Indication for PCI

Lecture for Master degree students

Mohammed Al-Kebsi
Outlines
PCI (Percutaneous Coronary Intervention)
STEMI
NSTE Acute Coronary Syndrome
Stable CAD
PCI vs CABG
LM disease
Multivessel disease
Diabetes
Outlines
PCI (Percutaneous Coronary Intervention)
STEMI
NSTE Acute Coronary Syndrome
Stable CAD
PCI in Specific Anatomic Situations
INTRODUCTION
Research continues to show that percutaneous coronary intervention
(PCI) is over-utilized in the United States.
More than 1 in 10 PCIs is inappropriate according to published criteria.
In patients with stable CAD, although PCI in addition to medical
treatment reduced the prevelance of angina, it did not reduce long term
rate of death and non-fatal MI.
Outlined some of the latest tools to help you
make smarter care decisions for PCI candidates
GNL 2011
Ethical Considerations
Place the patients best interest first and foremost when making
clinical decisions (beneficence).
Ensure that patients actively participate in decisions affecting their
care (autonomy).
Consider how decisions regarding one patient may also affect other
patients and providers (justice).
Plan and perform procedures and provide care with the intention of
improving the patients quality of life and/or decreasing the risk of
mortality, independent of reimbursement considerations and without
inappropriate bias or influence from industry, administrators,
referring physicians or other sources.
GNL 2011
Ethical Considerations
Before performing procedures, obtain informed consent after giving
an explanation regarding details of the procedure, risks and benefits
of both the procedure and alternatives to the procedure.
Plan and perform procedures according to standards of care and
recommended guidelines, and deviate from them when appropriate
or necessary to the care of individual patients.
Seek advice, assistance or consultation from colleagues when such
consultation would benefit the patient.
Optimal medical Tx should be
given to all CAD patients
Primary classification of CAD patient in
need of revascularization (PCI)
Acute ST-elevation myocardial infarction (STEMI)
NonST-elevation acute coronary syndrome (NSTE-ACS)
Stable angina
Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope)
Asymptomatic or mildly symptomatic patient with objective evidence of a
moderate-sized to large area of viable myocardium or moderate to
severe ischemia on noninvasive testing
Angiographic indications include hemodynamically significant lesions in
vessels serving viable myocardium (vessel diameter >1.5 mm).
Outlines
PCI (Percutaneous Coronary Intervention)
STEMI
NSTE Acute Coronary Syndrome
Stable CAD
PCI in Specific Anatomic Situations
PCI In acute STEMI
*Systems goal of performing primary PCI within 90 minutes of first medical contact when the patient
presents to a hospital with PCI capability (Class I, LOE: B), and within 120 minutes when the patient
presents to a hospital without PCI capability (Class I, LOE: B).
PCI in STEMI pPCI
Delayed or elective PCI in STEMI patient
Non-primary PCI
PCI in STEMI patient
With failed thrombolysis
Delayed or elective PCI in STEMI patient
Non-primary PCI
PCI in Cardiogenic Shock
Recommendations for Initial Reperfusion Therapy When
Cardiogenic Shock Complicates STEMI
*UA/NSTEMI GL with additional and more comprehensive recommendations
**Early invasive strategy = diagnostic angiography with intent to perform revascularization
***Recs from the 2011 UA/NSTEMI focused update (not in PCI GL)
UA/NSTEMI: Choice of Strategy*
General Considerations in Deciding Between an Early Invasive Strategy
and an Initial Conservative Strategy in UA/NSTEMI
Age 65 years
= 3 risk factors (hypertension, diabetes mellitus, family history,
lipids, smoking)
Known CAD (stenosis 50%)
Aspirin use in past 7 days
Severe angina (2 episodes within 24 hours)
ST-segment deviation 0.5 mm
Elevated cardiac markers
Risk of death or ischemic event through 14 days
Low: 02 (8.3% event rate)
Intermediate: 34 (19.3% event rate)
High: 57 (41% event rate).
