ð åèç
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è â Indications
- STEMI (emergent primary PCI within 90 min door-to-balloon)
- NSTEMI / Unstable Angina (within 24-72 hr typically; high-risk within 24 hr)
- Refractory or progressive angina
- Positive stress test
- HF etiology workup
- Pulmonary HTN (RHC required for PAH diagnosis)
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è â Coronary Anatomy
- LM bifurcates to LAD + LCx
- LAD: anterior wall + septum (âwidow makerâ if proximal)
- LCx: lateral wall
- RCA: RV + inferior wall + PDA (in 80% right dominant)
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è â Functional Assessment
- FFR < 0.80 = ischemia-causing (PCI)
- iFR < 0.89 = ischemia-causing
- FAME trial: FFR-guided PCI improves outcomes
- iFR-SWEDEHEART: iFR non-inferior to FFR (no adenosine needed)
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è â Radial vs Femoral
- Radial preferred 2024 (less bleeding + complications)
- Femoral for complex / structural interventions
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è â Stent Types
- DES (drug-eluting stent) = current standard
- DAPT (aspirin + P2Y12 inhibitor) post-DES typically 6-12 months
- DCB (drug-coated balloon) for in-stent restenosis
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è â DAPT Duration
- Standard post-DES: 6-12 months
- ACS post-PCI: 12 months
- High bleeding risk: 1-3 months then aspirin alone
- High ischemic risk: prolonged (12-36 months)
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è â CABG vs PCI
- SYNTAX score guides
- Left main + complex: CABG preferred
- Multi-vessel + high SYNTAX: CABG preferred
- Diabetic + multi-vessel: CABG (FREEDOM)
- Single-vessel + uncomplicated: PCI
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è â Complications
- Bleeding (most common; especially femoral)
- Contrast nephropathy (CKD + DM + elderly + contrast volume)
- Stroke (~ 0.1-0.5%)
- MI / stent thrombosis (DAPT non-compliance major risk)
- Aortic dissection (rare but serious)
- Cardiac tamponade (coronary perforation)
- Death ~ 0.1% elective; higher emergent
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è â PAH Hemodynamic Criteria
- Mean PA ⥠25 mmHg at rest (2018; some recent ⥠20)
- PAWP †15 mmHg
- PVR > 3 Wood units
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è â Constrictive vs Restrictive Hemodynamics
- Constrictive: equalization of diastolic pressures + discordance LV/RV systolic with respiration
- Restrictive: LV diastolic > RV diastolic + concordance