Cardiovascular

Coronary revascularization: PCI vs CABG decision-making

Clinical Overview and When to Suspect Revascularization Need

— Acute coronary syndrome (STEMI, NSTEMI, unstable angina) with culprit lesion(s)

— Chronic coronary disease with refractory angina despite optimal medical therapy (OMT) — typically two anti-anginals plus risk-factor control

— Positive functional testing (stress imaging) with >10% ischemic myocardium, or invasive FFR ≤0.80 / iFR ≤0.89

— Left main, proximal LAD, or multivessel disease on cath, especially with reduced EF (<35%) or diabetes

— Survival benefit (left main, multivessel CAD with diabetes or low EF, large ischemic burden)

— Symptom relief / quality of life (stable angina inadequately controlled by OMT)

— SYNTAX score: angiographic complexity. Low ≤22, Intermediate 23–32, High ≥33

— STS score: surgical mortality/morbidity risk for CABG

— Heart Team review is a Class I recommendation for left main and complex multivessel disease

Board pearl: STEMI = primary PCI within 90 min (or fibrinolysis if PCI unavailable in 120 min) — never delay for Heart Team discussion. Heart Team applies to stable, complex anatomy.

Step 3 management: Before any elective revascularization referral, document that the patient is on OMT (high-intensity statin, antiplatelet, beta-blocker, ACEi/ARB if indicated, BP/glucose/smoking control). Boards penalize jumping to cath before OMT in stable CAD with low ischemic burden — ISCHEMIA trial logic. Revascularization in stable CAD reduces angina but does not reduce death/MI vs OMT alone except in specific anatomic subsets.

Coronary revascularization = restoring perfusion to ischemic myocardium via percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); the choice hinges on anatomy, comorbidity, LV function, and patient preference, not symptoms alone.

When to suspect a revascularization decision is pending:

Two parallel goals drive the decision:

Anatomy stratifiers you must know:

Presentation Patterns and Key History

— Acute STEMI/NSTEMI: chest pressure, diaphoresis, dyspnea; troponin trajectory; ECG changes. Default = PCI of culprit vessel.

— Chronic stable angina uncontrolled on OMT: predictable exertional substernal pressure, relieved by rest/nitrates, progressing in frequency.

— Incidental high-risk anatomy found on cath after positive stress test in a diabetic or low-EF patient.

— Diabetes mellitus with multivessel CAD (FREEDOM trial: CABG lower death/MI)

— LV dysfunction (EF ≤35%) with multivessel disease (STICH trial: CABG survival benefit at 10 yr)

— Left main disease, especially with SYNTAX >32

— Three-vessel disease with proximal LAD involvement and high SYNTAX

— Concomitant severe valvular disease needing surgery (mitral, aortic)

— STEMI/high-risk NSTEMI — time is muscle

— Single-vessel disease (non-left main, non-proximal LAD complex)

— Frailty, advanced age, severe COPD, cirrhosis, recent stroke, hostile mediastinum (prior CABG, chest radiation)

— Low SYNTAX score (≤22) even in multivessel disease

— Patient preference for less invasive option after informed discussion

— Prior PCI/CABG, stent type and date (DAPT duration implications)

— Bleeding history, anticoagulant use, GI bleed, thrombocytopenia

— Surgical candidacy markers: ambulatory status, dialysis, EF, prior sternotomy

— Medication adherence — predicts DAPT compliance after PCI

Key distinction: A 62-year-old diabetic with 3-vessel CAD and proximal LAD involvement → CABG (FREEDOM). Same anatomy, non-diabetic, low SYNTAX, frail → PCI is reasonable.

Board pearl: Document a goals-of-care conversation before elective revascularization — symptom relief vs survival benefit are separate trade-offs and must be made explicit to the patient.

Three classic vignettes drive the PCI-vs-CABG question on Step 3:

History elements that shift the decision toward CABG:

History elements favoring PCI:

Always ask:

Physical Exam Findings and Hemodynamic Assessment

— BP, HR, mental status, urine output, lactate

— Signs of cardiogenic shock: cool extremities, narrow pulse pressure, S3, rales, elevated JVP, mottling

— Killip class in acute MI: I (no failure) → IV (shock). Killip III/IV warrants mechanical circulatory support consideration (IABP, Impella, VA-ECMO) alongside emergent PCI

— New systolic murmur post-MI → consider acute MR (papillary muscle) or VSD → surgical consult; CABG may be combined with mechanical repair

— S3 gallop, rales → LV dysfunction; favors CABG in multivessel disease per STICH

— Diminished/absent pulses, bruits → peripheral vascular disease may limit femoral access; consider radial-first PCI (lower bleeding, preferred per AHA)

— Allen test or plethysmography before radial access

— Femoral pulses, prior groin scars, AAA history

— Internal mammary artery (LIMA) availability — prior chest radiation or CABG limits conduit options

— Gait speed <0.65 m/s, grip strength, unintentional weight loss, exhaustion, low activity

— Frail patients have higher CABG mortality; PCI or even continued OMT may be preferred

CCS pearl: In a CCS case with acute MI + new murmur + hypotension → order bedside echo immediately, place arterial line, start norepinephrine, call cardiac surgery and cath lab simultaneously. Don't sequence — parallelize.

