Primary PCI for acute coronary syndrome

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.

References

1.CVIT Expert Consensus Document on Primary Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndromes 2026 (2026)