Percutaneous coronary intervention

STEMI

Treatment of choice in hospitals with an experienced team
In particular consider acute angioplasty for patients:
- with contraindications to thrombolysis
- presenting within 4h of a large anterior MI
- in whom MI may be due to vein graft occlusion
- with cardiogenic shock (poor prognosis even when treated with thrombolysis)
aim for balloon inflation within 60 minutes of arrival in hospital
evidence suggests that in patients presenting to a hospital without the facilities for PCI, transfer to a hospital with the appropriate facilities (including an experienced team) or PCI is associated with a better outcome if transfer can be completed sufficiently rapidly for PCI to start within 2 hours.
addition of glycoprotein IIa/IIIb inhibitor (eg abciximab) further reduces mortality
unclear whether use of PCI following thrombolysis reduces mortality or recurrent infarction. Thrombolysis following PCI does not reduce infarct size and increases bleeding
in patients with cardiogenic shock revascularization (PCI or CABG) results in increased 6 month and 1 year survival although 30 day survival is unaltered

Early invasive strategy for:

Recurrent angina at rest or low-level activity despite intensive anti-ischaemic therapy
Elevated TnT or TnI
New or presumed new ST-depression at presentation
Recurrent angina/ischaemia with CHF symptoms
High-risk findings on non-invasive stress testing
Depressed LV function on non-invasive study (ejection fraction<40%)
Haemodynamic instability or angina at rest or hypotension
Sustained VT
Percutaneous coronary intervention within 6 month
Prior CABG
Repeated admissions for acute coronary syndrome despite therapy without evidence of ongoing ischaemia or high risk

Aims:
- improve prognosis
- relieve symptoms
- prevent ischaemic complications
- improve functional capacity