Step 3 management: Always perform a focused neuro exam pre-revascularization. Baseline deficits matter for distinguishing periprocedural stroke (a key CABG complication, ~1–2%) postoperatively, and influence informed consent discussion.

Exam in the revascularization candidate is less about diagnosis and more about risk stratification and procedural planning.

Hemodynamic stability check (drives urgency and modality):

Cardiac exam clues that change strategy:

Vascular exam for access:

Frailty assessment (mandatory in elderly):

Diagnostic Workup — Initial Labs, ECG, and Biomarkers

— ST elevation ≥1 mm in 2 contiguous leads (≥2 mm in V2–V3 men, ≥1.5 mm women) or new LBBB with Sgarbossa criteria → STEMI → emergent PCI

— ST depression, T-wave inversion, transient ST elevation → NSTE-ACS pathway

— Posterior MI: tall R in V1–V2, ST depression V1–V3 → obtain posterior leads (V7–V9)

— High-sensitivity troponin at 0 and 1–3 hours; serial trajectory distinguishes acute injury from chronic elevation

— Rising/falling pattern + clinical context = type 1 MI → revascularization workup

— Stable elevation = chronic myocardial injury (CKD, HF) → does not automatically trigger cath

— CBC (anemia raises bleeding/transfusion risk and 1-year mortality)

— BMP — creatinine and eGFR drive contrast strategy and CABG risk scoring

— Coags, type & screen, HbA1c, lipid panel, TSH, LFTs

— BNP/NT-proBNP for HF stratification

— CXR: pulmonary edema, cardiomegaly, mediastinal width (rule out dissection in chest pain)

— Transthoracic echo: LV function, regional wall motion, valvular pathology, mechanical complications. EF is the single most important number for choosing CABG vs PCI in chronic CAD.

Board pearl: A new wall motion abnormality on echo in a patient with chest pain and nondiagnostic ECG + borderline troponin justifies invasive angiography in the NSTE-ACS pathway.

Key distinction: Type 1 MI (plaque rupture) → revascularization candidate. Type 2 MI (supply–demand mismatch from sepsis, anemia, tachyarrhythmia) → treat the trigger; cath only if ongoing ischemia after correction. Step 3 loves this distinction in ICU vignettes.

ECG — first test, within 10 minutes of presentation for any suspected ACS:

Cardiac biomarkers:

Core labs before revascularization:

Imaging:

Diagnostic Workup — Advanced and Confirmatory Studies

— Exercise ECG if baseline ECG interpretable and patient can exercise

— Stress imaging (echo or nuclear MPI) if baseline ECG uninterpretable (LBBB, paced, LVH, digoxin) or low exercise capacity

— Pharmacologic stress (regadenoson, dobutamine) if cannot exercise

— Coronary CTA: high negative predictive value; preferred in low-to-intermediate pretest probability per AHA/ACC 2021 Chest Pain Guidelines

— >10% ischemic myocardium on MPI

— Multiple territories of ischemia

— Drop in EF with stress, exercise-induced hypotension

— High-risk Duke treadmill score (≤ –11)

— Defines vessel count, lesion location (left main, proximal LAD), lesion complexity

— Enables SYNTAX score calculation

— FFR (≤0.80) or iFR (≤0.89) for intermediate lesions (40–70% stenosis) — guides whether to revascularize

— IVUS or OCT for left main, bifurcation, stent optimization

— In EF ≤35% with multivessel CAD, viability does not change survival benefit of CABG per STICH substudy — but commonly tested

— Hibernating myocardium = potential functional recovery with revascularization

Step 3 management: For stable chest pain in a 55-year-old with intermediate pretest probability and normal ECG → coronary CTA is now first-line. Reflexively ordering invasive cath in stable patients is a wrong-answer trap.

Board pearl: FFR-guided PCI is superior to angiographic-eyeball PCI (FAME trial). Deferring PCI on lesions with FFR >0.80 is safe and reduces unnecessary stenting.

