PERCUTANEOUS CORONARY INTERVENTION
“The Bower Meadow”, oil on canvas 1850 -1872, Dante Gabriel Rossetti, Manchester City Art Galleries, Manchester, UK This is Dante Gabriel Rossetti’s “The Bower meadow”. It is one of the most stunning works of the mid Nineteenth century artistic movement known as the “Pre-Raphaelite” brotherhood. The style depicted scenes and allegory from the classical and early medieval world, ie pre-Raphael.
Women were chosen as models by the brotherhood for their “stunning” qualities, in fact it was Rossetti himself who first coined the term “stunner” when referring to beautiful women he would approach to model for him. These women would sometimes take some convincing to pose as in the mid Nineteenth century the term “model” was conceived to be perilously close to prostitute! Nonetheless a great many very beautiful women did pose for the Pre-Raphaelite (and other) painters. The artists by convincing the women to pose would often achieve for them a degree of celebrity and “immortality” in the same manner as the film companies of the next century would do so for their “starlets”.
Models could come from a wide spectrum of society. In the Bower Meadow, the maiden on the left was posed for by no less than the daughter of the Greek Consul to London, Marie Spitalli, a “true stunner” in Rossetti’s words. The model for the maiden on the right was Alexa Wilding. In a twentieth century parallel to the “discovery” of Claudia Schiffer in a Berlin disco, Rossetti “discovered” her one day walking on the streets of London. Although reluctant to pose at first without her mother’s permission she did eventually agree and became immortalized as one of Rossetti’s most famous models. Although a “top shelf” stunner Alexa apparently had, to paraphrase Rossetti, “little conversation, and little curiosity of the world, being content to sit Sphinx-like as if in a continual daydream”. It would be these very qualities however that would make her one of Rossetti’s favourite models!
The best things in life sometimes take time. It is interesting to note that Rossetti took 22 years to complete “The Bower Meadow”! The landscape background was completed in 1850 just after the “Pre-Raphaelite” brotherhood came into being. The canvas then stood barren and neglected in his studio with several half hearted attempts to complete it, until in 1872, inspired by Marie and Alexa he finally added them into the foreground as the main subjects of a mediaeval troupe of women playing the exquisite instruments of those times, the “zither” and the “psalter”.
After sitting for many years barren and neglected the management of STEMI in the 21st century suddenly took rapid quantum steps in improvement! Initially by pharmacologic thrombolysis, then by percutaneous intervention. The canvas of STEMI treatment is now finally complete in the form of the modern Catheter Laboratory. The modern Cath Lab is now full of the latest “exquisite” instruments and is now able to accommodate the subjects it was always destined for. Although it is unlikely that any of these subjects will be “stunners”, it is to be hoped that like Ms Wilding, they will have “little conversation” and the capacity to sit “Sphinx-like” for extended periods of time to allow for the expert use of these instruments. Whilst “posing” in this manner it is unlikely that our subjects will achieve immortality or even celebrity, however it is to be hoped, a little more longevity and quality of life will ensue. PERCUTANEOUS CORONARY INTERVENTION
Introduction
Percutaneous coronary intervention is the preferred treatment in most cases of STEMI.
In selected cases it may also be performed for non-STEMI/ unstable angina.
It is vital to have in place systems (such as CODE STEMI) to ensure the timely delivery of coronary angiography and percutaneous intervention.
Lines of Communication
Clear and efficient lines of communication are essential for any PCI intervention.
Current best practice is that a specific hospital CODE call should be activated that alerts all personnel required to perform the procedure in a timely manner.
Relevant personnel should include:
● The interventional cardiologist on call
● The on site cardiology registrar
● The angiography suite personnel
● The Coronary Care Unit
Indications
Indications include:
1. STEMI
2. Some cases of Non-STEMI, in particular those with high risk factors.
High risk factors include:
● Significant ongoing pain.
● Dynamic ECG changes.
● Hemodynamic instability, persisting hypotension, arrhythmias.
Optimal timing:
Note that where significant delay to PCI is a factor, it may be a better option to thrombolyse a patient. This should be discussed with the cardiologist. Suggested time frames have been set out in the MJA ACS guidelines of 2006 as follows:
Management
Important initial management in the ED includes:
1. Control of pain:
● Give nitrates/ morphine as required.
2. Aspirin:
● 300mg orally.
3. Clopidogrel:
● Clopidogrel 600 mg (loading dose prior to PCI). 4
● Thereafter 150 mg daily for 7 days, then 75 mg daily for at least 12 months.
● Note that this may cause some increased bleeding in those who require subsequent CAGS, however the benefits of the anti-platelet effect override the small risk of the subsequent need for CAGS.
4. Anticoagulation therapy:
● This should be with an initial 5,000 unit heparin bolus. (Rather than with subcutaneous fractionated heparins (enoxaparin) in order to reduce the potential for bleeding complications during PCI). ● Note that if enxoparin has already been given PCI is not absolutely contraindicated.
● Although not ideal, it should be noted that prior thrombolysis does not exclude a PCI.
5. Glycoprotein IIb/IIIa inhibitor therapy:
A glycoprotein IIb/IIIa agent, is also recommended in patients who are to receive urgent PCI.
Current options include:
● Integrilin, (eptifibatide)
● Reopro, (abciximab)
● Tirofiban, (aggrastat).
The treating cardiologist will advise which agent is to be used.
6. Bivalirudin:
Bivalirudin is a direct thrombin inhibitor.
Amongst patients with STEMI undergoing primary PCI, the use of bivalirudin can be considered as an alternative to heparin and GP IIb/IIIa inhibitors.
7. Newer antiplatelet agents: prasugrel and ticagrelor:
Prasugrel, (a rapid-onset antagonist ofplateletadenosinediphosphateP2Y12 receptors), 60 mg orally, for patients not at an increased risk of bleeding.
Ticagrelor, ( a reversible oral P2Y12 inhibitor), 180 mg orally.
● In patients undergoing PCI, the use of an oral antiplatelet agent (prasugrel and ticagrelor) should be considered as an alternative to clopidogrel for subgroups at high risk of recurrent ischaemic events (e.g. those with diabetes, stent thrombosis, recurrent events on clopidogrel or a high burden of disease on angiography). 4
● Careful assessment of bleeding risk should be undertaken before using these agents.
8. Preparation for angiography:
● See specific nursing procedures for theatre preparation. Disposition
Following PCI all patients should then be admitted to CCU or ICU
Occasionally complications may arise during PCI, which necessitate a transfer to a facility with cardiothoracic surgical cover.
References
1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes. MJA 2006; 184 (8): S1-S32
2. Chew D.P et al. 2011 Addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the Management of Acute Coronary Syndromes (ACS) 2006, Heart, Lung and Circulation, Volume 20, Issue 8, Pages 487-502
Dr J. Hayes Acknowledgments: Geoff Gleeson, Manager of Cardiac Services Dr William van Gaal Chief Cardiology Northern Hospital Reviewed June 2012