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Post pci management of acs
- 1. POST-PCI MANAGEMENT OF ACS DR SHADAB AHMAD
- 2. INTRODUCTION • PCI is one of the most common procedures in the US, and remain a cornerstone in the management of ischemic heart disease. • Historically, a large proportion of PCI procedures were performed during inpatient hospitalization, allowing for a significant amount of time for monitoring postprocedure to ensure procedural success & identify bleeding or vascular complications, as well as for initiating secondary prevention. • However, technological pharmacological and procedural innovations, as well as payer expectations and cost considerations, have led to a shorter length of stay postprocedure and obviate hospital admission. • Most non-acute MI PCIs performed in the US now are performed under an outpatient designation.
- 3. POST-PCI DISCHARGE PLANNING • Discharge planning following PCI should begin prior to the procedure, with an emphasis on gathering information regarding preprocedure activity level, medication adherence, and patient social support at home. • Postprocedure management focuses on: • Access site management and monitoring for new ischemia and bleeding or vascular
- 4. PHYSICIAN-TO-PATIENT COMMUNICATION • The result of the procedure, including any complications and/or unexpected findings, should be explained clearly to the patient and his/her family • The type of intervention, if any, and the duration of DAPT should also be introduced and reinforced repeatedly by the team of care providers throughout the patient stay.
- 5. ACCESS SITE MANAGEMENT • Typically, manual compression, a compression device, and/or a vascular closure device (VCD) is used in patients following transfemoral access, whereas a wristband compression device is used most frequently among patients undergoing transradial access. • For patients undergoing transfemoral access and anticoagulated with heparin, the access sheats can generally be removed once the ACT falls below 175 sec if a closure device is not used. • The use of bivalirudin typically does not necessitate checking an ACT unless there is significant renal impairment (i.e., crcl<30ml/min, or hemodialysis); in that situation sheath may be removed once the ACT falls below 180 sec. • In patients without significant renal dysfunction, the femoral sheath can be removed 2 hours after the discontinuation of the bivalirudin infusion if a closure device is not used
- 6. POST PROCEDURE AMBULATION • The access site, method of hemostasis, intensity of procedure sedation, and anticoagulation strategy drive recommendations for activity immediately postprocedure. • Patients undergoing TR catheterization may ambulate as soon as sedation wanes. • For patients undergoing tranfemoral catheterization and PCI, strict bed rest is typically recommended for 4-8 hours if manual compression is used or 1-4 hour if a VCD is used. • Prior to ambulation, a care provider must ensure that hemostasis is achieved and there is no diminution of downstream pulses.
- 7. POSTPROCEDURE VITALS MONITORING • Every 15 minutes for the first 2 hours by trained nursing personnel.
- 8. POST-PCI MONITORING OF CARDIAC BIOMARKERS • To assess for evidence of periprocedural myocardial damage. • Historically, cardiac biomarkers had been checked serially every 8-12 hours postprocedure, however, the routine measurements of cardiac biomarkers post-PCI is controversial, because biomarker elevation in absence of clear evidence of adverse clinical outcomes may lead to a longer hospital length of stay, unnecessary evaluation and testing and increasing potentials for iatrogenic complications. • Traditionally, CKMB levels were checked routinely post PCI; but now, there has been a transition to cTn
- 9. BIOMARKER ELVATION PATTERN THIRD DEFINITION OF MI CLINICALLY RELEVENT MI Normal biomarkers at baseline Elevation of cTn>5x99th percentile URL and either: (a) evidence of prolonged ischemia; (b) ischemic ST changes or new Q waves; (c) angiographic evidence of flow limiting lesions; (d) imaging evidence of loss of viable myocardium Peak CKMB (cTn) rises to ≥10x ULN (≥70xULN for cTn) or ≥5xULN (≥35x ULN for cTn) with new pathologic Q waves in ≥2 contiguous leads or new LBBB Elevated at baseline but stable >20% rise of cTn from the most recent preprocedure value CKMB (or cTn) rises by absolute increment as those described above from the most recent preprocedure lvevel Elevated at baseline and not stable or falling No guidance CKMB (or cTn) rises by absolute increment as those described above from the most recent procedure level+ ST-elevation or depression along with signs of clinically relevant MI (new/worsening HF, hypotension, etc.)
