- Postoperative Care and Follow-Up After Coronary Stenting.
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It can be subdivided into three steps:. The clinical manifestations of coronary heart disease CHD include angina pectoris, myocardial infarction, signs of left-heart failure e. On the other hand, catheter studies and CT angiography still carry a residual risk, even at their current high state of development, and both techniques involve exposure to ionizing radiation. They are also very costly. For this article, we selectively reviewed pertinent literature retrieved by a PubMed search as well as the evidence-based guidelines of the American 3 , European 4 , and German 5 specialty societies and the German National Disease Management Guidelines for Coronary Heart Disease 6.
Other guidelines were also consulted 2 , 10 , 15 , 28 , 31 — 33 , e5 — e9.
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Coronary heart disease CHD is due to arteriosclerosis of the coronary arteries 7 , 8 , and endothelial dysfunction is the key element in the pathogenesis of arteriosclerosis 9. In the early stage of the disease, symptoms and signs are usually not yet evident; in its advanced stage, high-grade, flow-limiting stenoses cause a mismatch between oxygen supply and oxygen demand, leading to myocardial ischemia. Advanced CHD is often symptomatic, with manifestations including angina pectoris, myocardial infarction, left-heart failure, cardiac arrhythmias, and sudden cardiac death.
History taking and physical examination, including an assessment of cardiovascular risk factors and of evidence of myocardial ischemia, constitute the best way to assess the indication for coronary angiography. CHD can be treated with drugs, interventional procedures, and surgery. This article is concerned only with interventional treatment—in particular, with the follow-up of patients who have undergone coronary stent implantation.
Recent years have seen continual improvement in diagnostic and therapeutic cardiac catheterization with the introduction of better catheter techniques and new-generation stents and with the acquisition of knowledge from large-scale clinical trials 3. Most patients who undergo successful catheter treatment of life-threatening heart disease can now return to their previous daily routine within several days when they are treated in accordance with the current guidelines. The German, European, and American guidelines are regularly updated in the light of new findings 3.
The indications for cardiac catheterization Box 1 do not depend on whether the patient is known to have CHD or merely suspected of having it. If the patient has no more than mild or atypical anginal symptoms, non-invasive studies should be done first. These will serve to identify patients at high risk, who should then undergo diagnostic cardiac catheterization 2 , Patients with any of the following are considered at high risk: History taking and physical examination, including an assessment of cardiovascular risk factors and of evidence of myocardial ischemia, constitute the best way of detecting possible progression of coronary heart disease and determining whether coronary angiography should be performed 3 , 14 , Patients should be told that, in many situations, such an intervention can alleviate symptoms but does not affect life expectancy, unless angiography has revealed main-stem stenosis, proximal RIVA stenosis, or three-vessel disease.
Silent myocardial ischemia—which preferably affects e. Diagnostic coronary angiography may also be reasonable for patients who present repeatedly with atypical chest symptoms, in either an outpatient or an inpatient setting, even without evidence of ischemia in non-invasive testing.
Angiography is particularly useful when the symptoms have no clearly identifiable, non-cardiac cause, when the previous findings were not completely normal, or when the patient is severely distressed by anxiety about heart disease So-called silent myocardial ischemia is particularly common among diabetics but also appears in non-diabetic elderly men and women.
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These patients do not suffer from typical angina pectoris or equivalent symptoms, but their ECG may show evidence of ischemia at rest or on exercise, and otherwise unexplained arrhythmia can also arise. Because the extent and severity of silent myocardial ischemia are associated with the cardiovascular prognosis 16 , an early diagnostic evaluation of the coronary arteries should be performed whenever silent myocardial ischemia is suspected 2.
After balloon dilatation with or without stent implantation, stenoses can form outside the area of intervention; there can also be restenosis in the treated area. A somewhat more precise estimate can be made with determination of late lumen loss quantitative coronary angiography, QCA , intravascular ultrasonography IVUS , or measurement of fractional flow reserve. The causes of restenosis after simple balloon angioplasty include the migration and proliferation of smooth-muscle cells, platelet deposition, thrombus formation, elastic recoil loss of lumen area within a few minutes of balloon dilatation , and negative arterial remodeling lumen-narrowing changes of the vascular wall.
