Percutaneous Coronary Intervention

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Synonyms: percutaneous transluminal coronary angioplasty (PTCA), formerly known as balloon angioplasty

Percutaneous coronary intervention (PCI) is one of the two coronary revascularisation techniques currently used in the treatment of ischaemic heart disease, the other being coronary artery bypass grafting (CABG).[1]

PCI involves non-surgical widening of the coronary artery, using a balloon catheter to dilate the artery from within. A metallic stent is usually placed in the artery after dilatation. Antiplatelet agents are also used. Stents may be either bare metal or drug-eluting.

Note that indications for PCI may change as the procedures continue to be refined, and with emerging evidence.

  • ST segment elevation myocardial infarction (STEMI):[2]
    • When available, angioplasty with stenting is the optimal method of reperfusion for STEMI. The target 'door to balloon time' is 90 minutes.
    • As rescue treatment in patients treated by thrombolysis - if there is failure to reperfuse, further ischaemia or further myocardial infarction (MI).
    • As early intervention in patients treated with thrombolysis.
  • Non-ST elevation acute coronary syndrome (NSTACS) - unstable angina and non-ST elevation myocardial infarction (NSTEMI):[2]
    • For patients who are at medium-to-high risk of subsequent cardiac events, offer angiogram and/or PCI before discharge. Early invasive investigation and revascularisation (compared to conservative treatment) may reduce subsequent MI and refractory angina.
  • Overall, PCI treatment for non-acute coronary artery disease has shown no evidence of an effect on death or myocardial infarction when compared with medical therapy.[3][4] Revascularisation is appropriate for patients with stable angina for:[1]
    • Persistent limiting symptoms despite optimal medical therapy.
    • Certain anatomical patterns of disease or a proven significant ischaemic territory (even in asymptomatic patients). Significant left main artery stenosis, and significant proximal left anterior descending disease, especially in the presence of multivessel coronary artery disease, are strong indications for revascularisation.
    • In the most severe patterns of coronary artery disease, CABG appears to offer a survival advantage and a marked reduction in the need for repeat revascularisation (but with a higher risk of a cerebrovascular event), especially in left main artery disease..

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  • Consider the pros and cons of PCI versus optimal drug therapy and/or CABG.[5][6]
  • Because anti-platelet drugs are crucially important after PCI (to prevent thrombosis in the stent, see below), decisions about PCI and the type of stent used must bear in mind:[7][8]
    • Is there likelihood that surgery will be needed? Consider the increased risk of bleeding with antiplatelet drugs, but risk of thrombosis if these drugs are stopped.
    • Can the patient adhere to antiplatelet treatment (and is there funding to do so)?
    • Any contra-indications to antiplatelet drugs.

PCI options for patients with coronary artery disease include percutaneous balloon angioplasty, stent placement or percutaneous cutting balloon. Percutaneous laser coronary angioplasty may be used for carefully selected patients for whom conventional angioplasty would otherwise be technically difficult.[10]

  • PCI should be done by experienced, high-volume operators and institutions.
  • No anaesthetic is needed, although patients may be given a sedative. Patients can usually mobilise a few hours afterwards, and go home the same or next day.
  • The technique involves gaining arterial access via the femoral, radial or brachial arteries. Under fluoroscopy, a guide wire is passed into the coronary artery and across the stenosis; the balloon or stent catheter is passed over it, and the lesion dilated and/or stented.
  • Glycoprotein IIb/IIIa inhibitors are given in 'high-risk' procedures, and opiates may be used if angina occurs during angioplasty.
  • When given during PCI, intravenous glycoprotein IIb/IIIa inhibitors reduce the risk of death and of death or myocardial infarction at 30 days and at six months, but increase in the risk of severe bleeding.[11]

Types of coronary stent[8]

Currently, stents are implanted in nearly all patients undergoing PCI because the stent gives various advantages over simple balloon dilatation.

The two main types are:

  • Bare metal stents (BMSs) - usually stainless steel.
  • Drug-eluting stents (DESs) - metal struts are coated with a growth-inhibiting agent that inhibits smooth muscle cell proliferation.
    • This reduces the frequency of restenosis (by about 50%).
    • However, it also slows the process of re-endothelialisation, thus prolonging the risk of stent thrombosis.
    • In the UK, most DESs utilise paclitaxel - an anti-cancer agent, or sirolimus - an immunosuppressant.
DESs are recommended for use in PCI if:[12]
  • the target artery to be treated has a calibre <3 mm, or the lesion is longer than 15 mm, and
  • the price difference between DESs and BMSs is no more than £300.

