Red Flags
- Cardiogenic shock complicating STEMI — culprit-only PCI per CULPRIT-SHOCK; mechanical circulatory support (Impella, ECMO) per institutional algorithm[1]
- Slow flow / no reflow during primary PCI — distal embolisation; intracoronary nitroprusside, adenosine, or nicorandil; thrombus aspiration not routinely indicated[1]
- Coronary perforation Ellis grade III — covered stent, prolonged balloon inflation, pericardiocentesis if tamponade; cardiothoracic surgery on standby[1]
- Stent thrombosis (acute or subacute) — emergency repeat PCI with intravascular imaging; assess underlying cause (under-expansion, dissection, malapposition)[1]
First-line treatment
Interventions
- Radial artery access (preferred)[1]Default radial-first approach reduces bleeding, vascular complications, and mortality vs femoral; femoral reserved for failed radial or large-bore device need
- Drug-eluting stent placement[1]Latest-generation DES preferred. Stent sizing optimised by intravascular imaging; full lesion coverage; post-dilation with non-compliant balloon at high pressure
- Complete revascularisation strategy[1]Stage non-culprit lesions during index admission (PRAMI, COMPLETE) in stable haemodynamics; defer in cardiogenic shock
- Mechanical circulatory support in cardiogenic shock[1]Veno-arterial ECMO or Impella per institutional algorithm; intra-aortic balloon pump no longer routinely recommended
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Aspirin (loading)[1] | Antiplatelet | 162–325 mg chewed at first medical contact, then 75–100 mg daily | — | All ACS unless contraindicated |
| Prasugrel or ticagrelor[1] | P2Y12 inhibitor (loading) | Prasugrel 60 mg load → 10 mg daily; ticagrelor 180 mg load → 90 mg BD | — | Preferred over clopidogrel in PCI-treated ACS without high bleeding risk |
| Unfractionated heparin[1] | Parenteral anticoagulant | 70–100 U/kg IV bolus during PCI; titrate to ACT 250–300 sec | — | Standard for primary PCI; bivalirudin alternative in high bleeding risk |
| Intracoronary nitroprusside / nicorandil[1] | Microcirculatory vasodilator | Nitroprusside 50–200 mcg IC bolus; nicorandil 2 mg IC | — | Slow flow / no reflow during PCI |
Aspirin (loading)[1]
Antiplatelet
- Adult
- 162–325 mg chewed at first medical contact, then 75–100 mg daily
- Paediatric
- —
All ACS unless contraindicated
Prasugrel or ticagrelor[1]
P2Y12 inhibitor (loading)
- Adult
- Prasugrel 60 mg load → 10 mg daily; ticagrelor 180 mg load → 90 mg BD
- Paediatric
- —
Preferred over clopidogrel in PCI-treated ACS without high bleeding risk
Unfractionated heparin[1]
Parenteral anticoagulant
- Adult
- 70–100 U/kg IV bolus during PCI; titrate to ACT 250–300 sec
- Paediatric
- —
Standard for primary PCI; bivalirudin alternative in high bleeding risk
Intracoronary nitroprusside / nicorandil[1]
Microcirculatory vasodilator
- Adult
- Nitroprusside 50–200 mcg IC bolus; nicorandil 2 mg IC
- Paediatric
- —
Slow flow / no reflow during PCI
Safety-net
- Take dual antiplatelet therapy daily for 12 months without interruption — early discontinuation sharply raises stent-thrombosis risk[1]
- Watch the access site for swelling, bruising, or bleeding; pulsatile mass means false aneurysm — same-day care[1]
- Recurrent chest pain after PCI — immediate emergency services evaluation; could be stent thrombosis[1]
Referral criteria
- STEMI ECG diagnostic outside PCI-capable centreTransfer to cath lab; FMC-to-device target ≤120 min[1]
- Cardiogenic shock complicating ACSHeart team plus mechanical circulatory support consideration[1]
- Complex anatomy (left main, bifurcation, CTO, severe calcification) considered for PCIHigh-volume PCI centre with intravascular imaging and rotational atherectomy capability[1]
Clinical summary
Procedural and peri-procedural management of primary percutaneous coronary intervention for ACS — access, technique, antithrombotic, complication management.