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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Coronary revascularisation: PCI and CABG

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

STEMI, refractory ischaemia, haemodynamic instability or cardiogenic shock requires immediate interventional-cardiology activation; do not delay transfer for non-essential testing.

Synopsis

Choose the urgent or elective revascularisation route, explain PCI versus CABG trade-offs and manage the immediate antithrombotic and follow-up priorities.

  • 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.
  • 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.

Key red flags

STEMI requiring reperfusion

Persistent ST elevation or equivalent with compatible acute ischaemia requires immediate PPCI network activation and a documented symptom/ECG timeline.

Very-high-risk NSTE-ACS

Shock, ongoing/recurrent refractory pain, life-threatening arrhythmia or mechanical complication triggers immediate invasive management.

Acute stent thrombosis

Sudden recurrent ischaemic pain, ST elevation, ventricular arrhythmia or shock after PCI is an emergency requiring immediate cath-lab contact.

Post-CABG deterioration

Rising drain output, hypotension, tamponade physiology, new ischaemia, arrhythmia or low cardiac output requires urgent surgical/critical-care assessment.

Investigation priorities

01
12-lead ECG and serial ECGsFirst step

Define acute ischaemic territory and detect dynamic change or post-procedure occlusion.

Management branches

First-lineSTEMI reperfusion

STEMI within the reperfusion window

  1. Activate the regional primary-PCI pathway immediately and give ACS antithrombotic treatment unless contraindicated.
  2. Offer coronary angiography with primary PCI when this can be delivered within 120 minutes of when fibrinolysis could have been given under NICE NG185.
  3. If timely PPCI is not possible and fibrinolysis is appropriate, give fibrinolysis promptly and transfer through the rescue/routine angiography pharmaco-invasive pathway.
  4. Treat shock or mechanical complication concurrently with critical-care and surgical input.
Third-lineStable disease choice

Angina despite optimal medical therapy or prognostically important anatomy

  1. Confirm symptoms, adherence and ischaemia/anatomy through the NICE stable-angina/chest-pain pathway.
  2. Discuss continued medical therapy, PCI and CABG in terms of symptom relief, procedural risk, recovery and repeat revascularisation.
  3. Prefer Heart Team review when left-main or complex multivessel disease, diabetes, low LVEF, frailty or high surgical risk changes the balance.
  4. Proceed with the agreed strategy and continue lifelong secondary prevention.

Key medicines

AspirinFor 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.
TicagrelorACS: 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.Bleeding, previous intracranial haemorrhage, dyspnoea, bradyarrhythmia and CYP3A interactions; CABG timing requires specialist interruption planning.
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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.

  • NICE NG185: Acute coronary syndromesUK STEMI and NSTE-ACS invasive pathways.
  • NICE CG126: Stable angina managementElective symptom-led PCI/CABG decisions.
  • ESC 2024 Guidelines for chronic coronary syndromesCurrent European anatomy and revascularisation framework.
  • ESC 2023 Guidelines for acute coronary syndromesAcute invasive and shock strategy.
  • Ticagrelor 90 mg tablets SmPCLicensed ACS dose and duration.
  • Clopidogrel 75 mg tablets SmPCLicensed maintenance dosing.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom