Percutaneous Coronary Intervention (PCI): Basic Principles and Guidelines

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Epidemiology and Demographics

 * Approximately 850,000 PCIs are performed each year in the United States.

Classification of Recommendations:

 * Class I: Benefit >>> Risk
 * Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.


 * Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.


 * Class IIa: Benefit >> Risk
 * Weight of evidence/opinion is in favor of usefulness/efficacy.


 * Class IIb: Benefit ≥ Risk
 * Usefulness/efficacy is less well established by evidence/opinion.


 * Class III: Risk ≥ Benefit
 * Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.

Level of Evidence:

 * Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.
 * Level of Evidence B: Data derived from a single randomized trial, or nonrandomized studies.
 * Level of Evidence C: Only consensus opinion of experts,case studies, or standard-of-care.

==2011 ACCF/AHA/SCAI Guideline Recommendations: CAD Revascularization ==

Heart Team Approach to Revascularization Decisions
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Class I
1. A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD. (Level of Evidence: C)

Class IIa
1. Calculation of the Society of Thoracic Surgeons and SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores is reasonable in patients with unprotected left main and complex CAD. (Level of Evidence: B)}}

Revascularization to Improve Survival: Left Main Coronary Artery Disease
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Class I
1. CABG to improve survival is recommended for patients with significant (greater than or equal to 50% diameter stenosis) left main coronary artery stenosis. (Level of Evidence: B)

Class IIa
1. PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD with:


 * a. Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score [lower than or equal to 22], ostial or trunk left main CAD); and (Level of Evidence: B)


 * b. Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., Society of Thoracic Surgeons–predicted risk of operative mortality 5%).                    (Level of Evidence: B)

2. PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. (Level of Evidence: B)

3. PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG. (Level of Evidence: C)

Class IIb
1. PCI to improve survival may be reasonable as an alternative to CABG in selected stablepatients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD with:


 * a. Anatomic conditions associated with a low to intermediate risk of PCI procedural complicationsand an intermediate to high likelihood of good long-term outcome (e.g., low-intermediateSYNTAX score of lower than 33, bifurcation left main CAD); and (Level of Evidence: B)


 * b. Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; Society of Thoracic Surgeons–predicted risk of operative mortality greater than 2%).                     (Level of Evidence: B)

Class III (Harm)
1. PCI to improve survival should not be performed in stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG. (Level of Evidence: B)}}

Revascularization to Improve Survival: Non-Left Main Coronary Artery Disease
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Class I
1. CABG to improve survival is beneficial in patients with significant (greater than or equal to 70% diameter) stenoses in 3 major coronary arteries (with or without involvement of theproximal left anterior descending LAD) or in the proximal LAD plus 1 other major coronary artery. (Level of Evidence: B)

2. CABG or PCI to improve survival is beneficial in survivors of sudden cardiac deathwith presumed ischemia-mediated ventricular tachycardia caused by significant (greater than or equal to 70% diameter) stenosis in a major coronary artery. (CABG (Level of Evidence: B)  ; PCI (Level of Evidence: C) )

Class IIa
1. CABG to improve survival is reasonable in patients with significant (greater than or equal to 70% diameter) stenoses in 2 major coronary arteries with severe or extensive myocardial ischemia (e.g., high-risk criteria on stress testing, abnormal intra-coronary hemodynamic evaluation, or greater than 20% perfusion defect by myocardial perfusion stress imaging) or target vessels supplying a large area of viable myocardium. (Level of Evidence: B)

2. CABG to improve survival is reasonable in patients with mild-moderate left ventricular systolic dysfunction (ejection fraction 35% to 50%) and significant (greater than or equal to 70% diameter stenosis) multivessel CAD orproximal LAD coronary artery stenosis, when viable myocardium is present in the region of intended revascularization. (Level of Evidence: B)

3. CABG with a left internal mammary artery graft to improve survival is reasonable in patients with significant (greater than or equal to 70% diameter) stenosis in theproximal LAD artery and evidence of extensive ischemia. (Level of Evidence: B)

4. It is reasonable to choose CABG over PCI to improve survival in patients with complex3-vessel CAD (e.g., SYNTAX score greater than 22) with or without involvement of the proximal LAD artery who are good candidates for CABG. (Level of Evidence: B)

5. CABG is probably recommended in preference to PCI to improve survival in patients withmultivessel CAD and diabetes mellitus, particularly if a left internal mammary artery graft can be anastomosed to the LAD artery. (Level of Evidence: B)

Class IIb
1. The usefulness of CABG to improve survival is uncertain in patients with significant (greater than or equal to 70%) stenoses in 2 major coronary arteries not involving theproximal LAD artery and without extensive ischemia. (Level of Evidence: C)

2. The usefulness of PCI to improve survival is uncertain in patients with 2- or 3-vessel CAD (with or without involvement of the proximal LAD artery) or 1-vessel proximal LAD disease. (Level of Evidence: B)

3. CABG might be considered with the primary or sole intent of improving survival in patients with stable ischemic heart disease with severe left ventricular systolic dysfunction (ejection fraction less than 35%) whether or not viable myocardium is present. (Level of Evidence: B)

4. The usefulness of CABG or PCI to improve survival is uncertain in patients with previous CABG and extensive anterior wall ischemia on noninvasive testing. (Level of Evidence: B)

Class III (Harm)
1. CABG or PCI should not be performed with the primary or sole intent to improve survival in patients with stable ischemic heart disease with 1 or morecoronary stenoses that are not anatomically or functionally significant (e.g., greater than 70% diameter non–left main coronary artery stenosis, fractional flow reserve 0.80, no or only mild ischemia on noninvasive testing), involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium. (Level of Evidence: B)}}

Revascularization to Improve Symptoms
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Class I
1. CABG orPCI to improve symptoms is beneficial in patients with 1 or more significant (greater than 70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite guideline-directed medical therapy. (Level of Evidence: A)

Class IIa
1. CABG orPCI to improve symptoms is reasonable in patients with 1 or more significant (greater than 70% diameter) coronary artery stenoses and unacceptable angina for whom guideline-directed medical therapy cannot be implemented because of medication contraindications, adverse effects, or patient preferences. (Level of Evidence: C)

2. PCI to improve symptoms is reasonable in patients with previous CABG, 1 or more significant (greater than 70% diameter) coronary artery stenoses associated with ischemia, and unacceptable anginadespite guideline-directed medical therapy. (Level of Evidence: C)