TIMI Risk Scorefor Patients With Suspected
ACS- Variables (1 point each)
Appropriateness Criteria, 2012
Revascularization Criteria
~200 Clinical scenarios rated by 17 experts Based upon the
potential benefit to be gained from PCI. Patients stratified by
Severity of coronary anatomy (1-, 2-, 3-vessel disease, with
or without proximal left anterior descending artery [LAD] or
left main coronary disease).
Magnitude of ischemia on noninvasive testing and the
presence or absence of other prognostic factors, such as
congestive heart failure (CHF), depressed left ventricular
function, or diabetes
Intensity of medical therapy
Severity of symptoms (asymptomatic, Canadian
Cardiovascular Society [CCS] Class I, II, III, or IV)
CONSIDERATION for the appropriate use of
revascularization:
Clinical status/symptom complex, ischemic burden by
noninvasive functional testing.
Assume LM coronary artery stenosis (greater than or equal to
50% or proximal LAD stenosis (greater than or equal to 70%
borderline angiographic stenosis (50% to 60%) in epicardial
(non-left main) locations.
A significant stenosis for the purpose of the clinical scenarios
is defined as: Greater than or equal to 70% luminal diameter
narrowing, by visual assessment, of an epicardial stenosis
measured in the worst view angiographic projection.
All patients are receiving standard care, risk factor modification for
primary or secondary prevention.
In chronic stable angina, The specific definition of maximal anti-
ischemic medical therapy includes the use of 2 or more anti- anginal
medications.
Operators performing PCI or CABG have appropriate clinical training
and experience and have satisfactory outcomes as assessed by
quality ass. monitoring.
Revascularization by either PCI or CABG is performed in standards
of care.
CONSIDERATION for the appropriate use of
revascularization:
13 scenarios for acute coronary syndromes
36 scenarios for non-ACS without prior bypass surgery
12 scenarios for non-ACS with prior bypass surgery
8 scenarios for advanced CAD, CCS III or IV, and/or intermediate-
to high-risk findings on non-invasive testing
AUC 2012: The Whole Thing
69 Categories of Indications
Rating of Indications
appropriate use criteria (AUC)
7-9 (A):
Appropriate for the indication provided, meaning coronary revasc is
generally acceptable and is a reasonable approach for the indication and
is likely to improve the patients health outcomes or survival.
4-6 (U):
Uncertain for the indication provided, meaning coronary revasc may be
acceptable and may be a reasonable approach for the indication but with
uncertainty implying that more research and/or patient information is
needed to further classify the indication.
1-3 (I):
Inappropriate for the indication provided, meaning coronary revasc is not
generally acceptable and is not a reasonable approach for the indication
and is unlikely to improve the patients health outcomes or survival.
Uncertain and Inappropriate
Uncertain does NOT indicate that the procedure should NOT be
performed for that indication, but rather more
information/research is need to reach a firm conclusion
Uncertain does NOT indicate that the procedure should not be
reimbursed for that indication
AUC 2012: Indications
AUC 2012: Indications
In the clinical scenarios, no unusual extenuating circumstances
exist (such as inability to comply with antiplatelet agents, do not
resuscitate status, patient unwilling to consider revascularization,
technically notfeasible to perform revascularization, or comorbidities
likely to markedly increase procedural risk substantially)
Assume coronary angiography has been performed when these
findings are presented in the indications.
CONSIDERATION for the appropriate use of
revascularization:
Outlines
PCI (Percutaneous Coronary Intervention)
STEMI
NSTE Acute Coronary Syndrome
Stable CAD
PCI in Specific Anatomic Situations
Recommendations for PCI in Chronic Stable
Angina Patients
The decision to revascularization should be based on:
the presence of significant obstructive coronary artery stenosis
the amount of ischaemia induced by the stenosis
There are several anatomical conditions that, per se, may imply the
need for revascularization to improve prognosis regardless the
presence of symptoms:
significant left main disease with or without significant stenoses
in the three other vessels.
last remaining vessel.
multi-vessel disease with left ventricular dysfunction).
the presence of large areas of ischaemia (.10% by SPECT, for
instance) in the territory supplied by the stenosed artery or a
FFR 0.80 also indicate the need for revascularization.
