Percutaneous Coronary Intervention (PCI)

OVERVIEW

  • Percutaneous coronary intervention (PCI) is the preferred emergency reperfusion strategy in most cases of ST elevation myocardial infarction (STEMI)
  • PCI is also performed following non-ST elevation ACS (NSTEACS), though the timing depends on how ‘at risk’ the patient is

ACTIVATION OF THE CATH LAB

  • Current guidelines recommend that a specific hospital CODE call (e.g. “CODE STEMI”) should be activated
  • This alerts all personnel required to perform coronary angiography and PCI in a timely manner
  • Personnel involved should include:
    • interventional cardiologist
    • Emergency Department staff
    • Angiography suite staff
    • Coronary Care Unit

INDICATIONS FOR PCI

STEACS

  • All cases suitable for intervention are done emergently.
  • PCI is the preferred reperfusion strategy providing:
    • can be achieved within 90min of arrival to the ED
    • symptom onset within the previous 12h

NSTEACS

  • Time frames vary according to the level of risk.
    • Very High Risk NSTEACS: within 2h
    • High Risk NSTEACS: within 24h
    • Intermediate Risk NSTEACS: within 72h
    • Low Risk NSTEACS (no recurrent symptoms and no risk criteria): selective invasive strategy guided by provocative testing for inducible ischaemia

RISK STRATIFICATION OF PATIENTS WITH CONFIRMED ACS

Very High Risk

  • Haemodynamic instability:
    • Heart failure/ cardiogenic shock
    • Mechanical complications of myocardial infarction
  • Life-threatening arrhythmias or cardiac arrest
  • Recurrent or ongoing ischaemia (e.g. chest pain refractory to medical treatment) or recurrent dynamic ST segment and/or T wave changes, particularly with:
    • Intermittent ST segment elevation
    • de Winter T wave changes
    • Wellens syndrome (or LMCA syndrome)
    • Widespread ST elevation in two or more coronary territories

High Risk

  • Rise and/or fall in troponin level consistent with myocardial infarction
  • Dynamic episode of ST segment and/or T wave changes with or without symptoms
  • GRACE score >140

Intermediate Risk

  • Diabetes mellitus
  • Renal insufficiency (glomerular filtration rate < 60mL/min/1.73m2)
  • Left ventricular ejection fraction ≤ 40 %
  • Prior revascularization:
    • Percutaneous coronary intervention
    • Coronary artery bypass grafting
  • GRACE score >109 and <140

Low Risk

  • Patients with NSTEACS who have both of:
    • no recurrent symptoms
    • no risk criteria (as listed above)

MANAGEMENT

Initial management in the ED

  • Call Code STEMI and facilitate expeditious transfer to the Cath Lab
  •  Resuscitation
    • attend to ABCs
    • address immediate life threats
  • Control of pain
    • nitrates/ morphine as indicated
  • Aspirin 300mg po
  • Ticagrelor 180 mg (loading dose)
    • assess bleeding risk before administration
    • avoid if emergency coronary artery bypass grafting is likely
  • Anticoagulation therapy
    • initial 5,000 unit heparin IV bolus (preferred to subcutaneous fractionated heparins (e.g. enoxaparin) to reduce risk of bleeding complications during PCI)
    • if enoxaparin has already been given, or there prior thrombolysis gas been performed, PCI can still be performed
  • Glycoprotein IIb/IIIa inhibitor therapy
    • also recommended in patients who are to receive urgent PCI.
    • options include:
      • Integrilin (eptifibatide)
      • Reopro (Abciximab)
      • Aggrastat (Tirofiban)
  • Bivalirudin (direct thrombin inhibitor)
    • can be considered as an alternative to heparin and GP IIb/IIIa inhibitors for patients with STEMI undergoing primary PCI

Other considerations

  • If cardiac arrest occurs, consider transfer to the cath lab with mechanical CPR in progress
  • ECMO-CPR (if available) may be performed prior to, or following, transfer to the cath lab depending on logistics
  • Consider with-holding glycoprotein IIb/IIIa inhibitor therapy if mechanical CPR and/or ECMO-CPR is required

Disposition post-PCI

  •  all patients should then be admitted to CCU or ICU
  • if complications may arise during PCI, transfer to a cardiothoracic surgery center may be required

ASSESSMENT OF BLEEDING RISK

  • The routine use of a validated risk stratification tool, such as the CRUSADE Score, for bleeding events assists with individual patient clinical decision making
  • The CRUSADE Score is available on MDCALC [CRUSADE Score for Post-MI Bleeding Risk]
  • The CRUSADE score risk stratifies patients for bleeding complications according to 8 parameters:
    • Heart Rate
    • Systolic Blood Pressure
    • Hematocrit
    • Creatinine Clearance
    • Sex
    • Signs of CHF at Presentation
    • History of Vascular Disease
    • History of Diabetes Mellitus

References and Links

  • Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. The Medical journal of Australia. 205(3):128-33. 2016. [pubmed]
  • Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart, lung & circulation. 25(9):895-951. 2016. [pubmed] [free full text]
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Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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