Pci

1. Primary PCI
Prof A N Patnaik
Dr RAMACHANDRA BARIK
Dr Lalita Nemani

2. Define
 STEMI only
 Urgent angioplasty(with/out
stenting)- Preferably in ≤90min
 No TLT before or parallel
 Open the infarct—related

3.  Delayed PCI
PCI After TLT
1.Rescue(REACT/MERLIN/RESCU
E)
2.Facilitated(BRAVE/HERO/CAPI
TAL/WASTE/ASCEND)
Of its kinds

5. STEMI
Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardial
infarction. Circulation 2007;116:2634-53.

6. Today’s evening
• Abbreviating time is everything
1.Best transfer Protocol
2. Reverse Paradox
• PPCI vs. TLT
• Who need it?
• PPCI in Octagenerian
• Set up
1.Your Lab 2.Surgical Back up

7. Contd......
• Operator skill
• Initial therapy in ICCU
• Radial vs. Femoral
• Optimal anticoagulation
• POBA/ BMS/DES
• Hardware
• IABP/ECMO-When and its role

8. Contd....
• In cath lab
• After cathlab=ICCU
• Predischarge triage
• Finance
• Take home message

9. Politician also knows.....time is life

10. Time is muscle
Every minute counts
Gersh BJ, Stone GW, White HD, et al. Pharmacological facilitation of primary
percutaneous coronary intervention foracute myocardial infarction: is the slope of
the curve the shape of the future? JAMA 2005;293:979-86

11. Terkelsen CJ, Sorensen JT, Maeng M, et al. Systemdelay
and mortality among
patients with STEMI treated with primary percutaneous
coronary intervention.
J
AM
A2010;304:763-71.

12. Primary PCI vs. TLT
Choice
(TIMI)-3 Flow in 95% vs 54%(TLT)
Gersh BJ et al. Pharmacological facilitation of PPCI for STEMI: is
the slope of the curve the shape of the future? JAMA 2005;293:979-86
Stone GW et al. Comparison of angioplasty with stenting,with or without
abciximab, in acute myocardial infarction. N Engl J Med 2002;346:957-66

13. PCI IS THE
BEST
OPTION

14. PAMI Trial-1997
POBA provides a small-to-moderate, short-term
clinical advantage over TLT with t-PA.
PPCI when it can be accomplished promptly at experienced
centers, should be considered an excellent alternative
method for myocardial reperfusion.
The investigators and centers participating in the GUSTO
IIb Angioplasty Substudy ,Cleveland Clinic,USA

15. A 2003 meta-analysis
23 randomized trials
7739 patients
 Reductions in short-term death (7% vs 9%, P 0.0002),
 fatal reinfarction (3% vs 7%, P 0.0001),
 stroke (1% vs 2%, P 0.0004)
Keeley EC et al. Primary angioplasty versus intravenous thrombolytic
therapy foracute myocardial infarction: a quantitative review of 23
randomised trials. Lancet 2003;361:13-20

16. But TLT is the invaluable in certain conditions because delay in
opening artery causes
• CHF/ readmissions/OPD visits increases
 independently with mortality(HR/OR=1.1)
 detrimental in age<65, presenting within 2 hours
Death+ reinfarction+disabling stroke at 30
days was significantly < PCI in 2 of the
studies, with a trend toward significance in
the underpowered third study

17. “DIDO=Door-in-door-out=30”
Pretransfer TLT
CAPTIM
WEST

18. “Number Paradox”
Golden’s Hour:2-3Hrs.

19. Evidence

20. Evidence....

21. Evidence..
• MITRA STUDY(Maximal therapy in AMI)
• SWISS STUDY
• DANAMI II
• SHOCK(Shock)
• NRMI-II(CHF)

23. Then what to choose?
Then what to choose?
“Reperfusion paradox”
vs
Best transfer protocol

24. Coordinate...to reduce

25. Initial management =MONA
Oxygen
 Aspirin
Nitroglycerin
Opioids(Morphine)

26. Cath lab standard

27. Adjunctive Antithrombotic
Therapy
• Antiplatlets
• Anticoagulation

28. Antiplatlets

29. Antiplatlets

30. GROUP IIB-IIIA Inhibitors

31. Anticoagulants
‡The recommended ACT with planned GP IIb/IIIa receptor antagonist treatment is 200 to 250 s.
§The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 to 300 s (HemoTec device) or 300
to 350 s (Hemochron device).