Stress testing — for stable chest pain or risk stratification (not for acute ST elevation, hemodynamic instability, or unstable angina):

Findings that mandate cath:

Invasive coronary angiography — the definitive anatomic test:

Adjunctive intracoronary imaging:

Viability testing (cardiac MRI with LGE, PET, dobutamine echo):

Risk Stratification and First-Line Management Logic

— Left main disease (>50%): CABG preferred, especially SYNTAX >32; PCI acceptable for SYNTAX ≤22 (EXCEL/NOBLE — controversial; CABG remains class I)

— Three-vessel disease + diabetes: CABG (FREEDOM, class I)

— Three-vessel disease, non-diabetic, low SYNTAX: either reasonable; CABG still favored if proximal LAD involved or SYNTAX intermediate/high

— EF ≤35% with multivessel CAD: CABG (STICH 10-year survival benefit)

— Single-vessel disease (non–left main): PCI if OMT fails or large ischemic territory

— Proximal LAD isolated: PCI or LIMA-to-LAD CABG (both class I); CABG durability favored long-term

— STEMI: primary PCI of culprit lesion within 90 min of first medical contact (door-to-balloon)

— NSTE-ACS high risk (rising troponin, dynamic ECG, GRACE >140, hemodynamic instability, refractory angina): early invasive within 24 h

— NSTE-ACS intermediate risk: invasive within 24–72 h

— Cardiogenic shock complicating MI: culprit-vessel-only PCI (CULPRIT-SHOCK), not multivessel

— SYNTAX — anatomic complexity (favors CABG when high)

— STS — surgical risk (high STS shifts toward PCI)

— GRACE / TIMI — ACS short-term risk

— EuroSCORE II — alternative surgical risk

Key distinction: STEMI with multivessel disease but only one culprit and no shock → complete revascularization (staged or during index PCI) is now favored (COMPLETE trial). STEMI with shock → culprit-only (CULPRIT-SHOCK).

Board pearl: Heart Team review is a Class I recommendation before elective revascularization for left main and complex multivessel CAD. Failing to involve cardiothoracic surgery is a documented quality lapse.

The decision tree (chronic/stable multivessel CAD, post-cath):

Acute settings:

Risk scores to know:

Pharmacotherapy — First-Line Drug Regimen

— Aspirin 162–325 mg chewed immediately

— P2Y12 inhibitor loading dose:

— Ticagrelor 180 mg or prasugrel 60 mg (preferred in STEMI going to PCI; prasugrel contraindicated if prior stroke/TIA, age >75, weight <60 kg)

— Clopidogrel 600 mg if fibrinolysis, CABG-likely, or high bleeding risk

— Anticoagulation: unfractionated heparin (PCI), enoxaparin (NSTEMI medical), or bivalirudin (high bleeding risk PCI)

— High-intensity statin: atorvastatin 80 mg or rosuvastatin 40 mg — start immediately

— Beta-blocker within 24 h if no shock, no AV block, no severe HF (metoprolol tartrate, then transition to succinate)

— ACEi/ARB: within 24 h if EF <40%, HTN, DM, or anterior MI

— Nitrates for ongoing chest pain; avoid if RV infarct, hypotension, or PDE5 inhibitor in last 24–48 h

— Aldosterone antagonist (eplerenone, spironolactone) if EF ≤40% + symptomatic HF or diabetes, post-MI

— Hold ticagrelor 3–5 days, clopidogrel 5 days, prasugrel 7 days before elective CABG

— Aspirin continued through CABG (reduces graft thrombosis)

— Hold ACEi/ARB morning of surgery to reduce intraop hypotension

— DAPT (aspirin + P2Y12) for 6–12 months after DES in stable CAD; 12 months post-ACS regardless of stent

— Shorter DAPT (1–3 months) acceptable in high bleeding risk with newer-generation DES

Step 3 management: A patient on chronic warfarin or DOAC undergoing PCI → triple therapy (anticoagulant + aspirin + clopidogrel) for ~1 week, then double therapy (anticoagulant + clopidogrel) for up to 12 months, then anticoagulant alone. Avoid ticagrelor/prasugrel in triple therapy — bleeding risk.

Board pearl: Prasugrel is contraindicated with prior stroke/TIA — a recurring boards trap.

Pre-procedure / ACS initial therapy (MONA-BASH has been retired; current pillars):

CABG-specific considerations:

Post-PCI antiplatelet:

Procedures — PCI vs CABG Technical and Decision Details

— Radial access preferred (lower bleeding, mortality benefit in ACS — MATRIX trial)

— Angiography → lesion assessment ± FFR/iFR → balloon angioplasty + drug-eluting stent (DES) placement

— Second-generation DES (everolimus, zotarolimus) is standard — lower stent thrombosis vs first-gen

— IVUS/OCT for left main, bifurcations, long lesions, in-stent restenosis

— Complete revascularization in non-shock STEMI (staged within 45 days or same-setting)

— LIMA to LAD is mandatory — 20-year patency >90%, drives survival benefit

— Additional conduits: radial artery (preferred over saphenous for second graft per ART trial), right ITA, saphenous vein graft (SVG)

— Off-pump vs on-pump: similar long-term outcomes; on-pump more common in US

— Multiarterial grafting favored in younger patients with long life expectancy

— SYNTAX (2009): CABG superior in high SYNTAX (>32) multivessel/left main; equivalent in low SYNTAX

— FREEDOM (2012): CABG > PCI for diabetics with multivessel CAD (death, MI, stroke at 5 yr)

— EXCEL & NOBLE: left main — mixed; CABG remains preferred for complex left main

— STICH (2016): CABG + OMT > OMT alone in EF ≤35% multivessel CAD at 10 yr

— ISCHEMIA (2020): in stable CAD with moderate-severe ischemia, invasive strategy did not reduce death/MI vs OMT — symptom relief only

CCS pearl: Order post-PCI: continuous telemetry, serial troponin/ECG, hold metformin 48 h if contrast given and CKD, monitor access site, restart home meds with confirmed renal function.

