Post PCI Care, When to Refer?

Mohammad Saifur Rohman

Dept. of Cardiology and Vascular Medicine,
Faculty of Medicine, Brawijaya University /
Dr. Saiful Anwar Hospital, Malang
 Case I
Mr. S smoker 60 yo. male come to type C private hospital with
chief complaint of squeezing angina at resting more than 20
minutes. Chest pain radiated to the jaw, 2 hour prior to
admission worsen within the last 30 minutes. A companied
with 2x syncope and cold sweating.
Risk Factor: Hypertension, active smoker
GCS 456, BP 110/90 mmHg-> 90/50 mmHg, HR 64x/m regular
RR 24x/m saturation: 98%
Heart: within normal limits
Lung: within normal limits
Ext. : warm acral, normal vascular filling
ECG on Admission
Thorax X ray
 Laboratory Finding
LABORATORY FINDINGS
Lab value Normal Lab Value Normal
value value

Leuco 9.150 3.500-10.000 Na 133 136-145

Hb 13.5 11-16.5 K 4.2 3,5-5

Thrombo 230.000 150-390.103 Cl 112 98-105
PCV 39.5 35-50 Ureum 14.3 10-50
FH normal Creatinin 0.75 0,7-1.2
RBS 103 47 <200 Albumin 3,5-5,5

CK 300 39-300 SGOT 14 11-41

CKMB 105 7-25 SGPT 20 10-41

Trop I 10.8 Positif if ≥ 1
 Diagnosis
• STEMI anterior killip IV TIMI 5/14 GRACE 150

• Killip IV= Syock

 Treatment
• O2 2 L/min.
• Loading Nacl 200cc/20 min.
• Dobutamine 5 ug/kgBW/min.
• Chewed Aspilet 320 mg
• Ticagrelor 180 mg
• Atorvastatin 40 mg
• Primary PCI
ECG After pPCI
 Case Summary

2 hour onset Faskes I

prior to
Admission
• Heavy • Ant • Optimal Tx.
smoker 2 STEMI • Performed • Secondary
pack/day killp IV pPCI door to Prevention
TIMI balloon 90 • Awareness next
35 years minute CV event
5/14 PCI Capable
Grace Hospital
150
Pathological Mechanism Perspective: SCAD
Actually Not "Stable” (CCS)

Asymptomatic/stable
Progress !
SCAD ACS SCAD
Long-term outpatient Inpatient and
Long-term outpatient
management periprocedural management
stage

Plaque Repair of ruptured

AS progression Formation of plaque
rupture plaque

Stable •ACS •Post ACS

angina •Sudden •Post PCI/CABG
death

From the entire coronary bed of patients, the onset, progression,

formation, rupture and repair of atherosclerotic plaques keep
ongoing all the time
Pepine CJ. Am J Cardiol. 1998;82:23S-27S Daniel J, et al. Nature.2008;451, 904-913
 MI Patients Remain at High and Persistent Risk
of CV Events Post Discharge from Hospital
2-year rate of MI, stroke or all-cause mortality in NSTEMI and STEMI
patients ≥65 years of age.

11

Both NSTEMI and STEMI patients are at high risk of

recurrent CV events
Vora AN et al. Circ Cardiovasc Qual Outcomes 2016;9:513–522.
Pola Hidup

Rawat Ulang !
 Why worsen The Condition?
• Stigma : CAD=’end’; (life style)
• Misperception :
• 1. Activity prohibited  uncontrol risk factors; (measurable,
regular) (controlled risk factors)
• 2. No Sex (ok)
• 3. Drugs Damage the kidneys. (Protect the kidneys)
• 4. no symptoms = getting well  No MD visit, stop
medication, no diet ( vice versa)
• 5. < water; (as needed)
Recurrent CV event, heart attack,
Rehospitalization
Solusi?, CIE, routine visit, awareness, on time referral
 When to Refer ?
Worsening symptom
• Acute event
• New complication
Uncontrol risk factor
For the next staging procedure
 Worsening symptoms
CAD=Chronic coronary syndrome 

ACS
AHF
Arrhythmia
Syock
Cardiac Syncope
 Next Cardiovascular Event ?
Atherosclerosis Progress every time:
• Endothelial dysfunction (Chronic irreversible)
• Intake >output : Plaque accumulation
• Non Stent> dan stent <(DES) vessel
• Vulnerable plaque Prone to rupture
• Significant plaque Turbulence flow thrombus
• Triggering Factors; nonadherence, stress, infection, ect.
 Acute Coronary Syndrome
• Substernal
• Squeezing, heaviness
• Radiation
• Progressive angina
1. More severe
2. More frequent
3. Longer in duration
4. Milder precipitating factors
• First onset angina minimal CCS III
• Resting angina > 20 menit
• Angina post Infarction
 Heart failure
• Vascular problem  Fixed it
• Pumping problem  medication/device
• Pressure problem  optimize management
 Shock Cardiogenic
• Treat first than refer
• Vascular problem  Fixed it
• Pumping problem  medication/device
 Arrhythmia
• Vascular related /iskemik  Revascularization
• Heart failure related  Optimal treatment
• Substrate/fixed defect  eliminate/device
Complication: Risk vs Benefit !
 Summary

• CAD is chronic progressive disease, especially in

uncontrol patient risk factors
• CAD not really stable event after PCI
• On time referral results in a better outcome,
when worsen condition occur
• Stable patient could be maintained in Faskes I
with special precaution
• Faskes I – cardiologist collaboration would be cost
effective and also improve the outcomes
Thank you