32. Access
No but you better understand
No but you better understand

34. Shock
• Killip IV
• Ionotrope optimum
• Control IV fluid
• CPR
• IABP/ECMO
• LVAD
• CABG

35. IABP but use it!!!!!!!!
• No Δ in infarct size at 3-5 days
• No Δ in all cause death at 6 months
Ohman EM, et al. Use of aortic counterpulsation to improve sustained coronary artery patency during AMI.RCT.
The Randomized IABP Study Group. Circulation 1994.
Stone GW et al, (PAMI-II) Trial Investigators. J Am Coll Cardiol 1997; 29:1459.
Brodie BR et al,IABP, before PPCI reduces catheterization laboratory events in high-risk patients with AMI . Am J
Cardiol 1999
Patel MR,et al. CRISP AMI Trial. JAMA 2011; 306:1329.

36. Anticoagulation-ACT
Anticoagulation ACT
HEPARIN ONLY 250 to 350 seconds
+GIIB-IIIA 200-250
POST Procedural No heparin
Sheath removal ≤150-180sec
Heparin reversal
100 Unit=1mg of Protamin Sulphate IV bolus

37. Manual aspiration thrombectomy
• 1.Microvascular function improves
• 2.Decrease death
• 3.MCE
I IIa IIb III
 Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during
Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS):
a 1-year follow-up study. Lancet. 2008;371:1915–20
Intracoronary abciximab and aspiration thrombectomy in patients with large
anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA. 2012;307:
1817–26
No reduction infarction size in large AWMI

38. Culprit vs. Bystanders

39. Culprit vs. Bystanders
PCI should not be performed in a noninfarct artery at the time of
primary PCI in patients with STEMI who are hemodynamically
stable(2013 STEMI guideline).
I IIa IIb III
Preventive Angioplasty in Myocardial Infarction=PRAMI
2008 through 2013, at five centers in UK
465(234/234)
Subsequent PCI for inducible ischemia/refractory angina
 composite of death/nonfatal MI/refractory angina
 significantly reduced the risk of adverse cardiovascular events,
as compared with PCI limited to the infarct artery

40. STENTS
BMS/DES is useful
I IIa IIb III
BMS:High bleeding risk/noncomply with 1 year of DAPT/
anticipated invasive or surgical procedures in the coming year
I IIa IIb III
DES should not be used if unable to tolerate/comply with a
prolonged course of DAPT.
I IIa IIb III
Harm

41. POBA vs. BMS
 tenting further reduced subsequent TLR but not
shown a survival advantage
1. Stone GW et al. Comparison of angioplasty with stenting,
with or without abciximab, in acute myocardial infarction. N Engl J Med
2002;346:957-66
2. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without
stent
implantation for acute myocardial infarction. Stent primary angioplasty in
myocardial
infarction study group. N Engl J Med 1999;341:1949-56.

42. BMS vs. DES
DES greater reduction in TLR BUT not associated
with improved survival because added late ST
Stone GW et al. Paclitaxel-eluting stents versus bare-metal stents in acute
myocardial infarction. N Engl J Med 2009;360:1946-59.
Brar SS et al. Use of drug-eluting stents in acute myocardial infarction: a
systematic review and meta-analysis. J Am Coll Cardiol 2009;53:1677-89.
TYPHOON, PASSION, SESAMI, DEDICATION, and HORIZONS AMI

43. DES for STEMI
• TVR reduction >>BMS
• No extra stent thrombosis with DAP
• PCI with DES is not mandatory in STEM
• BMS may be preferable in cases in which comorbid
conditions, compliance, or financial means may
interfere with the required duration of dual-
antiplatelet therapy after DES placement