Key distinction: Stroke risk is higher with CABG (~2%) than PCI (~0.5%); repeat revascularization is higher with PCI. Trade-off central to informed consent.

PCI workflow:

CABG workflow:

Head-to-head trial evidence:

Hybrid revascularization: LIMA-LAD via mini-thoracotomy + PCI of non-LAD vessels — niche, multivessel disease with surgical risk

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher CABG operative mortality; frailty, cognitive status, functional capacity more predictive than chronologic age

— PCI preferred in frail elderly with multivessel disease when surgical risk is prohibitive

— Radial access strongly preferred — bleeding is the dominant adverse event

— DAPT duration often shortened (1–3 months) to balance bleeding vs ischemic risk

— Avoid prasugrel (age >75 contraindication unless prior MI and diabetic with low bleeding risk)

— Goals-of-care discussion mandatory — quality of life often outweighs marginal survival gain

— CKD is an independent predictor of worse outcomes for both PCI and CABG

— Contrast-induced AKI: pre-hydrate with isotonic saline 1–1.5 mL/kg/h for 6–12 h pre and post; minimize contrast volume; use iso-osmolar or low-osmolar contrast; N-acetylcysteine and sodium bicarbonate are not recommended (PRESERVE trial)

— Hold metformin at time of contrast if eGFR <30 or AKI; resume 48 h after confirming stable renal function

— Dialysis patients: CABG may offer better long-term survival in multivessel disease but with high perioperative risk

— Cirrhosis (Child-Pugh B/C, MELD >13) markedly raises CABG mortality from coagulopathy, bleeding, ascites

— PCI preferred in advanced cirrhosis; bleeding risk requires careful antiplatelet selection

— Ticagrelor avoided in severe hepatic impairment; clopidogrel preferred

— Statins remain indicated — monitor LFTs; do not withhold for compensated disease

Step 3 management: A 78-year-old with eGFR 28, multivessel CAD, stable angina → maximize OMT, consider PCI of culprit symptomatic vessel with minimal contrast over CABG. Document Heart Team discussion and patient preference.

Board pearl: Pre-procedure eGFR <30 + diabetes is the highest-risk combo for contrast nephropathy — hydration is the only proven prevention.

Elderly (≥75 years):

Chronic kidney disease:

Hepatic impairment:

Special Populations — Pregnancy, Women, and Younger Patients

— Pregnancy-associated MI is rare; most common cause is spontaneous coronary artery dissection (SCAD), especially peripartum

— SCAD management: conservative if hemodynamically stable — most heal spontaneously; PCI reserved for ongoing ischemia, instability, or left main involvement (high complication rate due to fragile vessel)

— If revascularization needed: PCI preferred over CABG due to fetal/maternal risk of bypass; shield fetus, minimize fluoroscopy

— Avoid prasugrel, ticagrelor, ACEi/ARB in pregnancy; aspirin low-dose acceptable; clopidogrel if essential with shortest course

— Statins: traditionally contraindicated; emerging data more permissive but avoid in pregnancy per current guidelines unless homozygous FH

— More likely to present with atypical symptoms (dyspnea, fatigue, jaw/back pain)

— Higher rates of MINOCA (MI with non-obstructive coronaries), SCAD, microvascular dysfunction

— Historically under-revascularized — Step 3 question writers love testing equitable application of guideline-directed therapy regardless of sex

— Similar benefit from PCI/CABG when guideline criteria met, but higher periprocedural bleeding risk → radial access, weight-based heparin

— Consider familial hypercholesterolemia, cocaine/methamphetamine use, vasculitis (Kawasaki sequelae), antiphospholipid syndrome, premature atherosclerosis

— Favor CABG with multiple arterial grafts in multivessel disease — graft longevity matters more in long life expectancy

— Aggressive secondary prevention and family screening

Key distinction: SCAD is not atherosclerotic — do not reflexively stent. Conservative management is first-line because stenting can propagate the dissection.

Board pearl: A peripartum woman with chest pain and troponin elevation → think SCAD, get angiography, manage conservatively unless unstable.

