11/4/2019
Caring for patients post PCI
(Catheter-base Intervention)
Emil Huriani
Secondary and Long-Term
Prevention: Post-PCI
Cardiac catheterisation
• The insertion of a catheter into a vein or artery, usually from
a groin or jugular access site, which is then guided into the
heart.
• Purpose: diagnostic or intervention.
• Diagnostic catheters are used to assess blood flow and
pressures in the chambers of the heart, valves and coronary
arteries, to assist in the diagnosis and management of
congenital heart defects.
• Interventional catheters are used as an alternative to open-
heart surgery when possible. These procedures include
closure of septal defects (ventricular septal defect device
closures, atrial septal defect closure), expansion of
narrowed passages (pulmonary stenosis), stent placement,
ablation of abnormal electrical pathways and opening of
new passages (foramen ovale).
Complications of PCI
• Acute complications
• 1.Coronary spasm
• 2.Coronary artery dissection
• 3.Acute coronary Thrombosis
• 4.Bleeding and hematoma formation at the site of vascular access
• 5.Contrast-induced kidney failure
• 6.Dysrhythmias
• 7.Vasovagal response during remove of sheath (hypotension-
bradycardia-diaphoresis)
• Late complications:
• 1.Restenosis after PCI ( using drug-eluting stents decreased this
complication)
• 2.Late thrombosis
Patient preparation
• ensuring antiplatelet medication has been given,
• the access site has been shaved
• the patient has consented to the procedure.
• Patients on metformin are at risk of lactic acidosis when receiving
iodine contrast media so it is generally recommended that
metformin should stop before PCI and restarted 48 hours later,
after assessment of renal function (Wijns et al, 2010).
• For patients with chronic kidney disease, the use of contrast
media can lead to acute kidney injury (Wijns et al, 2010) and
these patients may require pre and post-procedure hydration to
minimise this risk.
• The nurse needs to be aware of these risks and highlight to
medical staff if intervention is required before the procedure.
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Haemostasis of an arterial
Pharmacotherapy
puncture • A combination of anti-platelet and anti-thrombotic agents
• Aspirin and clopidogrel. Prasugrel, Ticagrelor
• Manual Compression (2–4 hours after an • Glycoprotein IIb/IIIa inhibitors can be used intravenously during an angioplasty
to prevent platelet aggregation and platelet formation. They can be considered
angioplasty) for higher risk patients (NICE, 2010) or in ‘bail out’ situations (such as thrombus,
slow flow, vessel closure and very complex lesions) (Wijns et al, 2010). Recent
• Passive VCDs trials do not demonstrate an additional benefit of the use of these agents if
patients have had a loading dose of 600 mg clopidogrel (Wijns et al, 2010). They
can, however, be used in the early management of higher risk ACS patients who
• prothrombotic material (e.g.. Clo-Sur P.A.D) have an angiogram planned within 96 hours of their hospital admission (NICE,
2010).
• mechanically assisted compression (e.g.. FemoStop
• Unfractionated heparin is used routinely during an angioplasty procedure.
compression device), Bivalirudin is an alternative anticoagulant that has been shown to reduce
bleeding rates compared to glycoprotein IIb/IIIa inhibitors alongside
• Active VCDs use material such as collagen plugs unfractionated heparin (Levine et al, 2011). As peri-procedural bleeding is
recognised to be associated with subsequent mortality, an avoidance of
(e.g.. Angio-Seal) or sutures (e.g.. Perclose) bleeding complications should be followed (Levine et al, 2011). Bivalirudin can
be used as an alternative to heparin and a glycoprotein IIb/IIIa inhibitor (NICE,
2010). It is important that the nurse recovering the patient following an
angioplasty knows what anticoagulation has been used as this will have a direct
impact on potential bleeding from the access site as well as later bleeding risk.
They must also understand what antiplatelet medication the patient will be
discharged on, along with the duration, so that they can counsel the patient
accordingly.

Nursing management
Monitoring for Recurrent Angina Monitoring the vascular Access site
• Observe the patient for recurrent angina or St elevation by
use of appropriate monitoring lead. • While the sheath is in place or removal, bleeding or
• Postprocedure angina may be caused by transient coronary hematoma at the insertion site may occur.
spasm or acute thrombosis.
• Nitroglycerine infused and may by titrated to alleviate of CP.
• The nurse must be observes the patient for
Prevention of Contrast-Induced AKI
bleeding and swelling at the puncture.
• Assessment of Kidney function testes • Control of VS
• Protective Strategies such as preprocedurehydration and • Direct pressure for 15-30 min
infusion of sodium bicarbonate.
• After PCI hydration is important to maintain adequate flow • CBR for 4-6 hour
through the kidney .
• Use of new Vascular closure Devices.

Patient education

• Emphasis on use of antiplatelet agent

• Report of chest pain ( 2-14 day after stent
placement myocardial infarction may be created.

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Discharge advice
• wwManagement of chest pain: This could be due to an in-stent thrombosis or
restenosis. The use of a glyceryl trinitrate (GTN) spray should be discussed and,
if the chest pain has not resolved in 10 minutes, 999 should be called
• wwA patient experiencing chest pain who feels unwell should call an
ambulance, whether they have used GTN or not
• wwMedication: To continue with antiplatelet medication without stopping. If
there are concerns about bleeding by other doctors, they should contact the
patient’s cardiologist before stopping aspirin or clopidogrel as the risk of in-stent
thrombosis is high without these drugs
• wwWound care: How to manage any bleeding (rest and apply pressure for 10
minutes, if not stopped call 999), have someone with them overnight, avoiding
hot baths and showers for a couple of days, and avoiding strenuous lifting for 48
hours as this causes more pressure on the artery leading to potential bleeding
• wwRisk-factor modification
• wwDriving: The patient can not drive for 1 week after successful PCI. If the
procedure was unsuccessful they must stop driving for at least 4 weeks (Driver &
Vehicle Licensing Agency, 2013). If they have had a heart attack this may be
longer, but this depends on the clinical circumstances.