Percutaneous Transluminal Coronary Angioplasty

From Anvita Health Wiki

Contents 1 More Specific Terms 2 Introduction 3 Indications 4 Contraindications 5 Laboratory 6 Procedure 7 Complications 8 Management 9 Notes 10 More General Terms 11 Additional Terms 12 References

More Specific Terms

• perfusion balloon angioplasty

Introduction

• An invasive procedure to enlarge the lumen of a narrowed coronary artery by balloon compression. The angioplasty catheter is inserted into a coronary artery, & the cylindrical balloon is inflated at the site of an obstructing atheroma.

Indications

• primary therapy for unstable angina with ST segment elevation* (see CAPITAL AMI study, STEMI) [17]
• rescue therapy following failed thrombolysis

• persistent hemodynamic instability or arrhythmia
• 60-90 minutes after initiation of thrombolytic therapy

• patient not eligible for thrombolytic therapy
• myocardial infarction complicated by shock or CHF [14]
• previous coronary artery bypass graft surgery
• failure of medical management following initial stabilization
• elective revascularization for coronary artery disease

• impaired left ventricular function

• 2 or more vessels with > 50% stenosis
• viable left ventricular myocardium with abnormal wall motion

• normal left ventricular function with left main, 3-vessel or severe 2-vessel disease
• proximal left anterior descending artery disease (common clinical practice)

• CABG is indicated for patients with diabetes mellitus who would otherwise be eligible for PTCA (better 5 year survival, 80% vs 65%)

• * may be better than thrombolysis for primary therapy [9] see ' PTCA vs thrombolysis for acute MI

Contraindications

• elective PTCA for one vessel disease does not:

• reduce future risk of myocardial infarction
• improve resting left ventricular function
• increase survival

• routine thrombectomy with PCI of no benefit (see thrombectomy)
• late PCI to restore perfusion of infarcted myocardium of no benefit. [18]
• preventive PCI in stable coronary disease of no benefit [19]
• PCI for stable occluded coronary artery disease of little to no benefit [23]
• late PCI for totally occluded coronary artery after myocardial infarction of no benefit [25]

Laboratory

• reperfusion is associated with higher peak serum CK-MB than persistent occlusion

Procedure

• loading dose of clopidogrel 600 mg, followed by 150 mg/day for 6 days, then 75 mg/day
• IV nitroglycerin for management of angina.
• eptifibatide ( Integrilin) for 12 hours after PTCA
• coronary stenting may reduce the rate of restenosis [7]
• treatment with abciximab with PTCA & coronary stenting may further reduce the rate of restenosis (10% at 6 months [7])
• facilitated PCI with reteplase plus abciximab or abciximab alone started early before PCI did improve outcomes, compared with primary PCI in STEMI patients [21]
• intracoronary abciximab (0.25 mg/kg), delivered into the thrombus region with an infusion catheter [32]
• manual aspiration thrombectomy with the Export catheter in patients with as large thrombus [32]
• bivalirudin anticoagulation [32]

Complications

• contrast nephropathy [12]
• 30-45% restenosis within 6 months (20% in [7]).

Management

• combination B vitamins for 6 months

• folate 1 mg, vitamin B12 400 ug, vitamin B6 10 mg PO QD
• reduces serum homocysteine
• reduced combined endpoint: myocardial infarction, death, restenosis ( revascularization) {15% vs 23%} [8]
• in other settings, the combination of folate, vitamin B6, & vitamin B12 have not been foun to reduce cardiovascular mortality
• intraluminal radiation, beta-radiation (18 Gy) or gamma-radiation may also reduce rate of restenosis, including those with restenosis after stenting [6]
• same day discharge after PTCA appears safe [29]

Notes

• angioplasty would appear superior to streptokinase thrombolysis in the treatment of myocardial infarction, but requires expertise not yet available at many hospitals [4]
• elective PTCA for multivessel disease has a slightly higher mortality than CABG [11]

• at 1 year (5% vs 4%)
• at 5 years (16% vs 14%)

• CABG is superior to PCI for

• severe coronary artery disease [24]; see Syntax trial
• patients with diabetes mellitus [26]
• patients > 65 years of age [26]
• left main coronary artery disease
• multivessel coronary artery disease with involvement of left anterior descending coronary artery ( LAD) & reduced LV ejection fraction [2]

