Risk reduction after PCI

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Overview

Risk Stratification and Benefits of PCI

Preparation of the Patient for PCI

Equipment Used During PCI

Pharmacotherapy to Support PCI

Vascular Closure Devices

Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

Post-PCI Management

Risk Reduction After PCI

Post-PCI follow up

Hybrid coronary revascularization

PCI Complications

Factors Associated with Complications
Vessel Perforation
Dissection
Distal Embolization
No-reflow
Coronary Vasospasm
Abrupt Closure
Access Site Complications
Peri-procedure Bleeding
Restenosis
Renal Failure
Thrombocytopenia
Late Acquired Stent Malapposition
Loss of Side Branch
Multiple Complications

PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
Severely Depressed Ventricular Function
Sole Remaining Conduit
Unprotected Left Main Patient
Adjuncts for High Risk PCI

PCI in Specific Lesion Types

Classification of the Lesion
The Calcified Lesion
The Ostial Lesion
The Angulated or Tortuous Lesion
The Bifurcation Lesion
The Long Lesion
The Bridge Lesion
Vasospasm
The Chronic Total Occlusion
The Left Internal Mammary Artery
Multivessel Disease
Distal Anastomotic Lesions
Left Main Intervention
The Thrombotic Lesion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Risk Reduction After PCI

2007 Focused Update of the PCI Focused Update ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention (DO NOT EDIT)[1]

Comprehensive Risk Reduction for Patients With Coronary and Other Vascular Disease After PCI (DO NOT EDIT)[1]

Smoking (DO NOT EDIT)[1]

Goal: Complete cessation, no exposure to environmental tobacco smoke

Class I
"1. Status of tobacco use should be asked about at every visit. (Level of Evidence: B)"
"2. Every tobacco user and family members who smoke should be advised to quit at every visit. (Level of Evidence: B)"
"3. The tobacco user’s willingness to quit should be assessed. (Level of Evidence: B)"
"4. The tobacco user should be assisted by counseling and developing a plan for quitting. (Level of Evidence: B)"
"5. Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological treatment) should be arranged. (Level of Evidence: B)"
"6. Exposure to environmental tobacco smoke at work and home should be avoided. (Level of Evidence: B)"

Blood Pressure Control (DO NOT EDIT)[1]

Goal: Less than 140/90 mm Hg or less than 130/80 mm Hg if patient has diabetes or chronic kidney disease

Class I
"1. For patients with blood pressure greater than or equal to 140/90 mm Hg (or greater than or equal to 130/80 mm Hg for patients with diabetes or chronic kidney disease), it is recommended to initiate or maintain lifestyle modification— weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. (Level of Evidence: B)"
"2. For patients with blood pressure greater than or equal to 140/90 mm Hg (or greater than or equal to 130/80 mm Hg for patients with diabetes or chronic kidney disease), it is useful as tolerated, to add blood pressure medication, treating initially with beta blockers and/or ACE inhibitors, with the addition of other drugs such as thiazides as needed to achieve goal blood pressure. (Level of Evidence: A)"

Lipid Management (DO NOT EDIT)[1]

Goal: LDL-C substantially less than 100 mg per dL (If triglycerides are greater than or equal to 200 mg per dL, non–HDL-C should be less than 130 mg per dL.)

Class I
"1. Starting dietary therapy is recommended. Reduce intake of saturated fats (to less than 7% of total calories), trans fatty acids, and cholesterol (to less than 200 mg per day). (Level of Evidence: B)"
"2. Promotion of daily physical activity and weight management is recommended. (Level of Evidence: B)"
"3. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated as recommended below before discharge according to the following schedule:
LDL-C should be less than 100 mg per dL. (Level of Evidence: B)
● If baseline LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be initiated. (Level of Evidence: A)
● If on-treatment LDL-C is greater than or equal to 100 mg per dL, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination) is recommended. (Level of Evidence: A)
● If triglycerides are greater than or equal to 150 mg per dL or HDL-C is less than 40 mg per dL, weight management, physical activity, and smoking cessation should be emphasized. (Level of Evidence: B)
● If triglycerides are 200 to 499 mg per dL, non–HDL-C target should be less than 130 mg per dL. (Level of Evidence: B)"
"4. Therapeutic options to reduce non–HDL-C include:
● More intense LDL-C–lowering therapy is indicated. (Level of Evidence: B)"
"5. If triglycerides are greater than or equal to 500 mg per dL, therapeutic options indicated and useful to prevent pancreatitis are fibrate or niacin before LDL-lowering therapy, and treat LDL-C to goal after triglyceride-lowering therapy. Achieving a non–HDL-C of less than 130 mg per dL is recommended. (Level of Evidence: C)"
Class IIa