Antiplatelet drug treatment following percutaneous coronary intervention[8][13]

  • All patients should take aspirin indefinitely (as secondary prevention of cardiovascular disease).
  • 'Dual antiplatelet therapy' is required for patients with coronary stents, to reduce the risk of stent thrombosis:
    • This normally comprises aspirin and clopidogrel. The duration of clopidogrel treatment depends on the clinical setting, but current recommendations are usually:
      • For BMSs, clopidogrel for at least one month.
      • For DESs, clopidogrel for at least 12 months. Some cardiologists feel that clopidogrel should be continued indefinitely.
  • Antiplatelet agents should not be stopped, and patients are advised to carry a warning card. Cards are available from the United Kingdom Clinical Pharmacy Association (admin@ukcpa.com).[14]
  • If surgery is required, consider whether the antiplatelet drugs can be continued; consult with a cardiologist as to the risks of discontinuing these drugs and any necessary precautions.[13]
  • The use of proton pump inhibitors (PPIs) together with clopidogrel (to prevent gastric bleeding) is controversial, after evidence suggesting that PPIs may worsen outcomes, and that the two drugs may interact.

Driving[15]

After elective PCI:

  • Group 1 licence - stop driving for one week; can recommence thereafter if there is no other disqualifying condition. DVLA need not be notified.
  • Group 2 licence - stop driving for at least six weeks. Re-licensing may be permitted thereafter provided that other functional test requirements can be met and there is no other disqualifying condition.
  • Stent thrombosis:
    • This is a risk until the stent becomes covered by endothelium.
    • It usually presents as acute MI, with a high mortality.
    • It is most frequent during the first month, but can occur months or years after the PCI.
    • It occurs in 1-2% of patients.
  • Restenosis of the stent:
    • This is due to excessive 'healing' of the vessel wall, which encroaches on the stent lumen.
    • Typically, it develops within 3-6 months.
    • It presents as a return of angina; it rarely causes MI.
    • It occurs in 4-20% of stents.
  • Other major complications are uncommon, but include death (0.2% but higher in high-risk cases), acute MI (1%) which may require emergency CABG, stroke (0.5%), cardiac tamponade (0.5%) and systemic bleeding (0.5%).
  • Minor complications are allergy to the contrast medium, nephropathy and complications at the access site, such as bleeding and haematoma.
  • Bioabsorbable stents are being trialled and have potential advantages.[16]
  • Triple antiplatelet therapy may be beneficial.[17]
  • New antithrombotic drugs, such as thrombin receptor (protease-activated receptor-1 (PAR-1)) antagonists might reduce thrombosis without affecting haemostasis.[18]

Further reading & references

  1. Guidelines for Myocardial Revascularisation, European Society of Cardiology (2010)
  2. Acute coronary syndrome, Map of Medicine (Cardiology)
  3. Pursnani S, Korley F, Gopaul R, et al; Percutaneous coronary intervention versus optimal medical therapy in stable coronary artery disease: a systematic review and meta-analysis of randomized clinical trials. Circ Cardiovasc Interv. 2012 Aug 1;5(4):476-90. doi: 10.1161/CIRCINTERVENTIONS.112.970954. Epub 2012 Aug 7.
  4. Trikalinos TA, Alsheikh-Ali AA, Tatsioni A, et al; Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis. Lancet. 2009 Mar 14;373(9667):911-8.
  5. Taggart DP; Coronary revascularisation. BMJ. 2007 Mar 24;334(7594):593-4.
  6. Mukherjee D, Moliterno DJ; Effectiveness of PCI for non-acute coronary artery disease. Lancet. 2009 Mar 14;373(9667):870-2.
  7. Bavry AA, Bhatt DL; Appropriate use of drug-eluting stents: balancing the reduction in restenosis with the concern of late thrombosis. Lancet. 2008 Jun 21;371(9630):2134-43.
  8. Managing patients with coronary stents; British Heart Foundation, Oct 2008.
  9. Grech ED; ABC of interventional cardiology: percutaneous coronary intervention. II: the procedure. BMJ. 2003 May 24;326(7399):1137-40.
  10. Percutaneous laser coronary angioplasty, NICE Interventional Procedure Guideline (January 2011)
  11. Bosch X, Marrugat J, Sanchis J; Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD002130. doi: 10.1002/14651858.CD002130.pub2.
  12. Coronary artery disease - drug-eluting stents, NICE Technology Appraisal Guidance (July 2008)
  13. Cruden NL, Harding SA, Newby DE; Coronary stent thrombosis in the perioperative period. BMJ. 2008 Nov 24;337:a2074. doi: 10.1136/bmj.a2074.
  14. Antoniou S, Rothman MT; Stent thrombosis: patient card on discontinuing clopidogrel is available. BMJ. 2007 Jan 13;334(7584):57.
  15. At a glance guide to the current medical standards of fitness to drive; Driver and Vehicle Licensing Agency
  16. Colombo A, Sharp AS; The bioabsorbable stent as a virtual prosthesis. Lancet. 2009 Mar 14;373(9667):869-70.
  17. Chen KY, Rha SW, Li YJ, et al; Triple versus dual antiplatelet therapy in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Circulation. 2009 Jun 30;119(25):3207-14. Epub 2009 Jun 15.
  18. Colombo A, Merlini P; The ischaemia/bleeding balance in PCI. Lancet. 2009 Mar 14;373(9667):872-3.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Naomi Hartree
Current Version:
Peer Reviewer:
Dr Helen Huins
Document ID:
2593 (v23)
Last Checked:
21/02/2013
Next Review:
20/02/2018