Pregnancy:

Women:

Young patients (<50 years):

Complications and Adverse Outcomes

— Access site: hematoma, pseudoaneurysm, retroperitoneal bleed (femoral), radial artery occlusion

— Contrast-induced AKI: peak Cr at 48–72 h

— Coronary dissection, perforation, tamponade — rare but life-threatening

— No-reflow / distal embolization — especially in saphenous vein graft PCI

— Stent thrombosis: acute (<24 h), subacute (1–30 d), late (>30 d), very late (>1 yr). Presents as STEMI; mortality ~20–40%. Premature DAPT cessation is the #1 cause

— In-stent restenosis: months to years out, presents as recurrent angina; treat with drug-coated balloon or repeat DES

— Periprocedural MI (type 4a) — small troponin bumps common

— Radiation skin injury, allergic reactions to contrast

— Stroke (1–2%) — higher than PCI

— Atrial fibrillation (~30%) — peaks postop day 2–4; treat with beta-blocker, rate or rhythm control, anticoagulation per CHA₂DS₂-VASc

— Mediastinitis / sternal wound infection — diabetics, obesity, bilateral ITA harvest are risks

— Perioperative MI, graft occlusion (SVG: 10–15% in first year)

— Acute kidney injury, prolonged ventilation, delirium, postpericardiotomy syndrome

— Cognitive decline ("pumphead") — controversial, multifactorial

— Bleeding — major bleeds increase 1-year mortality independently

— Recurrent ischemia requiring repeat revascularization (higher with PCI long-term)

CCS pearl: Post-CABG patient on day 3 with new irregularly irregular rhythm and rate 140 → rate control with IV beta-blocker or amiodarone, check K/Mg, repeat ECG, anticoagulation decision based on duration and CHA₂DS₂-VASc.

Board pearl: Sudden cardiac arrest 2 weeks post-DES placement in a patient who stopped clopidogrel for a dental procedure → acute stent thrombosis until proven otherwise.

PCI complications:

CABG complications:

Both modalities:

When to Escalate Care — ICU, Consult, and Inpatient Triage

— STEMI (door-to-balloon ≤90 min)

— New LBBB with clinical ACS context

— Cardiogenic shock complicating ACS — regardless of ECG

— Refractory ventricular arrhythmia in suspected ischemia

— Post-arrest ROSC with suspected coronary cause (especially if STEMI on post-ROSC ECG)

— Hemodynamic instability, vasoactive support

— High-grade AV block, sustained VT/VF

— Mechanical complications of MI (acute MR, VSD, free wall rupture)

— Acute decompensated HF with troponin elevation

— Post-PCI with complications or large infarct

— Left main disease, complex multivessel disease with high SYNTAX

— Diabetic with multivessel disease

— EF ≤35% with multivessel CAD

— Concomitant valve disease requiring intervention

— Mechanical complications post-MI

— Failed PCI or coronary anatomy not amenable to stenting

— IABP: bridging for cardiogenic shock, though no mortality benefit (IABP-SHOCK II)

— Impella: temporary LV unloading, high-risk PCI, shock

— VA-ECMO: refractory cardiogenic shock, biventricular failure, arrest

— LVAD / transplant evaluation: end-stage HF unsuitable for revascularization alone

Step 3 management: A STEMI patient en route to non-PCI hospital, expected transfer time 100 min → transfer for primary PCI (within 120 min total). If >120 min projected → fibrinolysis within 30 min, then pharmacoinvasive transfer within 3–24 h.

CCS pearl: In CCS, always order continuous telemetry, IV access ×2, arterial line if unstable, foley if shock, and notify cardiology before completing the full workup.

Immediate cath lab activation:

CCU / cardiac ICU admission criteria:

Cardiothoracic surgery consult triggers:

Mechanical circulatory support escalation:

Key Differentials — Same-Category (Ischemic) Causes

— Rest pain, often at night/early morning, transient ST elevation that resolves

— Triggers: smoking, cocaine, hyperventilation, methamphetamine

— Cath: normal or minimal CAD; provocation testing with acetylcholine/ergonovine confirms

— Treatment: calcium channel blockers (diltiazem, amlodipine), long-acting nitrates — not stents

— Typical angina with positive stress test but normal coronaries

— Female predominance; treat with beta-blockers, CCBs, statins, ranolazine; no revascularization

— Troponin elevation meeting MI criteria + <50% stenosis in all major vessels

— Causes: plaque erosion, SCAD, vasospasm, thromboembolism, microvascular

— Workup: cardiac MRI to differentiate myocarditis, Takotsubo, true infarct; OCT/IVUS for plaque erosion

— Young women, peripartum, fibromuscular dysplasia, connective tissue disease

— Conservative management preferred over PCI

— Sepsis, anemia, tachyarrhythmia, hypoxemia

— Treat underlying cause; cath only if persistent ischemia after correction

— Per ISCHEMIA: OMT first-line; revascularization for symptom control or high-risk anatomy

Key distinction: ST elevation that resolves spontaneously + recurs at rest = vasospasm, not STEMI. Stenting a spastic vessel can worsen disease — give CCB and nitrates, avoid beta-blockers (unopposed alpha may worsen spasm).

Board pearl: Cocaine chest pain → benzodiazepines, nitrates, aspirin; avoid pure beta-blockers. Cath if true ACS pattern; many resolve with vasodilator therapy alone.

