Monday, July 11, 2011


Percutaneous coronary intervention had her humble beginnings in 1977 in Zurich when Dr A Greuntzig, under flouroscopy guidance passed a very high profile and crude catheter ( rubber tubing ) with a balloon at the distal end. Once across the lesion ( which was at the proximal LAD ), he inflated the balloon repeatedly, until the lesion ws flattened and there was no longer any more pressure gradient across the lesion. The patient was a dentist, and the simple balloon angioplasty lasted him about 15 years.
Right across the "pond" in the USA, Dr Simon Stertzer and Dr Richard Myler were also experimenting with the same, with good results.
Angioplasty, or percutaneous coronary intervention ( PCI ) was born.
This small band of innovators went about conducting life demo courses hoping to teach and transfer knowledge of this new, and effective technology to as many cardiologist as possible, and they were successful. I had learn the technique from Dr David Clark who had worked with Dr David Myler.
In 2011 ( the last AHA PCI appropriateness criteria was issued in 2009 ), the indications remain as it was in 1977. The patient should have reversible myocardial ischemia as evidence by the presence of troublesome angina, and or stress ECG or other forms of investigation to document reversible ischemia, like thallium nuclear scans, stress echocardiogram. Positive MSCT is not considered an indication for PCI.
PCI should be performed by specialist, who has been trained to performed PCI, and it should be carried out in an institution where there are adequately trained paramedical staff both to assist in the safe performance of PCI and also to monitor the patient after PCI. With the advent of coronary stents, many of us feel that there in no longer a need for on-site cardio-surgical backup although the latest guidelines still say so.
As for disease subset when PCI should be performed, for patients with reversible ischemia and single or double vessel disease PCI is appropriate, unless the anatomy is unsuitable for PCI. For 3VD-CAD and Left Main Stem disease, we need to calculate what we call the Syntax score. Patients with high syntax score, should be recommended to go for CABG ( coronary artery bypass surgery ).
Coronary angiogram carries a mortality risk of 0.1% and on the average PCI carries a mortality risk of 1%.
They both require an overnight stay in hospital. Some, doing via the radial approach need on stay in hospital 6-8 hours for observation post-PCI.
The average cost of PCI show by RM 12K + the cost of stents or special devices. On the average, a drug eluting stent in my set-up cost about RM 8K, so PCI with 1 DES, would cost about RM 21K with tax. Of course, I am talking about FDA approved stents. Please be aware that there are many copycat stents in the market.
A bare metal stent in Malaysia should cost about RM 3K. It is true that stent cost to institutions also depends on whether the institution is buying, on having the stents consigned. If the institution buys a large volume, the price per stent would be cheaper, as there is cost savings with purchase and bulk purchase.
What we often do not emphasize enough is that with PCI, especially with drug eluting stents, the immediate cost is one thing. The followup cost with the use of clopidogrel or prasugrel, can also be substantial ( about RM 250 per month for 12 months with plavix ).
It must also be said, that with the latest generation of bare metal stents, the longterm results is only marginally inferior to drug eluting stents, if they are well implanted. In some situations, bare metal stents may even be safer and preferred.

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