44. POBA vs.BMS vs. DES(G1/G2)
Keeping to right is
right

45. BMS Vs DES( G1)
• no significant difference in mortality, (8.5 versus 10.2
percent; HR 0.85,(95% CI 0.70-1.04).
• TLR was lower with DES (12.7 versus 20.1 percent; HR 0.57, 95% CI
0.50-0.66).
• No Δ in the cumulative rate of ST (5.8 versus 4.3 percent; HR 1.13, 95% CI
0.86-1.47). VLS (events after two years) was higher for DES (HR 2.81, 95%
CI 1.28-6.19).
• No Δ in the cumulative rate of reinfarction (9.4 versus 5.9 percent; HR
1.12, 95% CI 0.88-1.41). 2Y- the rate significantly increased for DES (HR
2.06, 95% CI 1.22-3.49).
De Luca G, et al. DES vs BMS in primary angioplasty: a pooled patient-level meta-a

46. BMS vs DES -G2
Cobalt-chromium everolimus-eluting stents (CoCr-EES)
• one-year risk of cardiac death/ MI was reduced with the former but not
the latter (odds ratio [OR] 0.63, 95% CI 0.42-0.92 and 0.86, 95% CI 0.50-
1.49).
• one-year risk TVR was reduced with the former but not the latter (OR 0.45,
95% CI 0.29-0.66 and 0.60, 95% CI 0.34-1.05).
• the one-year risk of definite stent thrombosis was reduced with the
former but not the latter (OR 0.32, 95% CI 0.11-0.78 and 0.44, 95% CI 0.12-
1.79).
• lower one-year rates of cardiac death or MI, definite stent thrombosis, and
target vessel revascularization

47. The COMFORTABLE AMI trial
• WITH Biolums as polymer the MCE FURTHER
REDUCED

48. Drug-eluting balloon plus BMS
• First human trial
• not significantly different between the DEB-BMS
and BMS groups
• Drug is paclitaxel
Belkacemi A, J Am Coll Cardiol. 2012 Jun;59(25):2327-37. Epub 2012 Apr
11.

49. Direct Stenting
• significantly lower rate of all-cause death
• Lesser no flow/slow flow
• Better myocardial preservation
HORIZON AMI
 Loubeyre C et al. A RCT of direct stenting with conventional stent implantation in selected patients with AMI . J Am Coll Cardiol
2002; 39:15.
Ly HQ et al. Angiographic and clinical outcomes associated with direct versus conventional stenting among patients treated with
fibrinolytic therapy for ST-elevation acute myocardial infarction. Am J Cardiol 2005; 95:383.
Antoniucci D, et al. Direct infarct artery stenting without predilation and no-reflow in patients with acute myocardial infarction.
Am Heart J 2001; 142:684.

50. Bioresorbable vascular Scaffolds
• Safe
• Feasible
• Available Size, short expiry is limitation
• Not approved/not guide lined
• Long term result awaited
PRAGUE-19 Study,87 pts/3 yrs//started in 2012/Abbott vascular

51. Intra coronary IIB-IIIA
inhibitor(abciximab)
 Death+ reinfarction, p=0.03
 Death ,p=0.04)
 TVR ,p=0.045)
 Reinfarction; p=0.13
Raffaele Piccolo et al,Italy,Meta analysis,2012, Heart doi:10.1136/heartjnl-
2011-301101

52. Intracoronary Adenosine
• A bolus injection of intracoronary adenosine (900
micrograms in 5mL of 0.9% sodium chloride
solution). Control patients received an intravenous
bolus injection of adenosine (900 micrograms in 20
mL sodium chloride) during the procedure
• Elective intracoronary administration of high-dose
adenosine as adjunctive therapy to primary PCI
reduces MVO

53. INTRA CORONARY TLT
• 2.5 lakhs unit STK
• Improves no reflow
• Improves TFC
• EPICARDIAL coronary looks beautiful
• At 6 months ,no gain add to viable myocardium
Murat Sezer et al, Turkey, N Engl J Med 2007; 356:1823-1834,

54. Date of download:
9/28/2013
Copyright © The American College of Cardiology.
All rights reserved.
From: Effect of Intracoronary Streptokinase Administered Immediately After Primary Percutaneous Coronary
Intervention on Long-Term Left Ventricular Infarct Size, Volumes, and Function
J Am Coll Cardiol. 2009;54(12):1065-1071. doi:10.1016/j.jacc.2009.04.083

55. Intracoronary hyperoxemic
reperfusion therapy
• Safe and well tolerated
Dixon SR et al,Pilot study, J Am Coll Cardiol. 2002;39(3):387

56. Ischemic conditioning
• Ischemic preconditioning
• Ischemic post conditioning confer benefit
• Remote Ischemic conditioning
30sec-1min-30sec-1min-30sec
Kloner RA, Jennings RB.

