Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Coronary revascularisation: PCI and CABG
Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Time-critical presentation
STEMI, refractory ischaemia, haemodynamic instability or cardiogenic shock requires immediate interventional-cardiology activation; do not delay transfer for non-essential testing.
Purpose and principles
Choose the urgent or elective revascularisation route, explain PCI versus CABG trade-offs and manage the immediate antithrombotic and follow-up priorities.
PCI treats focal coronary obstruction using catheter-based balloon/stent techniques; CABG creates conduits beyond obstructed segments. Neither replaces secondary prevention because both treat the consequences rather than the systemic atherosclerotic process.
Urgency is set by presentation. STEMI is a reperfusion emergency; NSTE-ACS requires risk-led invasive timing; stable disease permits anatomical, functional and preference-based Heart Team planning.
The correct choice is not simply 'one vessel equals PCI, three vessels equals CABG'. Lesion complexity, left main involvement, diabetes, LV function, completeness of revascularisation, operative risk and goals all matter.
Key points
Primary PCI is the preferred STEMI reperfusion strategy when it can be delivered within the NICE time window; if it cannot, assess promptly for fibrinolysis and the pharmaco-invasive pathway.
For NSTEMI/unstable angina, the timing of angiography follows clinical instability and calculated risk; unstable patients need immediate invasive assessment.
In stable angina, revascularisation is primarily for symptoms not controlled by optimal medical therapy; prognostic benefit depends on anatomy and clinical context.
Indications, selection and cautions
STEMI requiring reperfusionRed flag
Persistent ST elevation or equivalent with compatible acute ischaemia requires immediate PPCI network activation and a documented symptom/ECG timeline.
Left-main or complex multivessel disease, particularly with diabetes or impaired LV function, warrants Heart Team review rather than ad hoc PCI.
Acute stent thrombosisRed flag
Sudden recurrent ischaemic pain, ST elevation, ventricular arrhythmia or shock after PCI is an emergency requiring immediate cath-lab contact.
Post-CABG deteriorationRed flag
Rising drain output, hypotension, tamponade physiology, new ischaemia, arrhythmia or low cardiac output requires urgent surgical/critical-care assessment.
Assessment before treatment
0112-lead ECG and serial ECGsFirst step
Why
Define acute ischaemic territory and detect dynamic change or post-procedure occlusion.
Interpretation and limitations
A diagnostic STEMI pattern activates reperfusion; do not wait for troponin before referral.
02High-sensitivity troponin
Why
Confirm myocardial injury in NSTE-ACS and support risk assessment.
Interpretation and limitations
Interpret rise/fall with clinical ischaemia; it does not replace the ECG or explain every elevation.
03Coronary angiography
Why
Define culprit lesion and overall anatomy and permit PCI where appropriate.
Interpretation and limitations
Assess left main, vessel count, lesion complexity and technical feasibility; functional or intravascular assessment may refine non-culprit decisions.
04Echocardiography
Why
Assess LVEF, regional motion, valves and mechanical complications.
Interpretation and limitations
LV function and valve disease materially affect operative risk and the revascularisation plan.
05FBC, U&E/eGFR, coagulation, glucose/HbA1c and group-and-save
Treatment approach
01First-lineSTEMI reperfusionFirst stepFirst lineSTEMI within the reperfusion window+
1Activate the regional primary-PCI pathway immediately and give ACS antithrombotic treatment unless contraindicated.
2Offer coronary angiography with primary PCI when this can be delivered within 120 minutes of when fibrinolysis could have been given under NICE NG185.
3If timely PPCI is not possible and fibrinolysis is appropriate, give fibrinolysis promptly and transfer through the rescue/routine angiography pharmaco-invasive pathway.
4Treat shock or mechanical complication concurrently with critical-care and surgical input.
02Second-lineNSTE-ACS invasive strategySecond lineNSTEMI or unstable angina+
Regimens, contraindications and interactions
Antiplatelet backbone after PCI and generally after CABG unless contraindicated.
Aspirin
For long-term post-revascularisation prevention, typically 75 mg orally once daily after the acute loading dose.
Active bleeding, allergy and ulcer risk; peri-operative timing and temporary interruption are decided by the treating cardiology/surgical team.
Potent P2Y12 inhibitor commonly used after ACS PCI.
Ticagrelor
ACS: 180 mg oral loading dose then 90 mg twice daily, generally with low-dose aspirin, for the planned course up to 12 months unless adjusted.
P2Y12 option in chronic coronary syndrome PCI and selected ACS/anticoagulation or intolerance scenarios.
Clopidogrel
Typical maintenance 75 mg orally once daily after the indication-specific loading dose; duration is presentation-, stent- and bleeding-dependent.
Bleeding and variable activation; omeprazole/esomeprazole interaction considerations. Never stop early after stenting without interventional advice.