Before committing a patient to revascularization, ensure the chest pain syndrome is truly obstructive epicardial CAD:

Vasospastic (Prinzmetal) angina:

Microvascular angina (cardiac syndrome X):

MINOCA (MI with non-obstructive coronaries):

Spontaneous coronary artery dissection (SCAD):

Demand ischemia / Type 2 MI:

Stable chronic CAD without high-risk features:

Key Differentials — Other-Category Causes of Chest Pain

— Tearing pain radiating to back, pulse/BP differential between arms, widened mediastinum on CXR

— CT angiography of chest confirms; type A → emergent surgery, type B → medical (esmolol, nitroprusside)

— Antiplatelets and anticoagulants are dangerous — must exclude before treating "ACS"

— Pleuritic pain, dyspnea, hypoxemia, sinus tachycardia, S1Q3T3

— Troponin can be elevated from RV strain; CT-PA confirms

— Pleuritic, positional pain; diffuse ST elevation with PR depression on ECG; pericardial friction rub

— Myocarditis can mimic ACS with troponin elevation — cardiac MRI distinguishes

— Apical ballooning, post-emotional/physical stress, postmenopausal women

— ECG mimics anterior MI; cath shows clean coronaries with apical akinesis

— Supportive care; recovers in weeks

Step 3 management: Before activating cath lab for "STEMI" in an unusual presentation (e.g., interscapular pain, pulse deficit, hypertensive crisis) → CT angiography to exclude dissection. Heparin in a missed dissection is catastrophic.

Board pearl: Diffuse ST elevation with PR depression = pericarditis. Regional ST elevation with reciprocal changes = STEMI. Don't stent pericarditis.

Non-ischemic chest pain mimics can produce troponin elevations or ECG changes that mislead toward unnecessary revascularization:

Aortic dissection:

Pulmonary embolism:

Pericarditis / myocarditis:

Takotsubo (stress) cardiomyopathy:

Esophageal causes: GERD, spasm, rupture (Boerhaave with mediastinitis)

Musculoskeletal: costochondritis, rib fracture

Pneumothorax, pneumonia, pleurisy

Anxiety / panic disorder — diagnosis of exclusion in atypical patients

Secondary Prevention and Discharge Medications

— Aspirin 81 mg daily, lifelong

— P2Y12 inhibitor for 12 months post-ACS (ticagrelor or prasugrel preferred over clopidogrel)

— 6 months post-elective PCI for stable CAD with DES (shorter if high bleeding risk)

— Post-CABG: aspirin lifelong; P2Y12 inhibitor optional, often 12 months if post-ACS

— LDL goal <70 mg/dL; consider <55 mg/dL in very-high-risk (recurrent events, multivessel, diabetes)

— Add ezetimibe then PCSK9 inhibitor (evolocumab, alirocumab) or inclisiran if goal not met

— Bempedoic acid for statin-intolerant

— BP <130/80

— HbA1c individualized (~7%)

— Smoking cessation — varenicline, NRT, counseling

— Mediterranean diet, weight loss, exercise

— Influenza and pneumococcal vaccines annually

Step 3 management: Patient missing cardiac rehab referral at discharge is a classic Step 3 quality gap — always include it.

Board pearl: Stopping DAPT early for "minor" surgery is the leading cause of stent thrombosis. Delay elective surgery 6 months after DES; if urgent, continue aspirin and resume P2Y12 ASAP.

Antiplatelet therapy (the cornerstone post-revascularization):

Statin: High-intensity statin (atorvastatin 40–80, rosuvastatin 20–40) lifelong

Beta-blocker: metoprolol succinate or carvedilol, especially post-MI with reduced EF; continue ≥1 year post-MI, indefinitely if HFrEF

ACEi/ARB: for EF <40%, HTN, DM, CKD; continue indefinitely if EF reduced

Aldosterone antagonist: EF ≤40% with symptomatic HF or post-MI diabetic

SGLT2 inhibitor: in diabetics with CAD (empagliflozin, dapagliflozin) — cardiovascular benefit independent of glucose

GLP-1 RA: semaglutide, liraglutide — CV benefit in T2DM with ASCVD

Risk factor control:

Cardiac rehabilitation: class I recommendation post-PCI/CABG/MI — 36 sessions over 12 weeks

Follow-Up, Monitoring, and Rehabilitation

— Primary care or cardiology within 1–2 weeks post-PCI/CABG/MI

— Cardiology at 4–6 weeks, then 3 months, 6 months, annually

— Cardiac rehab enrollment within 1–3 weeks of discharge

— Lipid panel at 4–12 weeks after statin start/intensification, then every 3–12 months

— Liver enzymes at baseline; routine monitoring not required unless symptoms

— CK only if myalgias suggest myopathy

— HbA1c every 3–6 months in diabetics

— BMP at 1–2 weeks if on ACEi/ARB/MRA, then periodically

— BP and HR monitoring; home BP logs encouraged

— Echo at 40 days post-MI if EF was reduced — guides ICD candidacy (EF ≤35% on OMT despite ≥40 days post-MI/≥90 days post-revascularization)

