Emergency visits after recent percutaneous coronary intervention

Percutaneous coronary intervention (PCI) is now standard treatment for the majority of patients with acute coronary syndromes or limiting stable angina. In 2008, 80,331 procedures were performed in the UK.¹ Most patients are discharged within 24 hours. While there is mandatory collection of data on major inpatient complications following PCI, less is known about symptoms experienced in the early post-discharge period. General practitioners (GPs) and acute physicians will usually undertake the initial assessment of these patients.

We undertook a retrospective analysis of the 30-day outcomes of the first 150 patients undergoing PCI in our new centre between September 2009 and May 2010. Sixty-five per cent of cases were performed electively and 92% of these as day-case procedures. In total, 100% follow-up data were obtained by telephone calls (62.7%), clinic visit (19.3%), postal questionnaires (17.3%), and calls to the GP (0.7%). Any complication was fully investigated with review of the medical records. Major adverse events (myocardial infarction (MI), stroke, revascularisation or all cause mortality) occurred in 2.7%, but only one such event (0.7%) occurred after discharge from cardiology care (ST segment elevation MI (STEMI) in a patient non-compliant with clopidogrel). Within 30 days of discharge, however, 14.7% (22) of patients sought medical help. In the majority, 9.3%, this was due to chest pain (Table 1). All nine of the ‘atypical chest pain’ patients presented between Days 1 and 7. Discharge diagnoses included: ‘atypical-, non-cardiac-, troponin negative-, anxiety or indigestion/palpitations-chest pain’. None had new enzyme release on their readmission or dynamic electrocardiogram (ECG) changes and most were discharged within a day of re-admission.

In this series one in every seven patients sought medical help within 30-days of discharge, suggesting that UK acute physicians or GPs may see more than 10,000 patients per year presenting with symptoms soon after PCI. The majority presented with chest pain but this symptom rarely indicated MI or ischaemia.

The aetiology of the atypical chest pain is unclear. A form of post-PCI syndrome has been previously described. This can range from pain presumed to result from vessel stretch and traumatic wall injury to a true, perhaps autoimmune mediated post-cardiac injury syndrome.² Although post-PCI pain is not associated with adverse early outcomes,³ there is some suggestion that those patients experiencing post-PCI pain are a cohort at higher risk of restenosis.⁴

The acute physician must be aware that the most important early complication of PCI is acute stent thrombosis. This presents in dramatic fashion with severe chest pain and ECG changes but is uncommon (incidence of 0.5-1.0% per annum).⁴ Such patients, at high risk of mortality or significant morbidity, need immediate attention from an interventional cardiologist. By contrast the majority of chest pain readmissions soon after PCI are benign and easily diagnosed by clinical assessment and the lack of major ECG abnormality. The symptoms respond to simple analgesia, and further investigation is usually unnecessary.

• © 2011 Royal College of Physicians