3. It is reasonable to choose CABG over PCI to improve symptoms in patients with complex 3-vessel CAD (e.g.,SYNTAX score greater than 22), with or without involvement of the proximal LAD artery who are good candidates for CABG. (Level of Evidence: B)

Class IIb
1. CABG to improve symptoms might be reasonable for patients with previous CABG, 1 or more significant (greater than 70% diameter) coronary artery stenoses not amenable to PCI, and unacceptable angina despite guideline-directed medical therapy. (Level of Evidence: C)

2. Transmyocardial laser revascularization performed as an adjunct to CABG to improve symptoms may be reasonable in patients with viableischemic myocardium that is perfused by arteries that are not amenable to grafting. (Level of Evidence: B)

Class III (Harm)
1. CABG orPCI to improve symptoms should not be performed in patients who do not meet anatomic (greater than 50% left main or greater than 70% non–left main stenosis) or physiological (e.g., abnormal fractional flow reserve) criteria for revascularization. (Level of Evidence: C)}}

Clinical factors that may influence the choice of revascularization: Dual Antiplatelet Therapy Compliance and Stent Thrombosis
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Class III (Harm)
1. PCI with coronary stenting (BMS or DES) should not be performed if the patient is not likely to be able to tolerate and comply with dual antiplatelet therapy (DAPT) for the appropriate duration of treatment based on the type of stent implanted. (Level of Evidence: B)}}

Hybrid Coronary Revascularization
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Class IIa
1. Hybrid coronary revascularization (defined as the planned combination of left internal mammary artery-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries) is reasonable in patients with 1 or more of the following:


 * a. Limitations to traditional CABG, such as heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI);(Level of Evidence: B)


 * b. Lack of suitable graft conduits; (Level of Evidence: B)


 * c. Unfavorable LAD artery or PCI (i.e., excessive vessel tortuosity or chronic total occlusion). (Level of Evidence: B)

Class IIb
1. Hybrid coronary revascularization (defined as the planned combination of left internal mammary artery-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries) may be reasonable as an alternative to multivessel PCI or CABG in an attempt to improve the overall risk-benefit ratio of the procedures. (Level of Evidence: C)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Pre-procedural Considerations ==

Radiation Safety
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Class I
1. Cardiac catheterization laboratories should routinely record relevant available patient procedural radiation dose data (e.g., total air kerma at the international reference point [Ka,r], air kerma air product [PKA], fluoroscopy time, number of cine images), and should define thresholds with corresponding follow-up protocols for patients who receive a high procedural radiation dose.(Level of Evidence: C)}}

Contrast-Induced Acute Kidney Injury
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Class I
1. 1. Patients should be assessed for risk of contrast-induced acute kidney injury before PCI. (Level of Evidence: C)

2. Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration. (Level of Evidence: B)

3. In patients with chronic kidney disease (CKD) (creatinine clearance ≤60 mL/min), the volume of contrast media should be minimized. (Level of Evidence: B)

Class III (No Benefit)
1. Administration of N-acetyl-L-cysteine is not useful for the prevention of contrast-induced acute kidney injury. (Level of Evidence: A)}}

Anaphylactoid Reactions
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Class I
1. Patients with prior evidence of an anaphylactoid reaction to contrast media should receive appropriate steroid and antihistamine prophylaxis before repeat contrast administration. (Level of Evidence: B)

Class III (No Benefit)
1. In patients with a prior history of allergic reactions to shellfish or seafood, anaphylactoid prophylaxis for contrast reaction is not beneficial. (Level of Evidence: C)}}

Statin Treatment
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Class IIa
1. Administration of a high-dose statin is reasonable before PCI to reduce the risk of peri-procedural myocardial infarction. (Level of Evidence: A for statin-naïve patients)      ; (Level of Evidence: B for those on chronic statin therapy) }}

Bleeding Risk
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Class I
1. All patients should be evaluated for risk of bleeding before PCI. (Level of Evidence: C)}}

Primary PCI in Hospitals Without On-Site Surgical Backup
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Class IIa
1. Primary PCI is reasonable in hospitals without on-site cardiac surgery, provided that appropriate planning for program development has been accomplished. (Level of Evidence: B)

Class III (Harm)
1. Primary or elective PCI should not be performed in hospitals without on-site cardiac surgery capabilities without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capability for transfer. (Level of Evidence: C)}}

Elective PCI in Hospitals Without On-Site Surgical Backup
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Class IIb
1. Elective PCI might be considered in hospitals without on-site cardiac surgery, provided that appropriate planning for program development has been accomplished and rigorous clinical and angiographic criteria are used for proper patient selection. (Level of Evidence: B)

Class III (Harm)
1. Primary or elective PCI should not be performed in hospitals without on-site cardiac surgery capabilities without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capability for transfer. (Level of Evidence: C)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Procedural Considerations ==

Vascular Access
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Class IIa
1. The use of radial artery access can be useful to decrease access site complications. (Level of Evidence: A)}}

Patients With Asymptomatic Ischemia or CCS Class I or II Angina
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Class IIa
1. PCI is reasonable in patients with asymptomatic ischemia or CCS class I or II angina and with 1 or more significant lesions in 1 or 2 coronary arteries suitable for PCI with a high likelihood of success and a low risk of morbidity and mortality. The vessels to be dilated must subtend a moderate to large area of viable myocardium or be associated with a moderate to severe degree of ischemia on noninvasive testing. (Level of Evidence: B)

2. PCI is reasonable for patients with asymptomatic ischemia or CCS class I or II angina, and recurrent stenosis after PCI with a large area of viable myocardium or high-risk criteria on noninvasive testing. (Level of Evidence: C)

3. Use of PCIis reasonable in patients with asymptomatic ischemia or CCS class I or II angina with significant left main CAD (greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG. (Level of Evidence: B)

Class IIb
1. The effectiveness of PCI for patients with asymptomatic ischemia or CCS class I or II angina who have 2- or 3-vessel disease with significantproximal LAD CAD who are otherwise eligible for CABG with 1 arterial conduit and who have treated diabetes or abnormal LV function is not well established. (Level of Evidence: B)

2. PCI might be considered for patients with asymptomatic ischemia or CCS class I or II angina with non-proximal LAD CAD that subtends a moderate area of viable myocardium and demonstrates ischemia on noninvasive testing. (Level of Evidence: C)

