Post-PCI management focuses on access site monitoring for bleeding, monitoring vitals and biomarkers to check for complications, ensuring proper medication and discharge instructions. Key aspects include checking access sites and vitals frequently initially, checking biomarkers if symptoms occur or complications seen, providing clear instructions on medication, activity levels, and follow up care. Proper post-PCI management aims to monitor for complications while allowing for safe recovery and secondary prevention education.
2. INTRODUCTION
• PCI is one of the most common procedures in the US, and remain a
cornerstone in the management of ischemic heart disease.
• Historically, a large proportion of PCI procedures were performed
during inpatient hospitalization, allowing for a significant amount of
time for monitoring postprocedure to ensure procedural success &
identify bleeding or vascular complications, as well as for initiating
secondary prevention.
• However, technological pharmacological and procedural innovations,
as well as payer expectations and cost considerations, have led to a
shorter length of stay postprocedure and obviate hospital admission.
• Most non-acute MI PCIs performed in the US now are performed
under an outpatient designation.
3. POST-PCI DISCHARGE PLANNING
• Discharge planning following PCI should begin prior to the procedure,
with an emphasis on gathering information regarding preprocedure
activity level, medication adherence, and patient social support at
home.
• Postprocedure management focuses on:
• Access site management and monitoring for new ischemia and bleeding or
vascular
4. PHYSICIAN-TO-PATIENT COMMUNICATION
• The result of the procedure, including any complications and/or
unexpected findings, should be explained clearly to the patient and
his/her family
• The type of intervention, if any, and the duration of DAPT should also
be introduced and reinforced repeatedly by the team of care
providers throughout the patient stay.
5. ACCESS SITE MANAGEMENT
• Typically, manual compression, a compression device, and/or a vascular
closure device (VCD) is used in patients following transfemoral access,
whereas a wristband compression device is used most frequently among
patients undergoing transradial access.
• For patients undergoing transfemoral access and anticoagulated with
heparin, the access sheats can generally be removed once the ACT falls
below 175 sec if a closure device is not used.
• The use of bivalirudin typically does not necessitate checking an ACT unless
there is significant renal impairment (i.e., crcl<30ml/min, or hemodialysis);
in that situation sheath may be removed once the ACT falls below 180 sec.
• In patients without significant renal dysfunction, the femoral sheath can be
removed 2 hours after the discontinuation of the bivalirudin infusion if a
closure device is not used
6. POST PROCEDURE AMBULATION
• The access site, method of hemostasis, intensity of procedure sedation, and
anticoagulation strategy drive recommendations for activity immediately
postprocedure.
• Patients undergoing TR catheterization may ambulate as soon as sedation
wanes.
• For patients undergoing tranfemoral catheterization and PCI, strict bed rest is
typically recommended for 4-8 hours if manual compression is used or 1-4
hour if a VCD is used.
• Prior to ambulation, a care provider must ensure that hemostasis is achieved
and there is no diminution of downstream pulses.
8. POST-PCI MONITORING OF CARDIAC BIOMARKERS
• To assess for evidence of periprocedural myocardial damage.
• Historically, cardiac biomarkers had been checked serially every 8-12
hours postprocedure, however, the routine measurements of cardiac
biomarkers post-PCI is controversial, because biomarker elevation in
absence of clear evidence of adverse clinical outcomes may lead to a
longer hospital length of stay, unnecessary evaluation and testing and
increasing potentials for iatrogenic complications.
• Traditionally, CKMB levels were checked routinely post PCI; but now,
there has been a transition to cTn
9. BIOMARKER ELVATION PATTERN THIRD DEFINITION OF MI CLINICALLY RELEVENT MI
Normal biomarkers at baseline Elevation of cTn>5x99th
percentile URL and either:
(a) evidence of prolonged
ischemia;
(b) ischemic ST changes or new Q
waves;
(c) angiographic evidence of flow
limiting lesions;
(d) imaging evidence of loss of
viable myocardium
Peak CKMB (cTn) rises to ≥10x ULN
(≥70xULN for cTn) or
≥5xULN (≥35x ULN for cTn) with new
pathologic Q waves in ≥2 contiguous
leads or new LBBB
Elevated at baseline but stable >20% rise of cTn from the most
recent preprocedure value
CKMB (or cTn) rises by absolute
increment as those described above
from the most recent preprocedure
lvevel
Elevated at baseline and not stable
or falling
No guidance CKMB (or cTn) rises by absolute
increment as those described above
from the most recent procedure
level+ ST-elevation or depression
along with signs of clinically relevant
MI (new/worsening HF, hypotension,
etc.)
