Optimizing PCI Outcomes Across the Spectrum of Coronary Disease (Podcast)

Continuation of stable angina in a patient on antianginal medications often raises the question of whether elective percutaneous coronary intervention (PCI) may be in order.

“If such a patient has an abnormal stress test, is he or she an appropriate candidate for stenting?” asks Cleveland Clinic interventional cardiologist Grant Reed, MD, MSc. “I think the current evidence supports an approach of optimizing antianginal therapy first. But what I see in my practice is that these patients often will be able to tolerate this approach to some degree, but they don’t want to wait too long. Patients often still want their coronary anatomy defined with catheterization.”

Questions concerning scenarios like this are posed to Cleveland Clinic interventional cardiologists fairly regularly by referring physicians and others. In a recent episode of Cleveland Clinic’s Cardiac Consult podcast, Dr. Reed discusses a number of these questions with his interventional cardiology colleague Laura Young, MD. Together they talk through their answers with references to recent studies and nuanced practical observations from their daily experience at Cleveland Clinic, including on the management of complex coronary disease.

Among the questions they explore:

• When are patients being referred for PCI these days, and when are stents being used?
• How best to address a patient with an abnormal stress test?
• How should patients with diabetes and/or multivessel disease be managed?
• Which newer techniques have optimized results from PCI, and how?
• How best to counsel patients (and even other providers) on the role of PCI versus medical therapies?

Click the podcast player above to listen to the 12-minute episode now or read on for an edited excerpt. Check out more Cardiac Consult episodes at clevelandclinic.org/cardiacconsultpodcast or wherever you get your podcasts.

Excerpt from the podcast

Grant Reed, MD, MSc: When we think about optimizing results from PCI, what are some recent techniques that we can offer here that have changed the game?

Laura Young, MD: First and foremost, it starts with intravascular imaging for us. That really helps us define what we need to do to optimize the vessel, starting with even the preparation. From a preparation standpoint, intravascular lithotripsy [IVL] is an amazing tool that can be a safe alternative to atherectomy for calcific lesions. It doesn’t take atherectomy off the table, however — certainly there are some patients where we need that as well. Oftentimes, it’s a combination of both atherectomy and lithotripsy to really break up the calcium involved.

Dr. Reed: That’s a great point. Imaging for guidance of PCI is underutilized nationally, and we're very keen on it here. I believe we use either intravascular ultrasound or optical coherence tomography guidance for the vast majority of PCI cases we do, whether that be for an acute myocardial infarction or for stable coronary disease. The data would suggest it improves outcomes, based on numerous observational studies and now also prospective data and even some randomized data. It starts with good imaging guidance and then with plaque modification and calcium modification using IVL and atherectomy, as you mentioned.

I’d also add contemporary treatment strategies for stenting. We offer ultra-low-profile stenting with the latest polymer designs, which have really improved target lesion failure and in-stent restenosis rates. I do think it makes a difference where patients are treated — it’s in those complex cases that I think our teams particularly excel.