Acute Coronary: Percutaneous Coronary Intervention

⚠️ Always consult cardiology before discontinuing antiplatelet therapy after stent insertion. 🚫 Stopping clopidogrel or other antiplatelets too early (especially with drug-eluting stents) risks catastrophic in-stent thrombosis. 🕐 Standard practice: Dual Antiplatelet Therapy (DAPT) - aspirin + clopidogrel/ticagrelor/prasugrel - for 6–12 months, with aspirin often lifelong. 👉 Local / guideline variations exist, so confirm with the cardiology team.

ℹ️ About

• PCI (Percutaneous Coronary Intervention): Opens blocked coronary arteries using balloons and stents to restore perfusion. Improves angina symptoms and quality of life, though elective PCI does not significantly reduce overall mortality.
• Originally developed to select candidates for CABG, PCI is now a primary treatment for many acute coronary syndromes (ACS).
• Widespread catheterization labs, even in district hospitals, allow rapid reperfusion without immediate need for cardiac surgery backup.

🧩 Stents

• 🛠️ Stents = metallic scaffolds to keep an artery open after balloon angioplasty.
• 🚑 Deployed via femoral or radial approach using guidewires and balloons under fluoroscopy.
• 💊 Drug-Eluting Stents (DES): Coated with antiproliferative drugs (e.g., sirolimus, paclitaxel) to reduce restenosis risk. Preferred in diabetics and complex lesions.
• ⚡ Difficult lesions: Long, calcified, eccentric, bifurcation, thrombotic, or tortuous arteries.
• 🩸 DAPT: Almost all patients receive aspirin + clopidogrel (or ticagrelor/prasugrel) for 6–12 months after PCI.

🏥 Indications (Mortality Benefit)

• 🚨 STEMI: Primary PCI within 90 minutes of first medical contact.
• 🚑 STEMI with hemodynamic compromise or failed thrombolysis.
• ⚡ STEMI in thrombolysis-contraindicated patients (e.g., recent intracranial hemorrhage).

📋 Other Indications

• High-risk NSTEMI.
• Unstable angina with high-risk features.
• Unexplained ischemic cardiomyopathy.
• Survivors of cardiac arrest where ischemia is suspected.
• Significant ventricular arrhythmias (VT) due to ischemic substrate.

🔍 Vascular Access

• Common sites: Radial artery (preferred for lower bleeding risk), femoral artery, or brachial artery.

📝 Protocol

• 🖊️ Consent: Mortality risk ~0.1% for diagnostic angiography, higher with PCI complexity.
• 🩸 Pre-procedure checks: FBC, platelets, U&Es, renal function, glucose, and peripheral pulses.
• 💊 Consider acetylcysteine in renal impairment (contrast nephropathy prevention - though evidence is mixed).
• 🚫 Fast for 6 hours, continue aspirin, load clopidogrel/ticagrelor as advised.

⚙️ Interventions

• 🎈 Balloon Angioplasty: Rarely used alone; risk of restenosis high.
• 🧱 Bare Metal Stents (BMS): Reduce restenosis vs balloon, but higher thrombosis risk. Shorter DAPT course than DES.
• 💊 Drug-Eluting Stents (DES): Reduce neointimal hyperplasia and restenosis; require longer DAPT.
• 🔀 Referral for CABG: Triple-vessel disease or significant left main stem involvement.

⚠️ Post-Procedure Complications

• 💉 Bleeding: At access site or retroperitoneal (suspect if hypotension + tachycardia).
• 🦵 Limb Ischemia: Cold, pale leg from thrombosis or dissection → urgent vascular review.
• 📈 Acute Stent Thrombosis: Presents like STEMI → urgent repeat PCI.
• 💧 Contrast Nephropathy: Monitor U&Es, hydrate well.
• 🧠 Stroke: Rare but serious embolic complication.
• 🦠 Infection / pseudoaneurysm / AV fistula: At puncture site, confirmed by ultrasound.

📚 Exam Tip: 👉 Always mention DAPT duration when discussing PCI. 👉 Drug-eluting stents reduce restenosis but require longer antiplatelet therapy. 👉 Radial access = fewer bleeding complications vs femoral.