A Practical Update on Percutaneous Coronary Intervention (PCI) for the General Physician, Answering Questions of Patient Type, Timing, and Device Choice

BACKGROUND: Since its inception in the 1970s, percutaneous coronary intervention (PCI) has undergone significant advances. This review provides an updated perspective on PCI to assist general physicians in navigating various clinical presentations, determining the appropriate patient and optimal timing for intervention, as well as selecting appropriate devices for different populations.

METHODS: Clinical trials from a targeted three-stage PubMed search, focusing on PCI indications, procedural timing, and device selection, were analyzed and integrated with consensus guidelines from leading cardiology organizations.

RESULTS: For patients presenting with ST-elevation myocardial infarction (STEMI), PCI is recommended within 12 h of the onset of symptoms, ideally achieving a door-to-balloon time of 90-120 min from the first medical contact. Beyond the 12 h mark, the procedure remains indicated for those exhibiting persistent ischemia, clinical symptoms, or complications such as shock, arrhythmia, or heart failure. In cases of non-STEMI (NSTEMI), patients generally benefit from PCI during their initial hospital stay, although an early invasive approach may not provide clinical advantages for frail elderly individuals. Complete revascularization is typically favored over treating only the culprit lesion, except in instances of cardiogenic shock. For those with chronic coronary syndrome (CCS), while PCI enhances quality of life and improves symptom management, most clinical trials report that it does not significantly reduce mortality or major cardiovascular incidents. The initial plain old balloon angioplasty faced complications of restenosis and acute vessel closure. While bare metal stents addressed acute closure, the problem of restenosis persisted and stent thrombosis was noted. Current drug-eluting stents (DESs) are the preferred choice owing to superior clinical outcomes, with lower restenosis and stent thrombosis rates. Although theoretically ideal, bioresorbable scaffolds (BRSs) are still undergoing further research since they have yet to prove superior to DESs in clinical trials. In addition, drug-coated balloons (DCBs) have become a specialized treatment, especially for managing in-stent restenosis.

CONCLUSION: The necessity for and timing of PCI are dictated by the patient's specific clinical presentation. Immediate intervention is critical for STEMI patients, within 12 h of onset, or those with complications, while NSTEMI cases should be treated during the hospital admission. For CCS, PCI serves as an elective option to alleviate symptoms without altering long-term survival. The DES remains the primary tool in modern PCI, with BRS still undergoing research trials and DCBs serving specialized roles.