Class III
1. PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II angina who do not meet the criteria as listed under the class II recommendations or who have 1 or more of the following:


 * a. Only a small area of viable myocardium at risk, (Level of Evidence: C)


 * b. No objective evidence of ischemia. (Level of Evidence: C)


 * c. Lesions that have a low likelihood of successful dilatation. (Level of Evidence: C)


 * d. Mild symptoms that are unlikely to be due to myocardial ischemia. (Level of Evidence: C)


 * e. Factors associated with increased risk of morbidity or mortality. (Level of Evidence: C)


 * f. Left main disease and eligibility for CABG. (Level of Evidence: C)


 * g. Insignificant disease (less than 50% coronary stenosis). (Level of Evidence: C)}}

Patients With CCS Class III Angina
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Class IIa
1. It is reasonable that PCI be performed in patients with CCS class III angina and single-vessel or multi-vessel CAD who are undergoingmedical therapy and who have 1 or more significant lesions in 1 or more coronary arteries suitable for PCI with a high likelihood of success and low risk of morbidity or mortality. (Level of Evidence: B)

2. It is reasonable that PCI be performed in patients with CCS class III angina with single-vessel or multi-vessel CAD who are undergoing medical therapy with focal saphenous vein graft lesions or multiple stenoses who are poor candidates for reoperative surgery. (Level of Evidence: C)

3. Use of PCIis reasonable in patients with CCS class III angina with significant left main CAD (greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG. (Level of Evidence: B)

Class IIb
1. PCI may be considered in patients with CCS class III angina with single-vessel or multivessel CAD who are undergoing medical therapy and who have 1 or more lesions to be dilated with a reduced likelihood of success. (Level of Evidence: B)

2. PCI may be considered in patients with CCS class III angina and no evidence of ischemia on noninvasive testing or who are undergoingmedical therapy and have 2- or 3-vessel CADwith significant proximal LAD CAD and treated diabetes or abnormal LV function. (Level of Evidence: B)

Class III
1. PCI is not recommended for patients with CCS class III angina with single-vessel or multivessel CAD, no evidence of myocardial injury or ischemia on objective testing, and no trial of medical therapy, or who have 1 of the following:


 * a. Only a small area of myocardium at risk. (Level of Evidence: C)


 * b. All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success. (Level of Evidence: C)


 * c. Ahigh risk of procedure-related morbidity or mortality. (Level of Evidence: C)


 * d. Insignificant disease (less than 50% coronary stenosis). (Level of Evidence: C)


 * e. Significant left main CAD and candidacy for CABG. (Level of Evidence: C)}}

PCI in patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction
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Class I
1. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). (Level of Evidence: B)

2. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events. (Level of Evidence: A)

3. The selection of PCI or CABG as the means of revascularization in the patient with acute coronary syndrome (ACS) should generally be based on the same considerations as those without ACS. (Level of Evidence: B)

Class III (No Benefit)
1. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is not recommended in patients with extensive co-morbidities (e.g., liver or pulmonary failure, cancer) in whom:


 * a. The risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization, (Level of Evidence: C)


 * b. There is a low likelihood of ACS despite acute chest pain, or (Level of Evidence: C)


 * c. Consent to revascularization will not be granted regardless of the findings. (Level of Evidence: C)}}

Coronary Angiography Strategies in STEMI
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Class I
1. A strategy of immediate coronary angiography with intent to perform PCI (or emergency CABG) in patients with STEMI is recommended for:


 * a. Patients who are candidates for primary PCI.    (Level of Evidence: A)


 * b. Patients with severe heart failure or cardiogenic shock who are suitable candidates for revascularization. (Level of Evidence: B)

Class IIa
1. A strategy of immediate coronary angiography (or transfer for immediate coronary angiography) with intent to perform PCI is reasonable for patients with STEMI, a moderate to large area of myocardium at risk, and evidence of failed fibrinolysis. (Level of Evidence: B)

2. A strategy of coronary angiography (or transfer for coronary angiography) 3 to 24 hours after initiating fibrinolytic therapy with intent to perform PCI is reasonable for hemodynamically stable patients with STEMI and evidence for successful fibrinolysis when angiography and revascularization can be performed as soon as logistically feasible in this time frame. (Level of Evidence: A)

Class IIb
1. A strategy of coronary angiography performed before hospital discharge might be reasonable in stable patients withSTEMI who did not undergo cardiac catheterization within 24 hours of STEMI onset. (Level of Evidence: C)

Class III (No Benefit)
1. A strategy of coronary angiography with intent to perform PCI is not recommended in patients withSTEMI in whom the risks of revascularization are likely to outweigh the benefits or when the patient or designee does not want invasive care. (Level of Evidence: C)}}

Primary PCI of the Infarct Artery
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Class I
1. Primary PCI should be performed in patients within 12 hours of onset of STEMI. (Level of Evidence: A)

2. Primary PCI should be performed in patients with STEMI presenting to a hospital with Primary PCIcapability within 90 minutes of first medical contact as a systems goal. (Level of Evidence: B)

3. Primary PCI should be performed in patients with STEMI presenting to a hospital withoutPrimary PCI capability within 120 minutes of first medical contact as a systems goal. (Level of Evidence: B)

4. Primary PCI should be performed in patients with STEMI who develop severe heart failure or cardiogenic shock and are suitable candidates for revascularization as soon as possible, irrespective of time delay. (Level of Evidence: B)

5. Primary PCI should be performed as soon as possible in patients with STEMI and contraindications to fibrinolytic therapy with ischemic symptoms for less than 12 hours. (Level of Evidence: B)

Class IIa
1. Primary PCI is reasonable in patients with STEMI if there is clinical and/or electrocardiographic evidence of ongoing ischemia between 12 and 24 hours after symptom onset. (Level of Evidence: B)

Class IIb
1. Primary PCI might be considered in asymptomatic patients with STEMI and higher risk presenting between 12 and 24 hours after symptom onset. (Level of Evidence: C)

Class III (Harm)
1. Primary PCI should not be performed in a non-infarct artery at the time of Primary PCI in patients withSTEMI without hemodynamic compromise. (Level of Evidence: B)}}

Delayed or Elective PCI in Patients with STEMI
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Class IIa
1. PCI is reasonable in patients with STEMI and clinical evidence for fibrinolytic failure or infarct artery reocclusion. (Level of Evidence: B)

