PERCUTANEOUS CORONARY INTERVENTION.

Synonyms: percutaneous transluminal coronary angioplasty (PTCA), formerly known as balloon angioplasty

Percutaneous coronary intervention (PCI) is one of the two coronary revascularisation techniques currently used in the treatment of ischaemic heart disease, the other beingcoronary artery bypass grafting .

PCI involves non-surgical widening of the coronary artery, using a balloon catheter to dilate the artery from within. A metallic stent is usually placed in the artery after dilatation. Antiplatelet agents are also used. Stents may be either bare metal or drug-eluting.

Indications for percutaneous coronary intervention

Note that indications for PCI may change as the procedures continue to be refined, and with emerging evidence.

1. ST segment elevation myocardial infarction (STEMI):

2.When available, angioplasty with stenting is the optimal method of reperfusion for STEMI. The target ‘door to balloon time’ is 90 minutes.

3.As rescue treatment in patients treated by thrombolysis – if there is failure to reperfuse, further ischaemia or further myocardial infarction (MI).

4.As early intervention in patients treated with thrombolysis.

5.Non-ST elevation acute coronary syndrome (NSTACS) – unstable angina and non-ST elevation myocardial infarction (NSTEMI):
For patients who are at medium-to-high risk of subsequent cardiac events, ,( utilise an Internationally accredited method to assess Risk stratification- Such as GRACE SCORE: see Forum), offer angiogram and/or PCI before discharge.

NOTE: Early invasive investigation and revascularisation (compared to conservative treatment) may reduce subsequent MI and refractory angina.

Overall, PCI treatment for non-acute coronary artery disease has shown no evidence of an effect on death or myocardial infarction when compared with medical therapy

.Revascularisation is appropriate for patients with stable angina for: For the following:

Persistent limiting symptoms despite optimal medical therapy.

Certain anatomical patterns of disease or a proven significant ischaemic territory (even in asymptomatic patients).
Significant left main artery stenosis, and significant proximal left anterior descending disease, especially in the presence of multivessel coronary artery disease, are strong indications for revascularisation.

In the most severe patterns of coronary artery disease, CABG appears to offer a survival advantage and a marked reduction in the need for repeat revascularisation (but with a higher risk of a cerebrovascular event), especially in left main artery disease.

Contra-indications and other considerations

Consider the pros and cons of PCI versus optimal drug therapy and/or CABG.

Because anti-platelet drugs are crucially important after PCI (to prevent thrombosis in the stent, see below), decisions about PCI and the type of stent used must bear in mind.
Is there likelihood that surgery will be needed? Consider the increased risk of bleeding with antiplatelet drugs, but risk of thrombosis if these drugs are stopped.
Can the patient adhere to antiplatelet treatment.
Any contra-indications to antiplatelet drugs.

The above offers an overview , on this key aspect of Ischaemic coronary artery disease. Carefully assessed clinical considerations, for each individual patient, coupled with experience and co discussions in management, by the Medical and surgical teams, and perhaps the patients views, are important in decision making.

See Part 2 for Procedure, types of stent.

G Mohan.