57. Suboptimal reperfusion after
PPCI/Complication
 Persistent stenosis or thrombosis
 Coronary dissection
 Intramural hematoma
 Side branch occlusion
 Coronary spasm
 Distal macroembolism
 Acute stent thrombosis
 No-reflow phenomenon
 Reperfusion injury
 Capillary blistering and edema of endothelial cells
 Edema and swelling of myocytes
PAMI:
Age ≥70 years
Diabetes
Longer time to reperfusion
Initial TIMI flow grade ≤1
Left ventricular ejection
fraction <50 percent

58. Ventricular Arrhythmias
• Immediate defibrillation or cardioversion for VF or
pulseless sustained VT,
• Early (within 24 hours of presentation)
administration of beta blockers.
• The prophylactic use of lidocaine is not
recommended.
• VPC, NSVT not associated with hemodynamic
compromise, and AIVR are not indicative of
increased SCD risk needs less attention.

59. No reflow phenomenon
• 10 – 30 %
• Influences the long term results of PCI significantly.
• Minimised by NTG(25 microgram). Verapamil,
diltiazem, GpIIBIIIA inhibitors, nikorandil(IONA),
thrombectomy, intracoronary STK, ischemic post
conditioning.

60. Rescue CABG < 3%
Aspirin should not be withheld
Short-acting intravenous GP IIb/IIIa receptor antagonists
(eptifibatide, tirofiban) should be discontinued at least 2 to 4
hours before urgent CABG.
Clopidogrel or ticagrelor should be discontinued at least 24 hours
before urgent on-pump CABG, if possible.
I IIa IIb III
I IIa IIb III
I IIa IIb III

61. RESCUE CABG
Abciximab should be discontinued at least 12 hours before
urgent CABG.
Urgent off-pump CABG within 24 hours of clopidogrel or
ticagrelor administration might be considered, especially if the
benefits of prompt revascularization outweigh the risks of
bleeding.
Urgent CABG within 5 days of clopidogrel or ticagrelor
administration or within 7 days of prasugrel administration
might be considered, especially if the benefits of prompt
revascularization outweigh the risks of bleeding.
I IIa IIb III
I IIa IIb III
I IIa IIb III

62. Role of third antiplatlet
Yes you may add,but
bleeding matters

63. Sheath removal timing
• ACT <160 SEC
• SHEATH SIZE α compression time
• USE OF Group IIA-IIIB inhibitors
• After 6 hrs for femoral and 2 hours for Radial

64. Beware of Bleeding

65. Very Elderly (≥85 Years)
 Claessen et al. Primary percutaneous
coronary intervention for ST elevation
myocardial infarction in octogenarians: trends
and outcomes. Heart 2010;96:843–7
Danish Registry Supports
Primary PCI in Elderly STEMI
Patients-2013
Senior-PAMI-2005

66. Secondary prevention
• Beta Blockers: initiated in the first 24 hours
unless C/I
• Renin-Angiotensin-Aldosterone System
Inhibitors:within 24 hrs
• Lipid Management

67. Posthospitalization Plan of Care
•Prevent hospital readmissions
•Should be used to facilitate the transition to effective
•Outpatient care
I IIa IIb III
•Exercise-based cardiac rehabilitation
•Secondary prevention programs
I IIa IIb III

68. Posthospitalization Plan of Care
Medication adherence
Follow-up
Dietary and physical activities
Compliance with interventions for secondary prevention should
be provided to patients with STEMI.
No smoking
No secondhand smoke
I IIa IIb III
I IIa IIb III