• facilitated percutaneous intervention is the use of pharmaceutical agents before a planned intervention

• mixed results
• pretreatment with clopidogrel decreased combined incidence of sudden death, myocardial infartion & stroke associated with PTCA in pateints with STEMI. (4% vs 6%) [15]
• offered no benefit, outcomes may be worse [16]

• combination of pretreatment with clopidogrel + treatment with abciximab + heparin (during or after procedure) may be of benefit in patient with non-STEMI (see ISAR-REACT 2 trial)
• PCI should be performed ASAP (as soon as possible) [27]
• prasugrel in combination with aspirin may be an option for patients with

• stent thrombosis during clopidogral treatment
• diabetes mellitus ( NGC, )

• percutaneous coronary intervention at hospitals without on-site cardiac surgery are noninferior to those at hospitals with on-site surgery [31]

More General Terms

• cardiology
• angioplasty

Additional Terms

• Bypass Angioplasty Revascularization Investivation (BARI)
• cardiac catheterization
• coronary artery bypass grafting (CABG)
• coronary stent/coronary stenting
• ISAR-REACT 2 trial
• Syntax trial
• TIMI study

References

1. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 88-89
4. Journal Watch, Mass Med Soc 19(23):181 (Dec) 1999
5. Journal Watch, Mass Med Soc 21(3):24 (Dec) 2001 Williams et al, Circulation 102:294, 2000
6. Journal Watch 21(5):42, 2001 Verin et al N Engl J Med 344:243, 2001 Leon et al N Engl J Med 344:250, 2001
7. Journal Watch 22(10):77, 2002 Stone GW et al, N Engl J Med 346:957, 2002
8. Journal Watch 22(19):149, 2002 Schnyder G et al, JAMA 288:973, 2002
9. Journal Watch 23(5):42, 2003 Keeley EC et al, Lancet 361:12, 2003
10. Journal Watch 24(8):62, 2004 Mathew V et al, Circulation 109:476, 2004 PMID: [1]
11. Journal Watch 24(14):111, 2004 Brener SJ, Lytle BW, Casserly IP, Schneider JP, Topol EJ, Lauer MS. Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Circulation. 2004 May 18;109(19):2290-5. Epub 2004 Apr 26. PMID: [2]
12. Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, Mintz GS, Lansky AJ, Moses JW, Stone GW, Leon MB, Dangas G. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004 Oct 6;44(7):1393-9. PMID: [3]
13. Le May MR, Wells GA, Labinaz M, Davies RF, Turek M, Leddy D, Maloney J, McKibbin T, Quinn B, Beanlands RS, Glover C, Marquis JF, O'Brien ER, Williams WL, Higginson LA. Combined angioplasty and pharmacological intervention versus thrombolysis alone in acute myocardial infarction (CAPITAL AMI study). J Am Coll Cardiol. 2005 Aug 2;46(3):417-24. PMID: [4]
14. Babaev A, Frederick PD, Pasta DJ, Every N, Sichrovsky T, Hochman JS; NRMI Investigators. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA. 2005 Jul 27;294(4):448-54. PMID: [5]
15. Sabatine MS, Cannon CP, Gibson CM, Lopez-Sendon JL, Montalescot G, Theroux P, Lewis BS, Murphy SA, McCabe CH, Braunwald E; Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY)-Thrombolysis in Myocardial Infarction (TIMI) 28 Investigators. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA. 2005 Sep 14;294(10):1224-32. Epub 2005 Sep 4. PMID: [6]
16. Keeley EC et al, Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: Quantitative review of randomised trials. Lancet 2006 Feb 18; 367:579-88. PMID: [7]
    - Stone GW and Gersh BJ. Facilitated angioplasty: Paradise lost. Lancet 2006 Feb 18; 367:543-6. PMID: [8]
17. Ting HH et al, A total of 1007 percutaneous coronary interventions without onsite cardiac surgery: Acute & long-term outcomes. J Am Coll Cardiolo 2006; 47:1713 PMID: [9]
18. Hochman JS et al, for the Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006, 355 (Nov 14) PMID: [10]
    - Hillis LD and Lange RA Myocardial infarction and the open-artery hypothesis. N Engl J Med 2006, 355 (Nov 14) PMID: [11]