- 10. CURRENT RECOMMENDATIONS • Class I: Measurement of CKMB or cTn value for patients with signs or symptoms of MI or in asymptomatic patients with significant persistent angiographic complications such as large scale occlusion no-reflow, or thrombosis • Class IIb: Routine measurement of cardiac biomarkers in all patients post PCI In absence of routine testing, a consensus document recommends performing an ECG 1-4 hours postprocedure after an uncomplicated PCI; if normal, biomarkers do not need to be checked In the presence of clinical symptoms, angiographic complications, or ECG changes, CKMB (or cTn if CKMB is unavailable) should be measurement 8-12 hours postprocedure, and if elevated, every 8-12 hours thereafter until they peak.
- 11. MONITORING OF PLATELET FUNCTION • To access the degree of platelet reactivity • High level of platelate reactivity have been associated with adverse outcomes • GRAVITAS & ARCTIC trials did not show a reduction in the primary composite end points • Routine platelet function testing is not currently recommended
- 12. RENAL FUNCTION MONITORING • Postprocedure renal injury is common • Causes- preexisting renal insufficiency aortic atheroembolism contrast induced injury • Only strategy proven to minimize risk include- volume expansion & minimization of contrast use. • Creatinine increase is observed 48-72 hours post-PCI (limited utility in measuring renal function within the first 24 hour) • SCAI recommendation-patient at increased risk for CIN should have a serum creatinine value checked about 5-7 days post procedure
- 13. DISCHARGE PHYSICAL EXAMINATION • Generally full physical examination prior to discharge • Additional focus – • Access site inspection- to ensure adequate hemostasis and perfusion. • Distal pulse palpation- to ensure no decrease in downstream perfusion • Access site auscultation- to ensure no bruit (pseudoaneurysm or AV fistula) • Demonstrate baseline level of ambulation without difficulty • Ensure pain is well controlled
- 14. DISCHARGE INSTRUCTIONS • Clear instructions regarding- • Site management, • Physical activity • Driving & return to work • Sexual activity • Medication reconcilation • Follow up, • Need for additional lab testing, & • Clear contact information of the physician in case of complication following discharge
- 15. SITE MANAGEMENT • Minor bruising &/or pain at the access site (should resolve within 1 month postprocedure) • Transfemoral access should not strain or lift anything >5pounds for 48 hours • Should apply pressure to the access site when sneezing or coughing • Clear action plan for access site complications (eg., active arterial bleeding, hematoma, erythema, purelence, numbness/tingling or paresthesia) should be provided
- 16. PHYSICAL ACTIVITY/DRIVING & RETURN TO WORK • Refrain from physical exercise & DRIVING for at least 48 hours (if not 1 week) • Post PCI patients should be enrolled in a cardiac rehabilitation program to develop a plan of graded exercise • Decision to return to work is individualized (often related to job satisfaction, financial stability, and/or company policy)
- 17. SEXUAL ACTIVITY • Refrain from sexual activity for 1 week • AHA consensus statement- sexual activity is reasonable for patients at low risk for cardiovascular complications or who can exercise for 3-5 METs without symptoms or ECG changes • In previous studies of SCD related to sexual activity- • 82-93% were men who died during intercourse • 75% were participated in extramarital sexual activity • Typically with a younger partner and • After excessive food and alcohol consumption
- 18. MEDICATION RECONCILATION • Barring specific contraindications, many patients undergoing PCI will be on DAPT (with aspirin & a P2Y12 antagonist), a β-blocker, an ACE inhibitor, and a high-intensity statin • SCAI recommendation- • Diabetic patients should withhold their metformin for 48 hours postprocedure • Patients previously on warfarin who have stopped it for the procedure should be restarted on their regimen and have an INR checked within 1 week postprocedure • No consensus guidelines have been provided for the NOACs, but they are generally started postprocedure as hemostasis is achieved and do not require close monitoring
- 19. FOLLOW UP • SCAI recommendations- • The patient follow up with his or her primary care physician, cardiologist, or midlevel physician extender within 2-4 weeks postprocedure, or sooner for patients with procedural complications or comorbidities such as anemia or renal dysfunction requiring more frequent lab test monitoring • Purpose of follow up visist- • Ensure compliance, especially with regard to DAPT • Reconcile medications • Reinforce aggressive secondary prevention measures (including dietary, exercise habit and smoking cessation) • Confirm that the patient has enrolled in a cardiac rehabilitation program