measured horizontally at the iliac crest) is 35 inches (89 cm) or greater in women and 40 inches (102 cm) or greater in men, it is useful to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. (Level of Evidence: B)”

“

Goal: HbA1c less than 7%

”

Class I

“1. It is recommended to initiate lifestyle and pharmacotherapy to achieve near-normal HbA1c. (Level of Evidence: B)”

“2. Beginning vigorous modification of other risk factors (e.g.,physical activity, weight management, blood pressure control, and cholesterol management as recommended above) is beneficial. (Level of Evidence: B)”

“3. Coordination of diabetic care with the patient’s primary care physician or endocrinologist is beneficial. (Level of Evidence: C)”

Class I

“1. For all post-PCI stented patients without allergy or increased risk of bleeding, aspirin 162 mg to 325 mg daily should be given for at least 1 month after BMS implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75 mg to 162 mg daily. (Level of Evidence: B)”

Class IIa

“2. In patients for whom the physician is concerned about risk of bleeding, lower-dose 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation. (Level of Evidence: C)”

Class I

“1. For all post-PCI patients who receive a DES, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). (Level of Evidence: B)”

“2. For all post-PCI non-stented STEMI patients, treatment with clopidogrel should continue for at least 14 days. (Level of Evidence: B)”

Class IIa

“1. Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI and non-STEMI patients who undergo PCI without reperfusion therapy. (Level of Evidence: C)”

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief:; Aysha Anwar, M.B.B.S[2]

According to AHA guidelines, routine periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed.^[1] However, there has been a conflicting evidence on benefits of coronary angiography versus clinical follow up to detect major complications such as restenosis and its impact on survival outcome.^[2][3] In the recent ReACT trial 2016, it is demonstrated that there is no difference in clinical benefit when coronary angiography is compared to regular clinical follow up after PCI. Study results demonstrated that there was increased incidence of coronary revascularization with the corornary angiography after one year following PCI but there was no difference in the primary endpoint which included composite of death, MI, stroke, or emergency hospitalizations for acute coronary syndrome or heart failure when compared to regular clinical follow up after 5 years.

Template:WikiDoc Sources

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

To perform percutaneous coronary intervention (PCI), there are two main methods to access the artery; radial artery and femoral artery. Studies have shown that access through radial artery has lower rate of vascular, and bleeding complications, with higher chance of early amubulation and better outcome. However, femoral artery remains the default PCI access in centers where expertise in the transradial approach is unavailable or if the patient has any anatomic or clinical limitations.

• Radial artery and femoral artery are two main methods to access the artery in percutaneous coronary intervention (PCI).^[1]
• The rate of PCI through radial artery catheterization has increased over the past decade and patients usually prefer this approach more that the femoral artery access.^[2][3]
• The following are the advantages of radial artery compared to the femoral artery approach:^[4]
  • Earlier ambulation
  • Lower rate of vascular complications
  • Lower rate of bleeding complications
  • Better cardiovascular outcomes
• It is recommended to evaluate the possibility of future need to radial artery for bypass grafting before using it for PCI. In cases that there is a high likelihood of future CABG, discussion with the patient and the cardiac surgeon is required.^[1]
• Femoral artery remains the default PCI access in centers where expertise in the transradial approach is unavailable or if the patient has any anatomic or clinical limitations.

Class 1 Recommendation, Level of Evidence: A[1]

1.Radial artery approach is recommended over the femoral artery access in patients with acute coronary syndromes (ACS) undergoing PCI due to lower rate of death, vascular and bleeding complications. 2.Radial artery approach is recommended over the femoral artery access in patients with stable ischemic heart disease (SIHD) undergoing PCI due to lower rate access site bleeding and vascular complications.

Template:Cardiac surgery procedures

Template:WH Template:WS