19. Boden WE et al, for the COURAGE Trial Research Group Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007, 356:1503 PMID: [12]
    - Hochman JS & Sten PG Does preventive PCI work? N Engl J Med 2007, March 27 PMID: [13]
20. King SB III et al, 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2007, 51:172 PMID: [14]
21. Ellis SG, Tendera M, de Belder MA, van Boven AJ, Widimsky P, Janssens L, Andersen HR, Betriu A, Savonitto S, Adamus J, Peruga JZ, Kosmider M, Katz O, Neunteufl T, Jorgova J, Dorobantu M, Grinfeld L, Armstrong P, Brodie BR, Herrmann HC, Montalescot G, Neumann FJ, Effron MB, Barnathan ES, Topol EJ; FINESSE Investigators. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med. 2008 May 22;358(21):2205-17. PMID: [15]
    - Leopold JA. Does thrombolytic therapy facilitate or foil primary PCI? N Engl J Med. 2008 May 22;358(21):2277-9. PMID: [16]
22. King SB et al, 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 2008 Jan 15;51(2):172-209 PMID: [17]
23. Mark DB et al for the Occluded Artery Trial Investigators. Quality of life after late invasive therapy for occluded arteries. N Engl J Med 2009 Feb 19; 360:774. PMID: [18]
24. Serruys PW et al for the SYNTAX Investigators. Percutaneous Coronary Intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009 Feb 18; [e-pub ahead of print]. [19] PMID: [20]
    - Lange RA and Hillis LD. SYNTAX in context. N Engl J Med 2009 Feb 18; [e-pub ahead of print]. [21] PMID: [22]
25. Mark DB et al. Quality of life after late invasive therapy for occluded arteries. N Engl J Med 2009 Feb 19; 360:774. PMID: [23]
26. Hlatky MA et al, Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials Lancet. 2009 Apr 4;373(9670):1190-7. Epub 2009 Mar 19. <PubMed> PMID: [24] <Internet> [25]
27. Rathore SS et al Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study BMJ 2009;338:b1807 <PubMed> PMID: [26] <Internet> [27]
28. Prescriber's Letter 16(10): 2009 The Case for a Higher Maintenance Dose of Clopidogrel (Plavix) Detail-Document#: [28] (subscription needed) [29]
29. Rao SV et al Prevalence and Outcomes of Same-Day Discharge After Elective Percutaneous Coronary Intervention Among Older Patients JAMA. 2011, 306(13):1461-1467 <PubMed> PMID: [30] <Internet> [31]
30. Levine GN et al 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary American College of Cardiology Foundation American Heart Association Task Force on Practice Guidelines Society for Cardiovascular Angiography and Interventions J Am Coll Cardiol, November 7, 2011 <PubMed> PMID: [32] <Internet> [33]
31. Aversano T et al. Outcomes of PCI at hospitals with or without on-site cardiac surgery. N Engl J Med 2012 Mar 25 <PubMed> PMID: [34] <Internet> [35]
32. Stone GW et al. Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: The INFUSE-AMI randomized trial. JAMA 2012 Mar 25 <PubMed> PMID: [36] <Internet> [37]
33. Heart Bypass Surgery/Angioplasty: NIH Institute and Center Resources [38]
34. National Guideline Clearinghouse ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention. A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to update the 2001 guidelines for percutaneous coronary intervention). ngc-guideline: [39]
    - Coronary angiography and indications for CABG or angioplasty. (Finnish Medical Society Duodecim) ngc-guideline: [40]
    - Percutaneous coronary intervention and adjunctive pharmaco- therapy in women: a statement for healthcare professionals from the American Heart Association. ngc-guideline: [41]
    - Thrombolytic therapy and balloon angioplasty in acute ST elevation myocardial infarction (STEMI) (Finnish Medical Society Duodecim) ngc-guideline: [42]
    - Guidelines for percutaneous coronary interventions. (European Society of Cardiology) ngc-guideline: [43]
    - Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [44]

percutaneous transluminal coronary angioplasty (PTCA, percutaneous coronary intervention, PCI)