Stent implantation prevents both elastic recoil and negative arterial remodeling. After stent implantation, the most common mechanism of restenosis is neointimal hyperplasia 3. Less than half of all patients with angiographically documented restenosis develop clinical manifestations clinically relevant restenosis within one year 3. This may be because angiographically demonstrable vascular narrowing is not necessarily associated with impaired distal myocardial perfusion.
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Less than half of all patients with angiographically documented restenosis develop clinical manifestations clinically relevant restenosis within one year. Known risk factors for restenosis are listed in Box 2 23 , How should patients be followed up after coronary stent implantation? Who should see them in follow-up, and what aspects need to be considered? When patients are discharged from the hospital or outpatient interventional cardiology practice after stenting, the physician tells them to avoid excessive movement of the limb where the puncture was performed for the next two days.
To prevent bleeding after femoral artery punctures, patients should avoid carrying heavy objects or taking long automobile or bicycle rides or hikes for two weeks. After radial artery punctures 25 , patients should try to rest the affected hand for a few days. Physical examination auscultation of the heart and lungs and of the puncture site, exclusion of inflow obstruction, wet rales, peripheral edema. Routine laboratory tests electrolytes, complete blood count, liver and renal function tests. Particular attention should be paid to Statin intolerance, if statin treatment has just been initiated muscle symptoms, liver values.
Continuation of prescribed drug treatment 4 , 26 , particularly of dual antithrombotic treatment after stent implantation. As recommended in the National Disease Management Guidelines 6 , patients with coronary heart disease and those who have undergone stent implantation should be followed up regularly every three to six months by their primary care physicians, independently of any additional visits that may be necessitated by worsening symptoms, comorbidities, or any other tests that need to be done recommendation grade B, evidence level 2.
In these regular follow-up visits, the physician should take a clinical history focusing particularly on current symptoms specific cardiac symptoms, but also fatigue or diminished performance , endurance level, and functional status, including effects on family life, occupation, everyday activities, sports, and sexual activity recommendation grade B, evidence level 2.
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At each visit, a physical examination should also be carried out, including the heart, lungs, limbs peripheral pulses, edema , weight BMI , blood pressure, and heart rate recommendation grade B, evidence level 2. The primary care physician should refer the patient to the cardiologist whenever symptoms and signs arise that might be due to CHD and cannot be adequately evaluated by the primary care physician alone 6. Referral to the cardiologist may also be indicated if the primary care physician cannot achieve adequate symptomatic relief or cannot implement the treatments drugs and other measures that are indicated to improve the prognosis, e.
Finally, referral is indicated when preexisting heart failure worsens, when the new onset of heart failure is suspected, or when new, clinically relevant arrhythmia is documented 6. An algorithm for the care of patients with known CHD by the cardiologist, adapted to the algorithm recommended by the National Disease Management Guidelines, is shown in the Figure 6.
The indication for a stress test should be determined by a cardiologist Figure. Routine stress testing after coronary interventions has no proven benefit and is not indicated 3 , 4 , 6 , 27 — Algorithm for patients with known CHD—care by cardiologist. Modified from 6. As recommended in the German National Disease Management Guidelines, patients with CHD and those who have undergone stent implantation should be followed up regularly every 3 to 6 months by their primary care physicians.
Patients who cannot tolerate physical stress of an adequate intensity to produce a reliable finding on stress ECG should have an imaging study under pharmacologically induced stress instead stress echocardiography, stress MRI, or SPECT [ 34 ] [ 6 ], recommendation grade A, evidence level 1. No clear recommendation is given for a specific type of imaging study.
An imaging modality should be chosen that is locally available and can be carried out with the necessary expertise; the adverse effects of ionizing radiation, contrast media, and pharmacological stressors should also be taken into account 4. Patients with chronic CHD and any of the following are considered to be at high risk [ 6 ], recommendation grade B, evidence level An occupation or hobbies in which a cardiac event would be particularly dangerous e.
