Primary Percutaneous Coronary Intervention

Definition

Primary Percutaneous Coronary Intervention (PPCI) is defined as angioplasty or stenting without prior or concomitant thrombolytic therapy.
PPCI is effective in achieving and maintaining coronary artery patency without exposing the patient to the increased bleeding risks of thrombolysis.
In the UK, PPCI has become the favoured option and systems are evolving to develop an exclusively PPCI-based approach to reperfusion for STEMI.

Evidence

There is robust evidence for the superiority of PPCI over in-hospital thrombolysis [3], with better short-term mortality, reduced re-infarction rates and a lower incidence of stroke. However, there is no robust evidence of superiority of PPCI over PHT [4].

The benefits of PPCI over thrombolysis are unequivocal in patients presenting later during the course of their event (symptom onset greater than 3 hours) [10] but are unproven early in the course of STEMI, and especially within the first two hours after symptom onset. In relation to the delay to PPCI when compared to thrombolysis (the balloon time minus the needle time), any potential benefit from PPCI may become harm when a period of somewhere between one and two hours is exceeded [5], irrespective of the time of onset of symptoms. The nature of UK geography and the way that ambulance services are organised means that the vast majority of patients (approximately 95%) are suitable for PPCI based on these time criteria. There may still be some remote areas within the UK where thrombolysis (or, more specifically, pre-hospital thrombolysis) is the only reperfusion strategy which can be delivered in a timely manner.

PPCI is the preferred option in patients presenting with cardiogenic shock, irrespective of time of onset of symptoms [6], and in those patients with a contra-indication to thrombolysis. Recommendations for reperfusion have been summarised in guidelines published by the American Heart Association/American College of Cardiology [7] and The European Society of Cardiology [8].

Learning Bite

PPCI offers definitive reperfusion, but delay to therapy may be harmful in some patients.

Summary Recommendations

Summary – Guidance from the AHA/ACC and the ESC [7,8]
Thrombolysis is generally preferred: Where there will be a delay to invasive strategy: i.e. when PCI is not available within 2 hours from first medical contact in any case or less than 90 minutes in early presenters (<2 hours post onset of symptoms)
PPCI is generally preferred: If a skilled PCI laboratory is available: i.e. time from first medical contact to balloon inflation should be less than 2 hours in any case and less than 90 minutes in early presenters (<2 hours post onset of symptoms) In patients with cardiogenic shock or a contraindication to thrombolysis.

Summary – Guidance from the AHA/ACC and the ESC [7,8]

Thrombolysis is generally preferred:

Where there will be a delay to invasive strategy: i.e. when PCI is not available within 2 hours from first medical contact in any case or less than 90 minutes in early presenters (<2 hours post onset of symptoms)

PPCI is generally preferred:

If a skilled PCI laboratory is available: i.e. time from first medical contact to balloon inflation should be less than 2 hours in any case and less than 90 minutes in early presenters (<2 hours post onset of symptoms)
In patients with cardiogenic shock or a contraindication to thrombolysis.

NICE²² has produced a visual summary of the recommendations on the early management of STEMI.

Private: Management of STEMI and its Complications

Primary Percutaneous Coronary Intervention