Your clock starts now !
Chronic stable angina : Most can be effectively managed by optimal /intensive medicines and life style Interventions .About 10% will require PCI/CABG.
ACS – STEMI: Primarily managed with rapid and competent pre-hospital care with prompt thrombolysis in or out of hospital .Patients with large STEMI who develop complications (Again about 10 %) require PCI and few additional lives can be saved.
ACS-NSTEMI : This is the group that demand an important role for PCI . All true high risk UA/NSTEMI patients should receive urgent coronary angiogram and critical lesions should either be stented or sent for CABG (If the lesions are multiple and complex ) The field of interventional cardiology is expected to play a major role in this category of patients for the simple reason , we not only give dramatic relief from angina and also prevent a potentially a huge MI that is waiting to happen !
* It is vital to emphasise the “Aim and objective” in NSTEMI management is critically different from other two. We know , in CSA the aim is to give relief symptoms and improve excercise capacity . Both PCI/CABG are unlikely to prevent a future MI in CSA..In STEMI it has already occurred .The aim is to salvage myocardium and prevent future events. While PCI can do the former , it can’t do the later . In STEMI scenerio ,we have very good alternate modality called thrombolysis which can easily beat the pPCI in , cost , availability and time (and hence efficiency as well in most countries !)
Counter thought
The above suggestion is too simplified ,generalized , misleading , and unscientific, should strongly be disagreed. For those people who disagree , I provide an alternate scheme .It is ultra short ,comes in 5 lines .Very practical and scientific too !
In any patient , who is suspected to have either acute or chronic coronary syndromes ,take them to the cath lab in an urgent or semi urgent fashion .Do an angiogram and stent all lesions that you feel important . If stenting is not possible manage with optimal medicines and /or send them to the surgeons.
Final message
The essence of catheter based coronary care is simple.We complicate it. To understand this concept 100’s of cardiology journals and as many conferences and infinite number of books are churned out every year !
Dr.S.Venkatesan MD 