10. CURRENT RECOMMENDATIONS
• Class I: Measurement of CKMB or cTn value for patients with signs or
symptoms of MI or in asymptomatic patients with
significant persistent angiographic complications such as
large scale occlusion no-reflow, or thrombosis
• Class IIb: Routine measurement of cardiac biomarkers in all patients
post PCI
In absence of routine testing, a consensus document recommends
performing an ECG 1-4 hours postprocedure after an uncomplicated PCI; if
normal, biomarkers do not need to be checked
In the presence of clinical symptoms, angiographic complications, or ECG
changes, CKMB (or cTn if CKMB is unavailable) should be measurement 8-12
hours postprocedure, and if elevated, every 8-12 hours thereafter until they
peak.
11. MONITORING OF PLATELET FUNCTION
• To access the degree of platelet reactivity
• High level of platelate reactivity have been associated with adverse outcomes
• GRAVITAS & ARCTIC trials did not show a reduction in the primary composite
end points
• Routine platelet function testing is not currently recommended
12. RENAL FUNCTION MONITORING
• Postprocedure renal injury is common
• Causes- preexisting renal insufficiency
aortic atheroembolism
contrast induced injury
• Only strategy proven to minimize risk include- volume expansion &
minimization of contrast use.
• Creatinine increase is observed 48-72 hours post-PCI (limited utility in
measuring renal function within the first 24 hour)
• SCAI recommendation-patient at increased risk for CIN should have a
serum creatinine value checked about 5-7 days post procedure
13. DISCHARGE PHYSICAL EXAMINATION
• Generally full physical examination prior to discharge
• Additional focus –
• Access site inspection- to ensure adequate hemostasis and perfusion.
• Distal pulse palpation- to ensure no decrease in downstream perfusion
• Access site auscultation- to ensure no bruit (pseudoaneurysm or AV fistula)
• Demonstrate baseline level of ambulation without difficulty
• Ensure pain is well controlled
14. DISCHARGE INSTRUCTIONS
• Clear instructions regarding-
• Site management,
• Physical activity
• Driving & return to work
• Sexual activity
• Medication reconcilation
• Follow up,
• Need for additional lab testing, &
• Clear contact information of the physician in case of complication following
discharge
15. SITE MANAGEMENT
• Minor bruising &/or pain at the access site (should resolve within 1
month postprocedure)
• Transfemoral access should not strain or lift anything >5pounds for 48
hours
• Should apply pressure to the access site when sneezing or coughing
• Clear action plan for access site complications (eg., active arterial
bleeding, hematoma, erythema, purelence, numbness/tingling or
paresthesia) should be provided
16. PHYSICAL ACTIVITY/DRIVING & RETURN TO WORK
• Refrain from physical exercise & DRIVING for at least 48 hours (if not 1
week)
• Post PCI patients should be enrolled in a cardiac rehabilitation
program to develop a plan of graded exercise
• Decision to return to work is individualized (often related to job
satisfaction, financial stability, and/or company policy)
17. SEXUAL ACTIVITY
• Refrain from sexual activity for 1 week
• AHA consensus statement- sexual activity is reasonable for patients at
low risk for cardiovascular complications or who can exercise for 3-5
METs without symptoms or ECG changes
• In previous studies of SCD related to sexual activity-
• 82-93% were men who died during intercourse
• 75% were participated in extramarital sexual activity
• Typically with a younger partner and
• After excessive food and alcohol consumption
18. MEDICATION RECONCILATION
• Barring specific contraindications, many patients undergoing PCI will
be on DAPT (with aspirin & a P2Y12 antagonist), a β-blocker, an ACE
inhibitor, and a high-intensity statin
• SCAI recommendation-
• Diabetic patients should withhold their metformin for 48 hours
postprocedure
• Patients previously on warfarin who have stopped it for the procedure should
be restarted on their regimen and have an INR checked within 1 week
postprocedure
• No consensus guidelines have been provided for the NOACs, but they are
generally started postprocedure as hemostasis is achieved and do not require
close monitoring
19. FOLLOW UP
• SCAI recommendations-
• The patient follow up with his or her primary care physician, cardiologist, or
midlevel physician extender within 2-4 weeks postprocedure, or sooner for
patients with procedural complications or comorbidities such as anemia or
renal dysfunction requiring more frequent lab test monitoring
• Purpose of follow up visist-
• Ensure compliance, especially with regard to DAPT
• Reconcile medications
• Reinforce aggressive secondary prevention measures (including dietary,
exercise habit and smoking cessation)
• Confirm that the patient has enrolled in a cardiac rehabilitation program