Complications, monitoring and follow-up
Recurrent chest pain, ECG change, rhythm and haemodynamics immediately after revascularisation.
Access-site or surgical bleeding, haemoglobin, platelets and need for transfusion/re-exploration.
Creatinine/eGFR and fluid status after contrast or surgery, especially with CKD or shock.
DAPT adherence, adverse effects and explicit review/stop dates; reconcile any oral anticoagulant.
Wound or radial/femoral access healing, infection and limb perfusion.
Angina, functional recovery, LVEF where abnormal, secondary-prevention targets and rehabilitation completion.
Special situations
Time comparison matters in STEMI
NICE's 120-minute test compares PPCI delivery with the time fibrinolysis could have been given, not simply arrival-to-balloon time.
CABG durability has a trade-off
Fewer repeat procedures may come at the cost of sternotomy, peri-operative complications and longer recovery; shared decision-making must show both sides.
Shock changes multivessel strategy
In MI with cardiogenic shock, immediate treatment is directed at the culprit lesion; routine immediate multivessel PCI is not the default.
Revascularised is not cured
Aspirin, lipid lowering, BP/diabetes management, smoking cessation and rehabilitation remain essential after either procedure.
DAPT interruption is high stakes
Suspected bleeding or planned surgery requires the team to balance stent thrombosis and bleeding; unsupervised cessation can be catastrophic.
Common pitfalls
01
Waiting for troponin before activating primary PCI in diagnostic STEMI.
02
Reducing PCI-versus-CABG choice to vessel count without anatomy, diabetes, LV function, risk and preference.
03
Performing ad hoc PCI in complex disease without a Heart Team discussion when both strategies are reasonable.
04
Stopping a P2Y12 inhibitor early after stenting without interventional-cardiology advice.
05
Omitting rehabilitation and secondary prevention because revascularisation was technically successful.
Practice
Two practice questions
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Question 1 of 2
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CardiologyOriginal SBA
Reperfusion when PPCI is delayed
A patient presents early with a clear STEMI. Primary PCI cannot be delivered within 120 minutes of the time fibrinolysis could be given, and there is no contraindication to fibrinolysis. What is the NICE-aligned next route?
Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
PCI is less invasive and has faster recovery but more repeat revascularisation; CABG is more invasive and often offers more durable treatment in complex multivessel or left-main disease.
Use a Heart Team and shared decision-making when PCI and CABG are both plausible, incorporating anatomy, diabetes, ventricular function, frailty, surgical risk and patient preference.
DAPT is essential after stenting but its agents and duration depend on ACS versus chronic coronary syndrome, bleeding risk and any anticoagulation indication.
New chest pain with ST elevation or haemodynamic collapse after PCI may be acute stent thrombosis; after CABG, consider graft failure, bleeding, tamponade, arrhythmia and peri-operative MI.
Why
Assess bleeding, renal, metabolic and procedural risk.
Interpretation and limitations
Correct modifiable abnormalities and plan contrast, antithrombotic and surgical management; do not delay emergency reperfusion unnecessarily.
06Non-invasive ischaemia or coronary CT assessment in stable disease
Why
Establish obstructive disease and symptom-ischaemia relationship before elective invasive treatment.
Interpretation and limitations
Use the current NICE stable-chest-pain/chronic-coronary pathway; emergency ACS bypasses elective testing.
1
Use clinical features, ECG, troponin and bleeding/renal risk to stratify; instability triggers immediate angiography.
2For clinically stable higher-risk disease, arrange angiography within the NICE-recommended timeframe and decide PCI, CABG or medical management from anatomy.
3Use Heart Team discussion for left-main/complex multivessel anatomy or when trade-offs are uncertain.
4Document DAPT/anticoagulation choice and duration after the selected strategy.
03Third-lineStable disease choiceThird lineAngina despite optimal medical therapy or prognostically important anatomy+
1Confirm symptoms, adherence and ischaemia/anatomy through the NICE stable-angina/chest-pain pathway.
2Discuss continued medical therapy, PCI and CABG in terms of symptom relief, procedural risk, recovery and repeat revascularisation.
3Prefer Heart Team review when left-main or complex multivessel disease, diabetes, low LVEF, frailty or high surgical risk changes the balance.
4Proceed with the agreed strategy and continue lifelong secondary prevention.
04EscalationPost-procedure emergencyEscalationRecurrent ischaemia, bleeding, shock, acute kidney injury or arrhythmia+
1After PCI, obtain ECG and call the interventional team immediately for suspected acute stent thrombosis or vessel closure.
2After CABG, involve the surgical team immediately for bleeding, tamponade, graft failure or low-output state.
3Resuscitate with ABCDE, echo and targeted laboratory assessment; reverse or adjust antithrombotics only through the procedural/bleeding plan.
4After stabilisation, reconcile antithrombotics, renal function, wound/access care, rehabilitation and secondary prevention.