2. PCI is reasonable in patients with STEMI and a patent infarct artery 3 to 24 hours after fibrinolytic therapy. (Level of Evidence: B)

3. PCI is reasonable in patients with STEMI who demonstrate ischemia on noninvasive testing. (Level of Evidence: B)

Class IIb
1. PCI of a hemodynamically significant stenosis in a patent infarct artery greater than 24 hours afterSTEMI may be considered as part of an invasive strategy. (Level of Evidence: B)

Class III (No Benefit)
1. PCI of a totally occluded infarct artery greater than 24 hours after STEMI should not be performed in asymptomatic patients with 1- or 2-vessel disease if patients are hemodynamically and electrically stable and do not have evidence of severe ischemia. (Level of Evidence: B)}}

Patients With STEMI: General and Specific Considerations
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Class I
1. If immediately available, primary PCI should be performed in patients with STEMI(including true posterior MI) or MI with new or presumably new left bundle-branch block who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation goal within 90 minutes of presentation) by persons skilled in the procedure (individuals who perform more than 75 PCI procedures per year, ideally at least 11 PCIs per year for STEMI). The procedure should be supported by experienced personnel in an appropriate laboratory environment (one that performs more than 200 PCI procedures per year, of which at least 36 are primary PCI for STEMI, and that has cardiac surgery capability). (Level of Evidence: A) Primary PCI should be performed as quickly as possible, with a goal of a medical contact-to-balloon or door-to-balloon time within 90 minutes. (Level of Evidence: B)

2. Primary PCI should be performed for patients less than 75 years old with ST elevation or presumably new left bundle-branch block who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. (Level of Evidence: A)

3. Primary PCI should be performed in patients with severe congestive heart failure and/orpulmonary edema (Killip class 3) and onset of symptoms within 12 hours. Themedical contact-to-balloon or door-to balloon time should be as short as possible (i.e., goal within 90 minutes). (Level of Evidence: B)

Class IIa
1. Primary PCI is reasonable for selected patients 75 years or older with ST elevationor left bundle-branch block or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who are suitable for revascularization and agree to invasive care may be selected for such an invasive strategy. (Level of Evidence: B)

2. It is reasonable to perform primary PCI for patients with onset of symptoms within the prior 12 to 24 hours and 1 or more of the following:


 * a. Severe congestive heart failure (Level of Evidence: C)


 * b. Hemodynamic or electrical instability (Level of Evidence: C)


 * c. Evidence of persistent ischemia (Level of Evidence: C)

Class IIb
1. The benefit of primary PCI for STEMI patients eligible for fibrinolysis when performed by an operator who performs fewer than 75 PCI procedures per year (or fewer than 11 PCIs for STEMI per year) is not well established.(Level of Evidence: C)

Class III
1. Elective PCI should not be performed in a non-infarct-related artery at the time of primary PCI of the infarct related artery in patients without hemodynamic compromise. (Level of Evidence: C)

2. Primary PCI should not be performed in asymptomatic patients more than 12 hours after onset of STEMIwho are hemodynamically and electrically stable. (Level of Evidence: C)}}

PCI in Fibrinolytic-Ineligible Patients
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Class I
1. Primary PCI should be performed in fibrinolytic-ineligible patients who present with STEMI within 12 hours of symptom onset. (Level of Evidence: C)

Class IIa
1. It is reasonable to perform primary PCI for fibrinolytic-ineligible patients with onset of symptoms within the prior 12 to 24 hours and 1 or more of the following:


 * a. Severe congestive heart failure, (Level of Evidence: C)
 * b. Hemodynamic or electrical instability, (Level of Evidence: C)
 * c. Evidence of persistent ischemia. (Level of Evidence: C)}}

Facilitated PCI
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Class IIb
1. Facilitated PCI might be performed as a reperfusion strategy in higher-risk patients when PCI is not immediately available and bleeding risk is low. (Level of Evidence: B)}}

Rescue PCI (PCI After Failed Fibrinolysis)
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Class I
1. Rescue PCI should be performed in patients less than 75 years old with ST elevationor left bundle-branch block who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. (Level of Evidence: B)

2. Rescue PCI should be performed in patients with severe congestive heart failure and/orpulmonary edema (Killip class 3) and onset of symptoms within 12 hours.(Level of Evidence: B)

Class IIa
1. Rescue PCI is reasonable for selected patients 75 years or older with ST elevationor left bundle-branch block or who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who are suitable for revascularization and agree to invasive care may be selected for such an invasive strategy. (Level of Evidence: B)

2. It is reasonable to perform rescue PCI for patients with 1 or more of the following:
 * a. Hemodynamic or electrical instability (Level of Evidence: C)
 * b. Evidence of persistent ischemia (Level of Evidence: C)

Class III
1. Rescue PCI in the absence of 1 or more of the above class I or IIa indications is not recommended. (Level of Evidence: C)}}

PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion
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Class I
1. In patients whose anatomy is suitable, PCI should be performed when there is objective evidence of recurrent MI. (Level of Evidence: C)

2. In patients whose anatomy is suitable, PCI should be performed for moderate or severe spontaneous or provocable myocardial ischemia during recovery from STEMI. (Level of Evidence: B)

3. In patients whose anatomy is suitable, PCI should be performed for cardiogenic shock or hemodynamic instability. (Level of Evidence: B)

Class IIa
1. It is reasonable to perform routine PCI in patients with LV ejection fraction less than or equal to 0.40, heart failure, or serious ventricular arrhythmias. (Level of Evidence: C)

2. It is reasonable to perform PCI when there is documented clinical heart failure during the acute episode, even though subsequent evaluation shows preserved LV function (LV ejection fractiongreater than 0.40). (Level of Evidence: C)

Class IIb
1. PCImight be considered as part of an invasive strategy after fibrinolytic therapy. (Level of Evidence: C)}}

PCI in patients with Cardiogenic Shock
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Class I
1. PCI is recommended for patients with acute myocardial infarction who developcardiogenic shock and are suitable candidates. (Level of Evidence: B)

2. A hemodynamic support device is recommended for patients with cardiogenic shock afterSTEMI who do not quickly stabilize with pharmacological therapy. (Level of Evidence: B)}}

