percutaneous coronary intervention detailed comparison and explanation

1. Ladi Anudeep
ISM-IUK

4. Coronary angiography of occluded
vessel

5. Treatment of Stable and Unstable Angina

6. Treatment of Acute Coronary Syndrome
• Reperfusion
• Thrombolytics
• Angioplasty
• PCI
• Aim of treatment
is to limit necrosis
• Reperfusion
therapy
• Aim of treatment
is to prevent
complications
• Contraindicated
reperfusion
therapy
• No angioplasty

7. Clinical features of IHD
• Chest pain
• Dyspnea
• Dizziness
• Fatigue
• Nausea
• Vomiting
• Anxiety
• Syncope

8. Indications of PCI
1. Acute ST elevated MI :Anginal symptoms at rest that result in
myocardial necrosis, as identified by elevated cardiac biomarkers
with ST segment elevation on the 12-lead ECG.
2. Unstable angina: ischemia caused by dynamic obstruction of
coronary artery due to plaque rupture or erosion with
superimposed thrombosis
3. Stable angina: ischemia due to fixed atheromatous stenosis of one
or more coronary arteries
4. Arrhythmia: altered conduction due to ischemia or infarction

10. • A)Early changes in MI (minutes to days):
• Hypoxia
• Shift to anaerobic metabolism
• Impaired glycolysis and ATP production → Impaired contractile protein function
• Systolic dysfunction – loss of synchronous myocyte contraction → Compromised cardiac output
• Diastolic dysfunction – reduced ventricular compliance & elevation of ventricular filling pressures
• Na-K-ATPase impairment (impaired ATP production):
• ↑ Intracellular Na → Intracellular edema
• ↑ Extracellular K → Alteration in transmembrane potential → Electrical instability and susceptibility to arrhythmias
• ↑ Intracellular Ca → Activation of degradative lipases and proteases → Tissue necrosis
• Acute inflammatory response with neutrophil infiltration and further tissue damage
• B) Late changes in MI (days to weeks):
• Resorption of irreversibly injured/dead myocytes by macrophages:
• Structural weakness of ventricular wall → Susceptibility to myocardial rupture
• Fibrosis and scarring
• Ventricular remodeling:
• Infarct expansion – thinning and dilation of necrotic tissue without additional necrosis
• Increased ventricular wall stress
• Further impairment in systolic contractile function
• Increased likelihood of aneurysm formation
• Remodeling of non-infarcted ventricle:
• Dilation due to overwork in response to increased wall stress (when reaches beyond limits of Frank-Starling’s
law → heart failure and predisposition to arrhythmias)

11. • Coagulopathy
• Decompensated congestive heart failure
• Uncontrolled hypertension
• Pregnancy
• Renal failure
• Active infection
Contraindications of PCI

13. Early complications
• Bleeding after the procedure
• Bruising
• Hematoma
• Infection
• Infection of the stent
• False aneurysm or arteriovenous fistula
• Kidney damage
• Allergic reaction
• Radiation exposure
• Blood clot
• Lost stent
• Change in heart rhythm
• Blood leaking into the sac that surrounds the heart
• Heart attack
• Stroke
• Radial artery spasm
• Stent restenosis
• Stent thrombosis
Late complications

14. PCI vs CABG

15. PCI success rate

16. • Dual anti platelet therapy with aspirin and P2Y12 receptor antagonist (prasugrel,
clopidogrel, or ticagrelor) for NSTEACS patients undergoing PCI before 48 hrs
ACC/AHA GUIDELINES ESC GUIDELINES
ANTI PLATELET THERAPY
Aspirin- dose: 81-325mg Aspirin- initial IV dose:80-150mg
maintenance dose: 75-100mg per day
P2Y12 inhibitor
• Prasugrel 60 mg loading dose, then 10 mg/day
• Clopidogrel 600 mg loading dose, then 75 mg/day
• Ticagrelor 180 mg loading dose, then 90 mg twice
daily
P2Y12 inhibitor
• Clopidogrel (300–600 mg loading dose, 75 mg/day
dose)
• Ticagrelor (180 mg loading dose, 90 mg twice daily)
• Prasugrel (60 mg loading dose, 10 mg daily dose)
Anticoagulation therapy
Bivalirudin 0.75 mg/kg
IV loading dose, then 1.75 mg/kg/h IV infusion
Bivalirudin (0.75 mg/kg bolus, followed by 1.75
mg/kg/h for up to 4 h
after the procedure)
Fondaparinux:85 IU/kg Fondaparinux:(85 IU/kg, or 60 IU/kg)
PCI: adjunctive pharmacologic treatment

18. Stent
• A stent is an extendable metal scaffold that can be used to
keep open previously narrowed coronary arteries after
angioplasty has been performed.
• The mechanism used to place the stent in a narrowed or
blocked coronary artery is very similar to balloon angioplasty.
• The difference is that the un-extended or collapsed stent
surrounds the balloon.
• The stent surrounding the balloon is expanded when the
balloon is inflated
• After the stent surrounding the balloon extends, it locks into
place against the plaque/arterial vessel wall.
• The stent stays inside the artery after the balloon is deflated.

19. • Stents are useful because they keep the coronary artery open when
the balloon is deflated, preventing most arteries from narrowing
again (termed elastic recoil) after the balloon is deflated.
• Recurrent narrowing (restenosis) sometimes may still occur after the
stent is placed due to formation of scar tissue.
• The newest stents are termed drug-eluting stents.
• These stents are covered in a drug that slowly comes off the stent and
prevents cell proliferation (scarring or fibrosis) at the stent site more
effectively than uncoated, bare-metal stents.
• There are many other stents beside coronary stents that are used for
various other arteries and tissues.
• These include carotid artery stents (for stroke prevention), femoral
artery stents, prostatic stents, esophageal stents, and many others.

23. Procedure
• Pci is done via percutaneous femoral, radial, brachial artery puncture
• Radial approach is technically demanding comparative femoral approach
but may reduce patient discomfort, improve time to ambulation and
reduce the incidence of some complications(e.g.bleeding)
• A guiding catheter is inserted into a large peripheral artery and threaded to
appropriate coronary osteum
• A balloon tipped catheter, guided by fluoroscopy or intravascular
ultrasonography, is aligned with in the stenosis, then inflated to disrupt the
atherosclerotic plaque and dilate the artery
• Angiography is repeated after the procedure to document any changes
• This procedure is commonly done in two or three vessels as needed.

25. Cost effectiveness in INDIA
• PCI appeared to be cost effective, with a ratio of $9,505 which is well below
the accepted conventional threshold of $50,000
• Before the original price of bare metal stent is 1595$ and drug eluting stent
is 3000$, but there is rapid fall in the prices due to advancement of
procedure
• Present Average price of bare metal stent is 628$
• Present Average price for drug eluting stent is 1419$
• There are re-stenosis issues of bare metal stent if used, so drug eluting
stents are widely used and cost of it is also high when compared with
bare metal stent
• Bare metal stent causes healing of endothelium which is a risk factor for
re-stenosis, but drug eluting stent has anti proliferative effect which has a
huge advantage which improves quality of life

27. Patients recovery after PCI
• Patients are often discharged within 24 hours after percutaneous
coronary intervention and are cautioned not to do any vigorous
activity or lift over about 20 lbs for about one to two weeks.
• Patients are treated with blood thinning anti-platelet agents such
as clopidogrel bisulfate (Plavix) and aspirin.