Recommendations for PCI in Chronic Stable
Angina Patients
Having settled the indication for revascularization, technical
feasibility should be assessed. Feasibility should not anticipate or
substitute a definitive indication.
In the event that a prognostic benefit of revascularization is not
anticipated (ischaemia less 10% of the left ventricle), or that
revascularization is technically not possible or potentially difficult, or
would be high-risk, the patient should remain on optimal medical
therapy. According to residual symptoms or the presence of a large
burden of ischaemia, additional therapies can be used.
When the benefit of revascularization can be anticipated and when
it is technically feasible, revascularization can be performed for
relief of pain and disability or to prolong or save lives.
Recommendations for PCI in Chronic Stable
Angina Patients
The decision-making process can be based on:
the anatomical scenario (e.g. single-vessel vs. multi-vessel vs.
left main disease), then on a few additional anatomical factors
(e.g. Chronic total occlusions (CTO) vs. non-CTO, ostial vs.
nonostial, bifurcation vs. non-bifurcation, angiographic scores,
etc)
Clinical conditions (diabetes, low EF vs. normal EF, renal
impairment, co-morbidities, age, gender, prior revascularization,
concomitant medication, etc.),
operator- or centre-related factors.
logistical factors (availability, cost of the procedure, etc).
Decision making according to severity of symptoms/ischaemia
Overall, medical therapy is recommended as first-line
therapy in patients with stable angina unless 1 or more
of the following indications for cardiac catheterization
and PCI or CABG are present:
A change in symptom severity
Failed medical therapy
High-risk coronary anatomy
Worsening LV dysfunction
Recommendations for PCI in Chronic
Stable Angina Patients
PCI I stable CAD (summary)
Asymptomatic patients who have no evidence of ischemia or
other abnormalities (for example: arrhythmias) on adequate
non-invasive testing are at very low risk for cardiac events. In
these patients, coronary angiography is unlikely to add
appreciable prognostic value .
Avoid coronary angiography to assess risk in asymptomatic
patients with no evidence of ischemia or other abnormalities on
adequate non-invasive testing.
For patients with stable ischemic heart disease, in the absence
of symptoms, there is limited clinical benefit to PCI unless
performed on a lesion with demonstrable hemodynamic
significance (FFR <0.8) or causing a significant amount of
ischemia as assessed by n on-invasive stress testing.
Rare exceptions would be a significant left main coronary artery
lesion or a >90% proximal lesion in a major coronary artery.
Outlines
PCI (Percutaneous Coronary Intervention)
STEMI
NSTE Acute Coronary Syndrome
Stable CAD
PCI in Specific Anatomic Situations
Revascularization Before Non-cardiac Surgery
SVG PCI
PCI in Specific Anatomic Situations
Five Things Physicians
and Patients Should Question
Avoid performing routine stress testing after percutaneous coronary
intervention (PCI) without specific clinical indications.
Avoid coronary angiography in post-coronary artery bypass
graft(CABG) and post-PCI patients who are asymptomatic, or who have
normal or mildly abnormal stress tests and stable symptoms not limiting
quality of life.
Avoid coronary angiography for risk assessment in patients with stable
ischemic heart disease (SIHD) who are unwilling to undergo
revascularization or who are not candidates for revascularization based
on comorbidities or individual preferences.
Avoid coronary angiography to assess risk in asymptomatic patients
with no evidence of ischemia or other abnormalities on adequate non-
invasive testing.
Avoid PCI in asymptomatic patients with stable SIHD without the
demonstration of ischemia on adequate stress testing or with normal
fractional flow reserve (FFR) testing.