— Routine stress testing in asymptomatic patients post-PCI/CABG is not recommended; perform only if symptoms recur

— Supervised exercise (aerobic + resistance), risk factor education, dietary counseling, psychosocial support, medication adherence

— Reduces all-cause mortality ~20%, recurrent MI, hospital readmissions

— Return to driving: typically 1 week post-uncomplicated PCI, 4 weeks post-CABG (vary by state)

— Sexual activity: resume when can climb 2 flights of stairs without symptoms; avoid PDE5i within 24–48 h of nitrates

— Return to work: 1–2 weeks (sedentary, post-PCI), 6–12 weeks (CABG, manual labor)

— Air travel: usually safe 2 weeks post-uncomplicated MI/PCI

Step 3 management: A patient post-anterior STEMI with EF 28% at discharge → repeat echo at 40 days; if EF remains ≤35% on OMT, refer for primary prevention ICD.

Board pearl: Depression screening (PHQ-9) at follow-up — post-MI depression doubles cardiac mortality and is undertreated.

Post-discharge follow-up cadence:

Monitoring labs and parameters:

Imaging follow-up:

Cardiac rehabilitation components:

Lifestyle counseling:

Ethical, Legal, and Patient Safety Considerations

— Must include specific risks: death, MI, stroke, bleeding, AKI, vascular injury, need for emergency CABG (PCI), prolonged ventilation (CABG), cognitive change

— Alternatives discussion: OMT, the other modality, doing nothing — all must be presented

— Heart Team documentation required for left main and complex multivessel — failure is a quality and medicolegal exposure

— Acute MI patient with delirium or sedation: use substituted judgment via surrogate (spouse, durable POA)

— In true emergency without surrogate available, implied consent applies for life-saving primary PCI

— STEMI Jehovah's Witness: respect refusal of blood; document; CABG may be feasible bloodless — early CT surgery consult

— ISCHEMIA data must be explicitly discussed: revascularization in stable CAD does not reduce death/MI but improves angina — this is a preference-sensitive decision

— Medication reconciliation at discharge — missed DAPT, statin, beta-blocker is a sentinel safety event

— Clear DAPT duration counseling with written instructions; flag dental and surgical providers

— Follow-up appointment scheduled before discharge, not "call to schedule"

— Patient education on return precautions for stent thrombosis (sudden severe chest pain → 911)

— Avoid inappropriate PCI of non-flow-limiting lesions; use FFR/iFR

— Appropriate Use Criteria (AUC) framework guides documentation

— Cocaine/methamphetamine-induced ACS does not trigger mandatory reporting in adults but warrants documented counseling and referral

— Impaired driving post-syncope/arrhythmia: state-specific reporting laws

Step 3 management: A discharge summary that omits DAPT duration, statin intensity, and rehab referral is the most common cause of preventable readmission — your discharge note must include all three explicitly.

Board pearl: Elective non-cardiac surgery should be deferred 6 months post-DES; if urgent, continue aspirin perioperatively.

Informed consent for revascularization:

Capacity and surrogate decisions:

Shared decision-making for stable CAD:

Transition of care risks (high Step 3 yield):

Conflict of interest and appropriate use:

Reporting:

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: Single blood supply to the posteromedial papillary muscle (from PDA only) makes it vulnerable to rupture in inferior MI → acute severe MR → emergent surgical repair often combined with CABG.

Door-to-balloon time: ≤90 minutes for primary PCI in STEMI

Door-to-needle time: ≤30 minutes for fibrinolysis

Transfer window: PCI within 120 minutes of first medical contact, else lyse

DAPT post-ACS: 12 months minimum

DAPT post-elective DES: 6 months (can shorten to 1–3 months if high bleed risk)

LIMA-to-LAD patency: >90% at 20 years

SVG patency: 50% at 10 years

FFR cutoff: ≤0.80 = ischemic, intervene

iFR cutoff: ≤0.89 = ischemic

SYNTAX: ≤22 low, 23–32 intermediate, ≥33 high

STICH: CABG benefit emerges at 5–10 years in EF ≤35%

FREEDOM: CABG > PCI in diabetics with multivessel CAD

SYNTAX trial: CABG > PCI in complex multivessel/left main

ISCHEMIA: OMT first in stable CAD without high-risk features

CULPRIT-SHOCK: in shock complicating MI, culprit-only PCI

COMPLETE: in non-shock STEMI with multivessel CAD, complete revascularization

MATRIX/RIVAL: radial > femoral access in ACS

PRESERVE: no benefit from bicarbonate or NAC for contrast nephropathy

EXCEL/NOBLE: left main — CABG generally preferred, especially high SYNTAX

Killip class mortality: I ~6%, II ~17%, III ~38%, IV ~81%

TIMI risk score (NSTEMI): age ≥65, ≥3 risk factors, known CAD, ASA in last 7 d, severe angina ×2 in 24 h, ST deviation, elevated biomarker