PCI in patients with Prior Coronary Bypass Surgery
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Class I
1. When technically feasible, PCI should be performed in patients with early ischemia (usually within 30 days) after CABG. (Level of Evidence: B)

2. It is recommended that distal embolic protection devices be used when technically feasible in patients undergoing PCI to saphenous vein grafts. (Level of Evidence: B)

Class IIa
1. PCI is reasonable in patients with ischemia that occurs 1 to 3 years after CABG and who have preserved LV function with discrete lesions in graft conduits. (Level of Evidence: B)

2. PCI is reasonable in patients with disabling angina secondary to new disease in a native coronary circulation after CABG. (If angina is not typical, objective evidence ofischemia should be obtained.) (Level of Evidence: B)

3. PCI is reasonable in patients with diseased vein grafts more than 3 years afterCABG. (Level of Evidence: B)

4. PCI is reasonable when technically feasible in patients with a patent left internal mammary artery graft who have clinically significant obstructions in other vessels. (Level of Evidence: C)

Class III
1. PCI is not recommended in patients with prior CABG for chronic total vein graft occlusions.(Level of Evidence: B)

2. PCI is not recommended in patients who have multiple target lesions with prior CABG and who have multi-vessel disease,failure of multiple SVGs, andimpaired LV function unless repeat CABG poses excessive risk due to severe comorbid conditions. (Level of Evidence: B)}}

Revascularization Before Non-cardiac Surgery
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Class IIa
1. 1. For patients who require PCI and are scheduled for elective non-cardiac surgery in the subsequent 12 months, a strategy of balloon angioplasty, or BMS implantation followed by 4 to 6 weeks of dual antiplatelet therapy (DAPT), is reasonable. (Level of Evidence: B)

2. For patients with drug eluting stent (DES) who must undergo urgent surgical procedures that mandate the discontinuation of dual antiplatelet therapy (DAPT), it is reasonable to continue aspirin if possible and restart the P2Y12 inhibitor as soon as possible in the immediate postoperative period. (Level of Evidence: C)

Class III (Harm)
1. Routine prophylactic coronary revascularizationshould not be performed in patients with stable CAD before noncardiac surgery. (Level of Evidence: B)

2. Elective non-cardiac surgery should not be performed in the 4 to 6 weeks after balloon angioplasty or BMS implantation or the 12 months after DES implantation in patients in whom the P2Y12 inhibitorwill need to be discontinued peri-operatively. (Level of Evidence: B)}}

Coronary Stents
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Class I
1. Before implantation of drug eluting stent (DES), the interventional cardiologist should discuss with the patient the need for and duration of dual antiplatelet therapy (DAPT) and the ability of the patient to comply with and tolerate DAPT. (Level of Evidence: C)

2. Drug eluting stent (DES) are useful as an alternative to BMS to reduce the risk of restenosis in cases in which the risk of restenosis is increased and the patient is likely to be able to tolerate and comply with prolonged dual antiplatelet therapy (DAPT). For elective PCI    (Level of Evidence: A); for UA/NSTEMI (Level of Evidence: C); for STEMI     (Level of Evidence: A).

3. Balloon angioplasty or BMS should be used in patients with high bleeding risk, inability to comply with 12 months of dual antiplatelet therapy (DAPT), or anticipated invasive or surgical procedures within the next 12 months, during which time dual antiplatelet therapy (DAPT) may be interrupted. (Level of Evidence: B)

Class III (Harm)
1. PCI with coronary stenting should not be performed if the patient is not likely to be able to tolerate and comply with dual antiplatelet therapy (DAPT). (Level of Evidence: B)

2. Drug eluting stent (DES) should not be implanted if the patient is not likely to be able to tolerate and comply with prolonged dual antiplatelet therapy (DAPT) or this cannot be determined before stent implantation. (Level of Evidence: B)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Adjunctive Diagnostic Devices ==

Fractional Flow Reserve
{{cquote|

Class IIa
1. Fractional flow reserve is reasonable to assess angiographic intermediate coronary lesions (50% to 70% diameter stenosis) and can be useful for guiding revascularization decisions in patients with Sudden ischemic heart disease (SIHD). (Level of Evidence: A)}}

Intravascular Ultrasound
{{cquote|

Class IIa
1. Intravascular ultrasound (IVUS) is reasonable for the assessment of angiographically indeterminant left main CAD. (Level of Evidence: B)

2. IVUS and coronary angiography are reasonable 4 to 6 weeks and 1 year after cardiac transplantation to exclude donor CAD, detect rapidly progressive cardiac allograft vasculopathy, and provide prognostic information. (Level of Evidence: B)

3. IVUS is reasonable to determine the mechanism of stent restenosis. (Level of Evidence: C)

Class IIb
1. IVUS may be reasonable for the assessment of non–left main coronary arteries with angiographically intermediate coronary stenoses (50% to 70% diameter stenosis). (Level of Evidence: B)

2. IVUS may be considered for guidance of coronary stent implantation, particularly in cases of left main coronary artery stenting. (Level of Evidence: B)

3. IVUS may be reasonable to determine the mechanism of stent thrombosis. (Level of Evidence: C)

Class III (No Benefit)
1. IVUS for routine lesion assessment is not recommended when revascularization with PCI or CABG is not being contemplated. (Level of Evidence: C)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Adjunctive Therapeutic Devices ==

Coronary Atherectomy
{{cquote|

Class IIa
1. Rotational atherectomy is reasonable for fibrotic or heavily calcified lesions that might not be crossed by a balloon catheter or adequately dilated beforestent implantation. (Level of Evidence: C)

Class III (No Benefit)
1. Rotational atherectomy should not be performed routinely for de-novo lesions orin-stent restenosis. (Level of Evidence: A)}}

Thrombectomy
{{cquote|

Class IIa
1. Aspiration thrombectomy is reasonable for patients undergoing primary PCI. (Level of Evidence: B)}}

Laser Angioplasty
{{cquote|

Class IIb
1. Laser angioplasty might be considered for fibrotic or moderately calcified lesions that cannot be crossed or dilated with conventional balloon angioplasty. (Level of Evidence: C)

Class III (No Benefit)
1. Laser angioplasty should not be used routinely during PCI. (Level of Evidence: A)}}

Cutting Balloon Angioplasty
{{cquote|

Class IIb
1. Cutting balloon angioplasty might be considered to avoid slippage induced coronary artery trauma during PCI for in-stent restenosis or ostial lesions in side branches. (Level of Evidence: C)

