Page 561 - Cardiac Nursing

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CHAPTER
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I I I I Interventional Cardiology Techniques:
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P P P Percutaneous Coronary Intervention
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Michaelene Hargrove Deelstra
ft
ev
th
M More than 30 years has passedd isince hthe iintr doduc ition off coronary di diseasee or equivalent (seveere stenosis off thee left anterioorr descendd-
le
as
se
(s
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an angioplasty by Andreas Gruentzig inn 1977. Intervventional cardi- in ing artery and circummflex arteries proximal to any major branch),
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ology has continued to evolve and improve techniques and proce- a large area of myocarddium att risk, pre-existing impairmentt fof left
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(L
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nt
d
h
us
re
t
me
at
dures ffor percutanneous treatment off coronary heart diisease vent iricullar (LVV) function or renal function, and collateral vessels
(CHD). Interventional coronary devices used to restore or enhance supplying significant areas of myocardium that originate distal to
myocardial blood flow include angioplasty balloons, atherectomy the segment to be treated. 3
4
devices, and intracoronary stents. Pharmacological therapies have ACC/AHA/SCAI recommends an early invasive strategy with
been an important partner in the development of device technol- PCI in patients with unstable angina/non-ST-elevation MI
ogy. This interventional cardiology chapter provides a review and (NSTEMI) who exhibit the following:
understanding of the evolution of device technology, patient man- ■ Recurrent angina, ischemia at rest or with low-level activities
agement, the current trends and devices used in the catheterization
despite intensive medical therapy
laboratory today to treat CHD, and a look at percutaneous devices ■ Elevated cardiac biomarkers, new or presumed new ST-segment
used for the treatment of cardiac structural abnormalities.
depression
The term percutaneous coronary intervention (PCI) refers to the ■ Signs or symptoms of heart failure or new worsening mitral re-
I
I
collective group of interventional procedures performed through
gurgitation
a percutaneous approach in the coronary arteries. PCI was ini- ■ High-risk findings on noninvasive testing or hemodynamic in-
tially limited to balloon angioplasty but now encompasses other
stability
procedures using atherectomy devices, thrombectomy devices, ■ Sustained ventricular tachycardia and prior CABG or reduced
and bare metal and drug-eluting stents (DES). Factors that have
LV ejection fraction .40.
improved the overall success and complication rates include oper- ■ PCI is not indicated for a persistently occluded infarct-related
ator experience, modifications in procedural instruments, newer
interventional devices, and advances in adjunctive pharmacologic artery after NSTEMI or ST-elevation MI (STEMI) older than
therapy. These improvements have led to the expansion of inter- 24 hours in a stable, asymptomatic patient.
ventional cardiology treatment to higher risk patients with more In patients with stable CAD optimal medical therapy alone
complex coronary lesions and comorbidities. These improvements can be considered versus PCI with optimal medical therapy. PCI
have influenced the short- and long-term success of PCI. 2 when added to optimal medical therapy in stable angina has been
shown to reduce the prevalence of angina symptoms but not to
reduce long-term rates of death, MI, or hospitalization for ACS. 5
PATIENT SELECTION FOR PCI
Special Subgroups of Patients
The American College of Cardiology/American Heart Associa- Receiving PCI
tion/ Society for Cardiovascular Angiography and Interventions
(ACC/AHA/SCAI) task force provides broad guidelines and rec- Patients Receiving Fibrinolytic Therapy
ommendations for appropriate application of PCI technology Facilitated PCI refers to a strategy of planned immediate PCI after
based on scientific evidence for revascularization. Recommenda- the administration of an initial pharmacological regimen intended to
tions for revascularization with PCI include patients presenting improve coronary patency before the procedure. Clinical trials of fa-
with significant ischemia on noninvasive testing, unstable angina, cilitated PCI have not demonstrated benefit in reducing infarct size
and acute coronary syndrome (ACS). When the patient is consid- or improving outcomes. In patients with STEMI, a planned reper-
ered for revascularization with PCI, the potential risks and bene- fusion strategy using full-dose fibrinolytic therapy (Chapter 22) fol-
fits should be discussed in detail with the patient and family and lowed by immediate PCI may be harmful and is not advocated.
be weighed against alternative therapies such as medical therapy Coronary angiography and intent to perform revascularization
or coronary artery bypass graft (CABG) surgery. Patients should are recommended for patients who have received fibrinolytic ther-
understand the possible complications associated with the proce- apy, are in cardiogenic shock, are candidates for PCI, and have
dure, the possibility of restenosis, stent thrombosis (see complica- severe heart failure or pulmonary edema or hemodynamically sig-
tions) postprocedure, and the potential for incomplete revascular- nificant ventricular arrhythmias. Rescue PCI should be consid-
ization in patients with diffuse coronary artery disease (CAD). ered in patients with STEMI who have received fibrinolytic agents
io
ra
g
perfusion (ST-segment resolution
The clinical and ang gg pphic variables associated with increased and have evidence of failed rep ( g
mortality include advanced age, female sex, diabetes mellitus, 50%) 90 minutes after initiation of fibrinolytic therapy, and
prior myocardial infarction (MI), multivessel disease, left main have a moderate-to-large area of myocardium at risk. 4
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