Indications for Percutaneous Coronary Intervention (PCI)

1. Acute Coronary Syndromes

Primary PCI is the preferred reperfusion strategy when it can be performed within guideline‑specified time windows. (ACC/AHA Class I) 1
Immediate PCI (Class I): Perform primary PCI in patients presenting ≤12 h from symptom onset, aiming for first‑medical‑contact‑to‑device ≤90 min at PCI‑capable hospitals or ≤120 min when transfer is required. (ACC/AHA Class I) 1
Cardiogenic shock (Class I): Perform immediate PCI regardless of treatment delay in patients with severe heart failure or cardiogenic shock who are suitable revascularization candidates. (ACC/AHA Class I) 1
Contraindications to fibrinolysis (Class I): Perform primary PCI as soon as possible in patients with contraindications to thrombolytic therapy and ischemic symptoms <12 h. (ACC/AHA Class I) 3
Failed fibrinolysis (Class IIa): Perform immediate PCI in patients with a moderate‑to‑large area of myocardium at risk and documented failure of fibrinolysis. (ACC/AHA Class IIa) 1
Post‑fibrinolysis strategy (Class IIa): In hemodynamically stable patients after successful fibrinolysis, perform angiography 3–24 h later. (ACC/AHA Class IIa) 1

High‑risk patients (Class I): An early invasive strategy with intent to perform PCI is indicated for patients with refractory angina, hemodynamic or electrical instability, or elevated risk scores after initial stabilization. (ACC/AHA Class I) 1
Timing (Class I): Early angiography (≤48 h) improves outcomes in high‑risk groups; deferral of intervention does not confer benefit. (ESC Class I) 6
Contraindication (Class III): Do not perform early invasive PCI in patients with extensive comorbidities (e.g., severe liver or lung failure, active cancer) where procedural risk outweighs benefit. (ACC/AHA Class III) 1

Unprotected left‑main disease:
- CABG is preferred for survival benefit (Class I). (ACC/AHA Class I) 2
- PCI is reasonable (Class IIa) when SYNTAX score ≤22 (low complexity) and surgical risk is high (STS‑predicted mortality ≥5%). (ACC/AHA Class IIa) 2
- PCI is of uncertain benefit (Class IIb) when SYNTAX score ≤33 (low‑intermediate complexity) and surgical risk is moderate (STS‑predicted mortality ≥2%). (ACC/AHA Class IIb) 2
- PCI is harmful (Class III) in left‑main disease with unfavorable anatomy in good surgical candidates. (ACC/AHA Class III) 2
Three‑vessel disease (with or without proximal LAD):
- CABG improves survival (Class I). (ACC/AHA Class I) 2
- CABG is reasonable (Class IIa) over PCI for complex three‑vessel disease (SYNTAX >22) in patients who are good surgical candidates. (ACC/AHA Class IIa) 2
- PCI provides uncertain survival benefit (Class IIb) in this setting. (ACC/AHA Class IIb) 2
Two‑vessel disease with proximal LAD involvement:
- CABG improves survival (Class I). (ACC/AHA Class I) 2
- PCI offers uncertain survival benefit (Class IIb). (ACC/AHA Class IIb) 2

Prerequisite: Document objective evidence of significant ischemia (>10 % of myocardium) using stress testing, fractional flow reserve ≤0.80, or instantaneous wave‑free ratio ≤0.89. (ACC/AHA Class IIa) 2
Symptomatic patients (CCS Class II‑IV) despite optimal medical therapy: PCI is appropriate for relief of moderate‑to‑severe angina when ischemia is documented. (ACC/AHA Class IIa) 2
Asymptomatic patients: PCI should not be performed without anatomic or physiologic criteria for revascularization (Class III – Harm). (ACC/AHA Class III) 2

Primary indication: CTO‑PCI is performed mainly for symptom improvement, not for survival benefit. (ESC Class IIa) 7
Patient selection: Perform CTO‑PCI in symptomatic patients with objective evidence of ischemia in the territory of the occluded vessel. (ESC Class IIa) 7
Secondary prevention: CTO‑PCI may be considered in patients with prior ventricular arrhythmias, although randomized data are lacking. (ESC Class IIb) 7

CABG with LIMA is preferred over PCI for survival benefit in diabetic patients with multivessel disease. (ACC/AHA Class I) 2

Risk assessment: Both patient‑related (e.g., LVEF < 25 %, left‑main stenosis ≥ 50 %, unprotected three‑vessel disease, single lesion jeopardizing > 50 % viable myocardium) and lesion‑related (e.g., diffuse disease > 2 cm, heavy calcification, extreme angulation > 90°, degenerated vein grafts, substantial thrombus) risks must be evaluated before PCI, especially at centers without on‑site cardiac surgery. (ACC/AHA Class IIa) 1
Facility limitation: High‑risk patients with high‑risk lesions should not undergo non‑emergency PCI at facilities lacking on‑site cardiac surgery. (ACC/AHA Class III) 1

Do not perform PCI in stable patients without documented ischemia – multiple trials show no mortality benefit and potential harm. (ACC/AHA Class III) 2
Do not choose PCI over CABG in diabetics with complex multivessel disease – CABG provides superior long‑term outcomes. (ACC/AHA Class I) 2
Do not delay primary PCI for STEMI to achieve “door‑to‑balloon” times – transfer for primary PCI is superior to on‑site fibrinolysis even with transport delays up to 120 min. (ACC/AHA Class I) 3
Do not perform PCI on non‑culprit lesions during primary PCI for STEMI unless they are flow‑limiting in patients with hemodynamic instability. (ACC/AHA Class III) 5