Class III (No Benefit)
1. Cutting balloon angioplasty should not be performed routinely during PCI. (Level of Evidence: A)}}

Embolic Protection Devices
{{cquote|

Class IIb
1. Embolic protection devices should be used during saphenous vein graft PCI when technically feasible. (Level of Evidence: B)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Percutaneous Hemodynamic Support Devices ==

Percutaneous Hemodynamic Support Devices
{{cquote|

Class IIb
1. Elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable in carefully selected high-risk patients. (Level of Evidence: C)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Antiplatelet Therapy ==

Oral Antiplatelet Therapy
{{cquote|

Class I
1. Patients already taking daily aspirin therapy should take 81 mg to 325 mg before PCI. (Level of Evidence: B)

2. Patients not on aspirin therapy should be given non-enteric aspirin 325 mg before PCI. (Level of Evidence: B)

3. After PCI, use of aspirin should be continued indefinitely. (Level of Evidence: A)

4. A loading dose of a P2Y12 receptor inhibitor should be given to patients undergoing PCI with stenting. (Level of Evidence: A) Options include:


 * a. Clopidogrel 600 mg (ACS and non-ACS patients).  (Level of Evidence: B)


 * b. Prasugrel 60 mg (ACS patients). (Level of Evidence: B)


 * c. Ticagrelor 180 mg (ACS patients). (Level of Evidence: B)

5. The loading dose of clopidogrel for patients undergoing PCI after fibrinolytic therapy should be 300 mg within 24 hours and 600 mg more than 24 hours after receiving fibrinolytic therapy. (Level of Evidence: C)

6. Patients should be counseled on the need for and risks of dual antiplatelet therapy (DAPT) before placement of intra-coronary stents, especially drug eluting stents (DES), and alternative therapies should be pursued if patients are unwilling or unable to comply with the recommended duration of dual antiplatelet therapy. (Level of Evidence: C)

7. The duration of P2Y12 receptor inhibitor therapy after stent implantation should generally be as follows:


 * a. In patients receiving a stent (bare metal stent (BMS) or drug eluting stent (DES)) during PCI for ACS, P2Y12 receptor inhibitor therapy should be given for at least 12 months. Options include clopidogrel 75 mg daily ,prasugrel 10 mg daily, and ticagrelor 90 mg twice daily. (Level of Evidence: B)


 * b. In patients receiving drug eluting stent (DES) for a non-ACS indication, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding.  (Level of Evidence: B)


 * c. In patients receiving bare metal stent (BMS) for a non-ACS indication, 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)

Class IIa
1. After PCI, it is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses. (Level of Evidence: B)

2. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 receptor inhibitor therapy after stent implantation, earlier discontinuation (e.g.,less than 12 months) of P2Y12 receptor inhibitor therapy is reasonable. (Level of Evidence: C)

Class IIb
1. Continuation of dual antiplatelet therapy (DAPT) beyond 12 months may be considered in patients undergoing drug eluting stent (DES)implantation. (Level of Evidence: C)

Class III (Harm)
1. Prasugrel should not be administered to patients with a prior history of stroke ortransient ischemic attack. (Level of Evidence: B)}}

Intravenous Antiplatelet Therapy: ST-Elevation Myocardial Infarction (STEMI)
{{cquote|

Class IIa
1. In patients undergoing primary PCI treated with unfractionated heparin (UFH), it is reasonable to administer a glycoprotein IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-bolus dose tirofiban), whether or not patients were pretreated with clopidogrel. (For glycoprotein IIb/IIIa inhibitor administration in patients not pretreated with clopidogrel, (Level of Evidence: A); for glycoprotein IIb/IIIa inhibitor administration in patients pretreated with clopidogrel,(Level of Evidence: C))

Class IIb
1. In patients undergoing primary PCI with abciximab, it may be reasonable to administerintracoronary abciximab. (Level of Evidence: B)

Class III (No Benefit)
1. Routine pre-catheterization laboratory (e.g., ambulance or emergency room) administration of glycoprotein IIb/IIIa inhibitors as part of an upstream strategy for patients with STEMI undergoing PCI is not beneficial. (Level of Evidence: B)}}

Intravenous Antiplatelet Therapy: Unstable Angina / Non-ST Elevation Myocardial Infarction (UA/NSTEMI)
{{cquote|

Class I
1. In UA/NSTEMI patients with high-risk features (e.g., elevated troponin level) not treated with bivalirudin and not adequately pre-treated with clopidogrel, it is useful at the time of PCI to administer a GP IIb/IIIa inhibitor (abciximab,double-bolus eptifibatide, or high-bolus dose tirofiban) in patients treated with unfractionated heparin therapy (UFH). (Level of Evidence: A)

Class IIa
1. In UA/NSTEMI patients with high-risk features (e.g., elevated troponin level) treated with unfractionated heparin therapy (UFH) and adequately pretreated with clopidogrel, it is reasonable at the time of PCI to administer a GP IIb/IIIa inhibitor (abciximab,double-bolus eptifibatide, or high-bolus dose tirofiban). (Level of Evidence: B)}}

Intravenous Antiplatelet Therapy: Sudden Ischemia Heart Disease (SIHD)
{{cquote|

Class IIa
1. In patients undergoing elective PCI treated with unfractionated heparin (UFH) and not pretreated with clopidogrel, it is reasonable to administer aGP IIb/IIIa inhibitor (abciximab,double-bolus eptifibatide, or high-bolus dose tirofiban). (Level of Evidence: B)

Class IIb
1. In patients undergoing elective PCI with stent implantation treated with unfractionated heparin (UFH) and adequately pretreated with clopidogrel, it might be reasonable to administer a GP IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, orhigh-bolus dose tirofiban). (Level of Evidence: B)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Anticoagulant Therapy ==

Use of Parenteral Anticoagulants during PCI
{{cquote|

Class I
1. An anticoagulant should be administered to patients undergoing PCI. (Level of Evidence: C)}}

Unfractionated Heparin
{{cquote|

Class I
1. Administration of intravenous UFH is useful in patients undergoing PCI. (Level of Evidence: C)}}

Enoxaparin
{{cquote|

Class I
1. An additional dose of 0.3 mg/kg intravenous enoxaparin should be administered at the time of PCI to patients who have received fewer than 2 therapeutic subcutaneous doses (e.g., 1 mg/kg) or received the last subcutaneous enoxaparin dose 8 to 12 hours before PCI. (Level of Evidence: B)

