Preventing in-hospital cardiac and renal complications in high-risk PCI patients

Percutaneous coronary intervention, a highly effective therapy for angina, is associated with in-hospital complications including death, myocardial infarction (MI), emergency coronary artery bypass grafting, stroke, contrast-induced nephropathy (CIN), and vascular access-site problems. Patients with risk factors including advanced age, unstable angina or acute MI, impaired ejection fraction, multivessel disease, peripheral vascular disease, and renal insufficiency (RI) are at increased risk of major adverse cardiac events (MACE). Furthermore, patients with RI, diabetes, congestive heart failure, hypertension, or pre-procedure shock are at increased risk of CIN, which may result in renal failure as well as increased morbidity and mortality from cardiovascular disease. Algorithms have been developed to predict the likelihood of peri-procedural MACE or CIN for individual patients, and at-risk patients should be managed carefully. Measures to avoid MACE include use of antithrombotic therapies such as aspirin, thienopyridines, glycoprotein Gp IIb/IIIa inhibitors, and anticoagulants. In addition, evidence shows that the use of the iso-osmolar, non-ionic, dimeric contrast medium iodixanol may reduce the in-hospital incidences of both MACE (particularly MI) and CIN when compared with the low-osmolar contrast media that it has been tested against. Other approaches to avoid CIN include discontinuation of nephrotoxic drugs, such as non-steroidal anti-inflammatory medications, use of a minimum volume of contrast, provision of intravenous hydration for 24 h beginning before the procedure, and possibly administration of N-acetylcysteine.