"1. Adding plant stanol/sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower LDL-C. (Level of Evidence: A)"

"2. Therapeutic options to reduce non–HDL-C include:

Niacin (after LDL-C–lowering therapy) can be beneficial. (Level of Evidence: B)
Fibrate therapy (after LDL-C–lowering therapy) can be beneficial. (Level of Evidence: B)"

"3. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated as recommended below before discharge according to the following schedule:

● If baseline LDL-C is 70 to 100 mg per dL, it is reasonable to treat to LDL-C less than 70 mg per dL. (Level of Evidence: B)"
● Further reduction of LDL-C to less than 70 mg per dL is reasonable. (Level of Evidence: A)
Class IIa
"1. It may be reasonable to encourage increased consumption of omega-3 fatty acids in the form of fish or in capsules (1 g per day) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. (Level of Evidence: B)"
"2. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid-lowering medication is indicated as recommended below before discharge according to the following schedule:
● If triglycerides are 200 to 499 mg per dL, further reduction of non–HDL-C to less than 100 mg per dL is reasonable. (Level of Evidence: B)"

Physical Activity (DO NOT EDIT)[1]

Goal: 30 minutes 5 days per week; optimal daily
Class I
"1. Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure) is recommended. (Level of Evidence: B)"
"2. For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription. (Level of Evidence: B)"
"3. For all patients, encouraging 30 to 60 minutes of moderate-intensity aerobic activity is recommended, such as brisk walking on most—preferably all—days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work). (Level of Evidence: B)"
Class IIb

"1. Encouraging resistance training 2 days per week may be reasonable. (Level of Evidence: C)"

Weight Management (DO NOT EDIT)[1]

Goal: BMI: 18.5 to 24.9 kg/m2

Waist circumference: men less than 40 inches (102 cm), women less than 35 inches (89 cm)

Class I
"1. It is useful to assess BMI and/or waist circumference on each visit and consistently encourage weight maintenance/ reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a BMI between 18.5 and 24.9 kg/m2. (Level of Evidence: B)"
"2. The initial goal of weight-loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. (Level of Evidence: B)"
"3. If waist circumference (measured horizontally at the iliac crest) is 35 inches (89 cm) or greater in women and 40 inches (102 cm) or greater in men, it is useful to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. (Level of Evidence: B)"

Diabetes Management (DO NOT EDIT)[1]

Goal: HbA1c less than 7%

Class I
"1. It is recommended to initiate lifestyle and pharmacotherapy to achieve near-normal HbA1c. (Level of Evidence: B)"
"2. Beginning vigorous modification of other risk factors (e.g.,physical activity, weight management, blood pressure control, and cholesterol management as recommended above) is beneficial. (Level of Evidence: B)"
"3. Coordination of diabetic care with the patient’s primary care physician or endocrinologist is beneficial. (Level of Evidence: C)"

Aspirin (DO NOT EDIT)[1]

Class I
"1. For all post-PCI stented patients without allergy or increased risk of bleeding, aspirin 162 mg to 325 mg daily should be given for at least 1 month after BMS implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75 mg to 162 mg daily. (Level of Evidence: B)"
Class IIa
"2. In patients for whom the physician is concerned about risk of bleeding, lower-dose 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation. (Level of Evidence: C)"

Clopidogrel (DO NOT EDIT)[1]

Class I
"1. For all post-PCI patients who receive a DES, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). (Level of Evidence: B)"
"2. For all post-PCI non-stented STEMI patients, treatment with clopidogrel should continue for at least 14 days. (Level of Evidence: B)"
Class IIa
"1. Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI and non-STEMI patients who undergo PCI without reperfusion therapy. (Level of Evidence: C)"

References


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