Class IIb
1. Performance of PCI with enoxaparin may be reasonable in patients either treated with upstreamsubcutaneous enoxaparin for UA/NSTEMI or who have not received prior antithrombin therapy and are administeredintravenous enoxaparin at the time of PCI. (Level of Evidence: B)

Class III (Harm)
1. Unfractionated heparin (UFH) should not be given to patients already receiving therapeuticsubcutaneous enoxaparin. (Level of Evidence: B)}}

Bivalirudin and Argatoban
{{cquote|

Class I
1. For patients undergoing PCI, bivalirudin is useful as an anticoagulant with or without prior treatment with unfractionated heparin (UFH). (Level of Evidence: B)

2. For patients with heparin-induced thrombocytopenia, it is recommended thatbivalirudin or argatroban be used to replace unfractionated heparin (UFH). (Level of Evidence: B)}}

Fondaparinux
{{cquote|

Class III (Harm)
1. Fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered because of the risk ofcatheter thrombosis. (Level of Evidence: C)}}

No-Reflow Pharmacological Therapies
{{cquote|

Class IIa
1. Administration of an intracoronary vasodilator (adenosine, calcium channel blocker, or nitroprusside) is reasonable to treat PCI-related no-reflow that occurs during primary or elective PCI. (Level of Evidence: B)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: PCI in Specific Anatomic Situations ==

Chronic Total Occlusions
{{cquote|

Class IIa
1. PCI of a chronic total occlusion in patients with appropriate clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise. (Level of Evidence: B)}}

Saphenous Vein Grafts
{{cquote|

Class I
1. Embolic protection devices should be used during saphenous vein graft PCI when technically feasible. (Level of Evidence: B)

Class III (No Benefit)
1. Platelet GP IIb/IIIa inhibitors are not beneficial as adjunctive therapy during saphenous vein graft PCI. (Level of Evidence: B)

Class III (Harm)
1. PCI is not recommended for chronic saphenous vein graft occlusions. (Level of Evidence: C)}}

Bifurcation Lesions
{{cquote|

Class I
1. Provisional side-branch stenting should be the initial approach in patients with bifurcation lesions when the side branch is not large and has only mild or moderate focal disease at the ostium. (Level of Evidence: A)

Class IIa
1. It is reasonable to use elective double stenting in patients with complex bifurcation morphology involving a large side branch where the risk of side-branch occlusion is high and the likelihood of successful side-branch reaccess is low. (Level of Evidence: B)}}

Aorto-Ostial Stenoses
{{cquote|

Class IIa
1. IVUS is reasonable for the assessment of angiographically indeterminant left mainCAD. (Level of Evidence: B)

2. Use of DES is reasonable when PCI is indicated in patients with anaorto-ostial stenosis. (Level of Evidence: B)}}

Calcified Lesions
{{cquote|

Class IIa
1. Rotational atherectomy is reasonable for fibrotic or heavily calcified lesions that might not be crossed by a balloon catheter or adequately dilated beforestent implantation. (Level of Evidence: C)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: PCI in Specific Patient Population ==

Chronic Kidney Disease
{{cquote|

Class I
1. In patients undergoing PCI, the glomerular filtration rate should be estimated and the dosage of renally cleared medications should be adjusted. (Level of Evidence: B)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Peri-procedural Myocardial Infarction Assessment ==

Peri-procedural Myocardial Infarction Assessment
{{cquote|

Class I
1. In patients who have signs orsymptoms suggestive of myocardial infarctionduring or after PCI or in asymptomatic patients with significant persistent angiographic complications (e.g., large side-branch occlusion, flow-limiting dissection, no reflow phenomenon, or coronary thrombosis), creatinine kinase-MB and troponin I or T should be measured. (Level of Evidence: C)

Class IIb
1. Routine measurement of cardiac biomarkers (creatinine kinase-MB and/or troponin I or T). (Level of Evidence: C)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Vascular Closure Devices ==

Vascular Closure Devices
{{cquote|

Class I
1. Patients considered for vascular closure devices should undergo a femoral angiogram to ensure their anatomic suitability for deployment. (Level of Evidence: C)

Class IIa
1. The use of vascular closure devices is reasonable for the purposes of achieving faster hemostasis and earlier ambulation compared with the use of manual compression. (Level of Evidence: B)

Class III (No Benefit)
1. The routine use of vascular closure devices is not recommended for the purpose of decreasing vascular complications, including bleeding. (Level of Evidence: B)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Post-procedural Antiplatelet Therapy ==

Post-procedural Antiplatelet Therapy
{{cquote|

Class I
1. After PCI, use of aspirin should be continued indefinitely. (Level of Evidence: A)

2. The duration of P2Y12 inhibitor therapy after stent implantation should generally be as follows:


 * a. In patients receiving a stent (bare metal stent (BMS) or drug eluting stent (DES)) during PCI for ACS,

P2Y12 inhibitor therapy should be given for at least 12 months. Options include clopidogrel 75 mg daily, prasugrel 10 mg daily , and ticagrelor 90 mg twice daily. (Level of Evidence: B)


 * b. In patients receiving drug eluting stent (DES) for a non-ACS indication, clopidogrel 75 mg daily should be given for at least 12 months if the patient is not at high risk of bleeding.   (Level of Evidence: B)


 * c. In patients receiving bare metal stent (BMS) for a non-ACS indication, 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)

3. Patients should be counseled on the importance of compliance with dual antiplatelet therapy (DAPT) and that therapy should not be discontinued before discussion with their cardiologist. (Level of Evidence: C)

Class IIa
1. After PCI, it is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses. (Level of Evidence: B)

2. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., less than 12 months) of P2Y12 inhibitor therapy is reasonable. (Level of Evidence: C)

Class III
1. Continuation of clopidogrel, prasugrel or ticagrelor beyond 12 months may be considered in patients undergoing placement of drug eluting stent (DES). (Level of Evidence: C)}}

Proton Pump Inhibitors and Anti-platelet Therapy
{{cquote|

Class I
1. Proton pump inhibitors should be used in patients with a history of priorgastrointestinal bleeding who require dual antiplatelet therapy (DAPT). (Level of Evidence: C)

