1. Non-ST-segment elevation ACS
Evidence-based medical evidence suggests that early interventional strategies show a clear advantage in patients with high risk.The indication for PCI is based on risk stratification. The Global Registry of Acute Coronary Events (GRACE) risk score is newly recommended as the preferred scoring method for risk stratification. It is recommended that the GRACE score >140 and the number of high-risk factors be used as a basis for selecting urgent (<2h) and delayed (within 72h) invasive treatment strategies.
Conditions requiring urgent coronary angiography.
(1) Persistent or recurrent ischemic symptoms that are not controlled by adequate pharmacological therapy.
(2) Spontaneous ST-segment dynamic evolution (depression >0.1 mV or transient elevation).
(3) Elevated blood cardiac enzyme markers.
(4) Hemodynamic instability.
(5) Severe ventricular arrhythmias.
(6) Heart failure or mitral regurgitation or worsening of pre-existing regurgitation.
(7) Interventional therapy or previous coronary artery bypass grafting within 6 months.
If coronary angiography shows that PCI is appropriate, the offender vessel should be identified and intervention performed based on coronary imaging characteristics and ECG; if multiple vessel lesions are shown and it is difficult to determine the offender vessel, it is best to perform FFR to determine the treatment strategy.
For hemodynamically unstable or complex and aggressive lesions, PCI with intra-aortic balloon counterpulsation (IABP) support is recommended.
For low-risk and early non-PCI patients, the necessary evaluation should be performed before discharge, and the appropriate treatment should be taken according to the cardiac function, myocardial ischemia and the risk of recurrent cardiovascular events.
2. Acute ST-segment elevation heart attack
Evidence-based medical evidence has shown that PCI is effective in reducing overall mortality in STEMI, and such patients are the clinical type with the strongest indications for PCI.
Indications for direct PCI in STEMI patients
(1) All STEMI within 12 hours of onset and within 90 minutes of D-to-B (visit to balloon dilation) with an experienced operator and team operation.
(2) Patients with contraindications to thrombolysis.
(3) PCI is more likely to be preferred >3 hours after onset.
(4) with cardiogenic shock, age <75 years, MI onset <36 hours, shock <18 hours; age >75 years, cardiogenic shock, MI onset <36 hours, shock <18 hours, PCI may be considered on balance.
(5) There is still evidence of ischemia at 12 to 24 hours of onset, or there is cardiac dysfunction or hemodynamic instability or severe arrhythmias.
A prehospital diagnostic and transfer network is required to rapidly transfer patients to a center where direct PCI is feasible (IA). If a patient is sent to a facility with emergency PCI facilities but lacks sufficient qualified physicians, a physician from a higher-level hospital (who has established a regular contact in advance) may also be considered to rapidly visit the facility to perform direct PCI (IIbC).
Meanwhile, the emergency PCI center can start direct PCI (IB) within 90 min of admission; if direct PCI is not available, patients without contraindications to thrombolysis should be thrombolytically treated as soon as possible and full thrombolytic agent (IIaA) should be considered.
In patients with STEMI combined with cardiogenic shock, regardless of the time of onset and regardless of whether thrombolysis has been used, urgent coronary angiography should be performed, and if the lesion is suitable, immediate direct PCI (IB) is recommended to deal with severe lesions in all major vessels to achieve complete revascularization; IABP support (IB) should be applied to those who cannot be rapidly stabilized hemodynamically after drug therapy. It is important to point out in particular: the mortality rate of such patients is more than 80% if they do not intervene with hemodynamic reconstruction therapy as early as possible, and their mortality rate can be reduced by about 50% if they receive timely PCI treatment, but the mortality rate is still very high, and they should fully communicate with their families and get exact understanding before PCI intervention to avoid unnecessary medical disputes. This is especially important in the current medical environment in China.
Except for cardiogenic shock, PCI (direct, remedial or post-thrombolysis) should be limited to opening the offender lesion vessel (IIaB).
Routine application of IABP support should be avoided in patients without hemodynamic disturbances (IIIB).