Special Issue Percutaneous Coronary Intervention for Coronary Artery Disease Myung Ho Jeong, M.D. Department of Cardiovascular Medicine Chonnam Nation

Special Issue Percutaneous Coronary Intervention for Coronary Artery Disease Myung Ho Jeong, M.D. Department of Cardiovascular Medicine Chonnam National University Medical School & Hospital E mail : myungho@chollian.net Abstract Recently the incidence of coronary artery disease has been increasing in Korea. Percutaneous coronary intervention (PCI) has been established as one of the most effective therapeutic methods in addition to medical therapies, especially for patients with acute coronary syndrome (ACS). ACS refers to unstable angina (UA), non ST segment elevation myocardial infarction (NSTEMI), and ST segment elevation myocardial infarction (STEMI). UA / NSTEMI is a common but heterogeneous disorder with patients exhibiting a wide variety of risks. In patients with UA / NSTEMI, early risk stratification is at the center of the management program and can be achieved by using clinical criteria, electrocardiographic changes and biomarkers, or both. Platelet glycoprotein (GP) IIb/IIIa receptor blockers are indicated in high risk patients who are likely to undergo PCI, but are not indicated in the management of lower risk patients who do not undergo PCI. There is a hard evidence to support the substitution of the low molecular weight heparin for unfractionated heparin. Many recent trials have demonstrated the benefit of an early invasive strategy with coronary angiography followed by PCI in patients at high and intermediate risk. Prompt reperfusion of ischemic myocardium is the major focus of acute treatment of patients with STEMI. Two reperfusion strategies have been developed: thrombolytic therapy and primary PCI. Although these two strategies have traditionally been considered distinct and at times competing options, it is likely that the care of patients with STEMI will be improved in the future if they are viewed as a single integrated effort for reperfusion. However, PCI has been shown to be superior to thrombolysis in the treatment of STEMI admitted to highly experienced PCI centers. A meta analysis of many randomized trials found significantly lower mortality rate, and lower rate of nonfatal reinfarction and intracerebral hemorrhage with primary PCI compared with thrombolysis. Currently, a primary PCI strategy may begin with the initiation of a platelet GP IIb/IIIa receptor blocker in the emergency center, together with aspirin and heparin (especially low molecular weight heparin), followed by rapid application of coronary angioplasty with stenting. Primary PCI is feasible in community hospitals without surgical capability, however, due to the concerns about timing and safety margin, this approach is not yet advocated in the current guidelines. Keywords : Angina; Myocardial infarction; Percutaneous coronary intervention; Thrombolysis 736

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Suspected myocardial infarction on ECG No Suspected ischemia on ECG Yes No Yes No risk factors One risk factor Two or more risk factors Zero or one risk factor Two or more risk factors Very low risk (<1%) Low risk (approximately 4%) Intermediate risk (approximately 8%) High risk (>16%) 739

Special Issue High risk At least one of following features must be present : Prolonged, ongoing (>20min) rest pain Pulmonary edema Angina with new or worsening mitral regurgitation murmurs Rest angina with dynamic ST changes of at least 1 mm Angina with S3 or rales Angina with hypotension Intermediate risk No high risk features but must have any of the following : Rest angina now resolved but not low likelihood of coronary disease Rest angina (>20 min or relieved with rest or nitroglycerin) Angina with dynamic T wave changes Nocturnal angina New onset Canadian Cardiovascular Society class III or IV angina in past 2 weeks but not low likelihood of coronary disease Q waves or ST depression of at least 1mm in multiple leads Age > 65 years Low risk No high risk or intermediate-risk feature but may have any of the following : Increased angina frequency, severity, or duration Angina provoked at a lower threshold New onset angina within 2 weeks to 2 months Normal or unchanged ECG 740

LMCD, 3VD+LV Dys., or Diab. Mell. CABG MANAGEMENT OF UA / NSTEMI High/Intermediate Risk Cor. Arteriography 1 or 2V D, suitable for PCI Clopidogrel, llb/llla inhib. PCI Discharge on ASA, Clopidogrel, Statin, ACE 1 MANAGEMENT OF UA / NSTEMI Lower Risk Stress Test Normal Consider Alternative Diagnosis +High Risk +Not High Risk Negative Coronary Arteriography High Risk Strategy Clopidogrel, Statin, ACEI, Outpatient Rx LMCD : VD : LV Dys : ASA : ACE I : Consider Alternative Diagnosis 741