Such patients should be regularly monitored with imaging studies even if asymptomatic [ 6 ], recommendation grade B, evidence level 2 [ 4 ], class IIa-C recommendation. Multidetector computed tomographic angiography has a low positive predictive value for the detection of significant coronary stenosis. The indication for treating a stenosis depends on the inducibility of ischemia, rather than on the structural features of the stenosis Thus, routine CT angiography is not indicated after coronary stent implantation.
In general, the indications for coronary angiography after PCI are the same as those for primary coronary angiography. The benefits of the study must be weighed against its risks. Routine stress testing after coronary interventions has no proven benefit and is not indicated. When a patient with a coronary stent develops acute symptoms, the possibility of stent thrombosis—a life-threatening complication—must always be considered. Symptomatic patients whose findings in a stress test imply low risk ischemia under intense stress, late-onset ischemia, wall-motion abnormality in a single segment or small reversible perfusion deficits, no evidence of ischemia should be managed conservatively with optimized drug treatment 4 , 36 — 38 class I-B recommendation.
On the other hand, symptomatic patients whose findings in a stress test imply intermediate or high risk ischemia under mild stress, early-onset ischemia, wall-motion abnormalities in multiple segments, large reversible perfusion deficits should undergo coronary angiography [ 4 ], class I-C recommendation. Asymptomatic high-risk patients who have had a stress test should be managed as if they were symptomatic patients with the same stress test findings [ 4 ] , class IIa-C recommendation. The risk of stent thrombosis is still present for several years after stent implantation.
If stent thrombosis is suspected, cardiac catheterization should be performed without delay, with the option of performing an emergency PCI at the same procedure [ 2 ], class I-C recommendation.
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That is, the indications for coronary angiography after PCI are the same as those for primary coronary angiography. Some centers routinely perform a coronary follow-up study six months after any coronary intervention, whether or not there is any evidence of ischemia in stress testing.
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The purpose of this is to identify asymptomatic, but angiographically significant stenoses. The six-month interval is based on the observation that neointima formation and vascular remodeling in the area of the stent have generally run their full course by this time. Some intervention studies have shown, however, that patients who undergo routine coronary follow-up studies end up having more coronary interventions than those who have such studies only when they become symptomatic Moreover, an interventional treatment of a non-flow-limiting in-stent stenosis retriggers the remodeling process and might, therefore, actually lead to a worse result.
While uncontrolled studies suggest as such studies often do a survival advantage 14 for patients undergoing routine follow-up angiography after balloon dilatation e1 or stent implantation e2 , randomized controlled trials e3 show that routine follow-up angiography merely increases the number of interventions to treat irrelevant coronary stenoses, without any improvement of outcome. A similar recommendation is found in the myocardial revascularization guidelines of the European Society of Cardiology ESC , issued The authors state that cardiac catheterization may be indicated three to twelve months after a PCI on an unprotected main stem.
The change was justified by the good intermediate-term results for main-stem catheter interventions that were found in the SYNTAX trial. It is also stated in the guidelines of the German Cardiac Society Deutsche Gesellschaft für Kardiologie-, Herz- und Kreislaufforschung that coronary angiography is not indicated for the routine follow-up of patients who have undergone coronary interventions 2. This select group of patients is not discussed or defined in any further detail.
We recommend follow-up angiography for patients who have had their last patent coronary vessel treated; for those who have undergone complex coronary interventions with long stented segments and suboptimal results, or complex interventions on an unprotected main stem; and for those who have had recurrent in-stent stenoses followed by a myocardial infarction. Routine follow-up angiography merely increases the number of interventions to treat irrelevant coronary stenoses, without any improvement of outcome.
Ideally, a patient who has undergone coronary stent implantation should be cared for by the primary care physician and the cardiologist working closely together. Any progression of coronary heart disease can be reliably detected by means of history taking, physical examination, an assessment of risk factors, and a search for evidence of ischemia.