Class IIa
1. Use of proton pump inhibitors is reasonable in patients with an increased risk ofgastrointestinal bleeding (e.g., advanced age, concomitant use of warfarin, steroids,nonsteroidal antiinflammatory drugs, Helicobacter pylori infection) who require dual antiplatelet therapy (DAPT). (Level of Evidence: C)

Class III (No Benefit)
1. Routine use of a proton pump inhibitor is not recommended for patients at low risk ofgastrointestinal bleeding, who have much less potential to benefit from prophylactic therapy. (Level of Evidence: C)}}

Clopidogrel Genetic Testing
{{cquote|

Class IIb
1. Genetic testing might be considered to identify whether a patient at high risk for poor clinical outcomes is predisposed to inadequate platelet inhibition with clopidogrel. (Level of Evidence: C)

2. When a patient predisposed to inadequate platelet inhibition with clopidogrel is identified by genetic testing, treatment with an alternate P2Y12 inhibitor (e.g., prasugrel or ticagrelor) might be considered. (Level of Evidence: C)

Class III (No Benefit)
1. The routine clinical use of genetic testing to screen patients treated with clopidogrelwho are undergoing PCI is not recommended. (Level of Evidence: C)}}

Platelet Function Testing
{{cquote|

Class IIb
1. Platelet function testing may be considered in patients at high risk for poor clinical outcomes. (Level of Evidence: C)

2. In patients treated with clopidogrel with high platelet reactivity, alternative agents, such as prasugrel or ticagrelor, might be considered. (Level of Evidence: C)

Class III (No Benefit)
1. The routine clinical use of platelet function testing to screen patients treated withclopidogrel who are undergoing PCI is not recommended. (Level of Evidence: C)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Restenosis ==

Restenosis
{{cquote|

Class I
1. Patients who develop clinical restenosis after balloon angioplasty should be treated with bare metal stent (BMS) or drug eluting stent (DES) if anatomic factors are appropriate and if the patient is able to comply with and toleratedual antiplatelet therapy (DAPT). (Level of Evidence: B)

2. Patients who develop clinical restenosis after bare metal stent (BMS) should be treated with drug eluting stent (DES) if anatomic factors are appropriate and the patient is able to comply with and tolerate dual antiplatelet therapy (DAPT). (Level of Evidence: A)

Class IIa
1. IVUS is reasonable to determine the mechanism of stent restenosis. (Level of Evidence: C)

Class III
1. Patients who develop clinical restenosis after drug eluting stent (DES) may be considered for repeat PCI with balloon angioplasty, bare metal stent (BMS), or drug eluting stent (DES) containing the same drug or an alternative antiproliferative drug if anatomic factors are appropriate and the patient is able to comply with and tolerate dual antiplatelet therapy (DAPT). (Level of Evidence: C)}}

Exercise Testing
{{cquote|

Class IIa
1. In patients entering a formal cardiac rehabilitation program after PCI, treadmill exercise testing is reasonable. (Level of Evidence: C)

Class III (No Benefit)
1. Routine periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed. (Level of Evidence: C)}}

Cardiac Rehabilitation
{{cquote|

Class I
1. Medically supervised exercise programs (cardiac rehabilitation) should be recommended to patients after PCI, particularly for moderate- to high-risk patients for whom supervised exercise training is warranted. (Level of Evidence: A)}}

==2011 ACCF/AHA/SCAI Guideline Recommendations: Quality and Performance Considerations ==

Quality and Performance
{{cquote|

Class I
1. Every PCI program should operate a quality-improvement program that routinely


 * i. reviews quality and outcomes of the entire program; (Level of Evidence: C)


 * ii. reviews results of individual operators; (Level of Evidence: C)


 * iii. includes risk adjustment; (Level of Evidence: C)


 * iv. provides peer review of difficult or complicated cases; and (Level of Evidence: C)


 * v. performs random case reviews. (Level of Evidence: C)

2. Every PCI program should participate in a regional or national PCI registry for the purpose of benchmarking its outcomes against current national norms. (Level of Evidence: C)}}

Certification and Maintenance of Certification
{{cquote|

Class IIa
1. It is reasonable for all physicians who perform PCI to participate in the American Board of Internal Medicine interventional cardiology board certification and maintenance of certification program. (Level of Evidence: C)}}

Operator and Institutional Competency and Volume
{{cquote|

Class I
1. Elective/urgent PCI should be performed by operators with an acceptable annual volume (greater than or equal to 75 procedures) at high-volume centers (more than 400 procedures) with on-site cardiac surgery. (Level of Evidence: C)

2. Elective/urgent PCI should be performed by operators and institutions whose current risk-adjusted outcomes statistics are comparable to those reported in contemporary national data registries. (Level of Evidence: C)

3. Primary PCI for STEMI should be performed by experienced operators who perform more than 75 elective PCI procedures per year and, ideally, at least 11 PCI procedures for STEMI per year. Ideally, these procedures should be performed in institutions that perform more than 400 elective PCIs per year and more than 36 Primary PCI procedures forSTEMI per year. (Level of Evidence: C)

Class IIa
1. It is reasonable that operators with acceptable volume (75 PCI procedures per year) perform elective/urgent PCI at low-volume centers (200 to 400 PCI procedures per year) with on-sitecardiac surgery. (Level of Evidence: C)

2. It is reasonable that low-volume operators (75 PCI procedures per year) perform elective/urgent PCI at high-volume centers (more than 400 PCI procedures per year) with on-site cardiac surgery. Ideally, operators with an annual procedure volume of fewer than 75 procedures per year should only work at institutions with an activity level of more than 600 procedures per year. Operators who perform fewer than 75 procedures per year should develop a defined mentoring relationship with a highly experienced operator who has an annual procedural volume of at least 150 procedures. (Level of Evidence: C)

Class IIb
1. The benefit of primary PCI for STEMI patients eligible for fibrinolysis when performed by an operator who performs fewer than 75 procedures per year (11 PCIs for STEMI per year) is not well established. (Level of Evidence: C)

Class III (No Benefit)
1. It is not recommended that elective/urgent PCI be performed by low-volume operators (75 procedures per year) at low-volume centers (200 to 400 procedures per year) with or without on-sitecardiac surgery. An institution with a volume of fewer than 200 procedures per year, unless in a region that is underserved because of geography, should carefully consider whether it should continue to offer this service. (Level of Evidence: C)}}

Guideline Resources

 * 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions


 * 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)