Prasugrel contraindications: prior stroke/TIA, age >75, weight <60 kg

ICD post-MI: wait ≥40 days post-MI, ≥90 days post-revascularization, EF ≤35% on OMT

Stent thrombosis triad to suspect: recent stent + DAPT cessation + chest pain

Acute MR post-MI: posteromedial papillary muscle (single blood supply from PDA) most vulnerable

VSD post-MI: usually 3–7 days post-MI, anterior > inferior

Free wall rupture: 3–7 days post-MI, tamponade, PEA arrest

Sgarbossa criteria: diagnose MI in LBBB

Board Question Stem Patterns

— 62 y/o diabetic, 3-vessel CAD with proximal LAD involvement, SYNTAX 28

— Answer: CABG (FREEDOM)

— 58 y/o, stable angina, stress test 5% ischemia, single-vessel mid-RCA

— Answer: Optimize medical therapy first (ISCHEMIA)

— Primary PCI of culprit, then staged complete revascularization

— Answer: Complete revascularization (COMPLETE)

— Answer: Culprit-only PCI (CULPRIT-SHOCK)

— Answer: CABG (STICH 10-yr survival)

— Answer: CABG

— Hold ticagrelor 3–5 d, clopidogrel 5 d, prasugrel 7 d; continue aspirin

— Delay if possible; if urgent, continue aspirin, hold P2Y12 for ~5 days, resume immediately postop; coordinate with cardiology

— Recently stopped clopidogrel for dental work → STEMI → emergent cath

— Think SCAD → conservative management unless unstable

— New holosystolic murmur + pulmonary edema = acute MR; harsh murmur + thrill + step-up in O₂ in RV = VSD; muffled heart sounds + JVD + hypotension = free wall rupture / tamponade

— EF 28% at 50 days post-MI, on OMT → wait until ≥40 d post-MI (met), revascularization ≥90 d (check), then ICD

— Answer: isotonic saline hydration, not bicarbonate or NAC

Step 3 management: Recurring trap — choosing invasive strategy in low-risk stable CAD when OMT and lifestyle answer is correct. ISCHEMIA changed the boards.

Board pearl: When the stem mentions "diabetes" + "three-vessel", the answer is almost always CABG unless explicitly prohibitive surgical risk.

Pattern 1 — Diabetic with multivessel CAD:

Pattern 2 — Stable angina, mild ischemia:

Pattern 3 — STEMI with multivessel disease, no shock:

Pattern 4 — Cardiogenic shock with multivessel disease:

Pattern 5 — EF 30% with multivessel CAD:

Pattern 6 — Left main 70% stenosis, SYNTAX 35:

Pattern 7 — Pre-CABG antiplatelet management:

Pattern 8 — Post-DES patient needs urgent surgery in 3 months:

Pattern 9 — Acute stent thrombosis vignette:

Pattern 10 — Peripartum woman with MI:

Pattern 11 — Post-MI murmur and shock:

Pattern 12 — ICD eligibility post-MI:

Pattern 13 — Contrast nephropathy prevention:

One-Line Recap

The choice between PCI and CABG hinges on coronary anatomy (SYNTAX), comorbidity (diabetes, EF, frailty, CKD), and clinical urgency (STEMI vs stable CAD) — with CABG favored for diabetics with multivessel disease, left main, complex SYNTAX, and reduced EF, and PCI favored for acute STEMI, single-vessel disease, frail/high-surgical-risk patients, and patients who decline sternotomy — all built on a foundation of optimal medical therapy.

Board pearl: The three-letter mnemonic for choosing CABG over PCI = "DLM" — Diabetes with multivessel, Left main or Low EF, Multivessel complex (high SYNTAX). Everything else trends PCI or OMT.

Step 3 management: Never finalize a revascularization plan without (1) confirming the patient is on OMT, (2) documenting Heart Team discussion for complex anatomy, (3) explicit shared decision-making about symptom relief vs survival benefit, and (4) a discharge bundle including DAPT duration, statin, beta-blocker, ACEi/ARB if indicated, SGLT2i/GLP-1 RA in diabetics, cardiac rehab referral, and follow-up within 1–2 weeks.

Acute STEMI → primary PCI of culprit within 90 minutes; complete revascularization staged if no shock, culprit-only if shock

Diabetic + multivessel CAD → CABG (FREEDOM); EF ≤35% + multivessel → CABG (STICH); complex left main / SYNTAX >32 → CABG

Stable CAD with low-risk anatomy → optimal medical therapy first (ISCHEMIA); revascularization for symptom control or high-risk features (>10% ischemia, FFR ≤0.80)

Post-revascularization essentials → DAPT (12 mo post-ACS, 6 mo post-elective DES), high-intensity statin to LDL <70, beta-blocker, ACEi/ARB if EF reduced, cardiac rehab, smoking cessation, and structured follow-up