Special Issue Recurrent ischemia and/or ST segment shift, or deep T wave inversion, or positive cardiac markers Aspirin blockers Nitrates Antithrombin regimen GP llb/llla inhibitor Monitoring(rhythm and ischemia) Early invasive strategy Early conservative strategy Immediate angiography for possible recanalization therapy 12 24 hr angiography for possible recanalization therapy Recurrent symptoms/ischemia Heart failure Serious arrhythmia Patient stabilizes Evaluate LV function Stress test EF <.40 EF.40 Not low risk Low risk EF : GP : Follow on medical therapy 742

16 FRISC II Conservative 14 12 10 8 Invasive 6 4 P=0.005 2 0 0 2 4 6 Months 8 10 12 20 16 12 Invasive 8 P=0.025 4 0 0 1 2 3 4 5 6 Months RITA 3 30 20 Death/MI(%) Death/MI/Rehosp(%) Death/MI/RA(%) 10 TACTICS TIMI 18 Conservative Conservative 0 0 2 4 6 8 10 12 Months P=0.003 Invasive 743

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Special Issue ReoPro stent (n=43) Control stent (n=42) p value Preintervention Proximal reference EEM CSA(mm 2 ) 14.2±3.1 13.7±2.8 0.232 Lesion site EEM CSA(mm 2 ) 13.8±3.6 12.7±3.9 0.204 Lesion site lumen CSA(mm 2 ) 4.1±1.0 4.0±0.8 0.777 Lesion site P&M CSA(mm 2 ) 9.7±3.2 8.7±3.6 0.280 Lesion site plaque burden (%) 70.3±6.3 66.5±8.5 0.119 Distal reference EEM CSA(mm 2 ) 12.7±3.2 12.4±2.8 0.604 Postintervention Stent CSA(mm 2 ) 7.8±2.2 7.7±1.4 0.898 lumen CSA(mm 2 ) 7.8±2.2 7.7±1.4 0.898 NIH area(mm 2 ) 0.0±0.0 0.0±0.0 1.000 Follow up Proximal reference EEM CSA(mm 2 ) 14.1±3.5 13.5±3.0 0.211 Stent CSA(mm 2 ) 7.7±2.0 7.6±1.5 0.178 Intrastent lumen area(mm 2 ) 5.7±1.6 4.2±0.8 0.001 Intrastent NIH area(mm 2 ) 2.0±1.6 3.4±1.7 0.001 Distal reference EEM CSA(mm 2 ) 12.4±2.8 12.1±2.4 0.587 Serial (after intervention to follow up) comparison Proximal reference EEM CSA(mm 2 ) 0.1±0.7 0.2±1.0 0.821 Stent CSA(mm 2 ) 0.1±1.1 0.1±1.2 0.978 Intrastent lumen area(mm 2 ) 2.1±1.6 3.5±1.8 0.001 Intrastent NIH area(mm 2 ) 2.0±1.6 3.4±1.7 0.001 Distal reference EEM CSA(mm 2 ) 0.3±1.2 0.3±1.4 0.967 EEM : (external elastic membrane), CSA : (cross sectional area), P & M : (plaque and media), NIH : (neointiam hyperplasia) 746

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Special Issue Dominant strategy : Institution capable of performing PCI? Yes Recommend catheterization followed by PCI or CABG as cilnically indicated : Recommend clopidogrel Recommend GP llb/llla inhibitor(e.g., abciximab) plus UFH Door to balloon time < 90 minutes? No No Chest pain ST segment elevation or new or presumably new bundle branch block Treat With : Aspirin, blockers Nitroglycerin, Morphine sulfate Chest pain No Medical management Chest pain Persistent symptoms? Yes Consider reperfusion Aggressive medical therapy Yes Contraindication to thrombolysis or cardiogenic shock? Yes Cardiac catheterization PCI pr CABG No Fibrinolysis Preferred anticoagulant Enoxaparin* plus Tenecteplase Alteplase or Reteplace Door to needle time < 30 min. *Unfractionated heparin(alternative) Consider No Clinical evidence of reperfusion (chest pain and ECG with resolution) Yes Continued medical therapy If any one of the following : Recurrent pain CHF Hemodynamic instability Sustained V Tech PCI within 6 months Prior CABG Yes Early PCI No Continued medical therapy 748

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