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Background: Coronary artery dissection is managed primarily conservatively with serial imaging or percutaneous coronary intervention (PCI). Exposure to contrast in either modality could potentially result in acute tubular necrosis (ATN). However, no data compares ATN incidence in these management strategies. This study compares the incidence of ATN and associated mortality of PCI and conservative management of coronary artery dissection., Methods: A retrospective analysis was performed using data from the National Inpatient Sample database, including patients with coronary artery dissection between 2016 through 2020. We analyzed the incidence of ATN and associated mortality of PCI and conservative management of coronary artery dissection., Results: We found that the odds of developing ATN were 22% lower in patients managed with PCI than those managed conservatively. There was no difference in the in-hospital mortality or hospital length of stay between the two groups but the mortality rate in patients with ATN was double that of those who did not develop ATN in both PCI and conservatively managed groups., Conclusions: The higher incidents of ATN in patients with coronary dissection being managed with conservative measures compared to PCI suggest that the use of CTA may be harmful. Additionally, persons who developed ATN may have higher mortality. Therefore, more studies in the management of coronary artery dissection need to be done which would allow further steps to be taken to reduce this harm., Competing Interests: Declaration of competing interest No disclosures/conflicts of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Aim: To evaluate outcomes after percutaneous coronary intervention (PCI) in patients with cancer and atrial fibrillation (AF)., Methods: Data of all adult discharges undergoing PCI between October 2015 and December 2018 were obtained from the National Inpatient Sample (NIS) database. Adjusted odds ratios (aOR) of adverse complications were calculated using binominal logistic regression., Results: 1387320 patients were detected, out of which 15.4% had AF but no cancer, 1.9% had cancer but no AF, and 0.6% had both cancer and AF. Compared with cancer patients without AF, those with AF had a greater aOR of mortality (aOR 1.20, 95%CI 1.08-1.33), major adverse cardiac and cerebrovascular events (MACCE) (aOR 1.18, 95%CI 1.07-1.29), and bleeding (aOR 1.23, 95%CI 1.08-1.39). However, the risk of ischemic stroke was similar between the two groups. Patients with solid cancer and AF had a higher aOR for all outcomes, including mortality (aOR 1.28, 95%CI 1.09-1.50), MACCE (aOR 1.37, 95%CI 1.19-1.57), ischemic stroke (aOR 1.48, 95%CI 1.10-1.99), and bleeding (aOR 1.66, 95%CI 1.39-1.98) compared with the solid cancer group without AF. In patients with hematological cancer, AF was associated only with significantly increased risk of mortality (aOR 1.40, 95%CI 1.16-1.70) and MACCE (aOR 1.26, 95%CI 1.06-1.49)., Conclusions: The presence of AF in solid cancer patients increases the risk of mortality, MACCE, stroke, and major bleeding, while in the setting of hematological cancer it is only associated with a higher risk of mortality and MACCE.

Background: Glycated Albumin (GA) and atherogenic index of plasma (AIP) are two important biomarkers that respectively reflect lipid and glucose levels. Previous research has revealed their roles in cardiovascular diseases (CVD) and diabetes. However, their combined predictive ability in forecasting cardiovascular events (CVE) after percutaneous coronary intervention (PCI) among postmenopausal acute coronary syndrome (ACS) patients remains insufficiently studied., Methods: Based on the levels of AIP (AIP-L and AIP-H) and GA (GA-L and GA-H), four groups were used to categorize the patients. The CVE assessed included cardiac death, nonfatal myocardial infarction (MI) and nonfatal stroke. To evaluate the relationship between AIP, GA, and CVE, multivariate Cox regression analyses were performed., Results: 98 patients (7.5%) experienced CVE during follow-up. AIP and GA were revealed as strong independent predictors of CVE through multivariate analysis (AIP: HR 3.324, 95%CI 1.732-6.365, P = 0.004; GA: HR 1.098, 95% CI 1.023-1.177, P = 0.009). In comparison to those in the initial group (AIP-L and GA-L), the fourth group (AIP-H and GA-H) of patients exhibited the greatest CVE risk (HR 2.929, 95% CI 1.206-5.117, P = 0.018). Derived from the model of baseline risk, the combination of AIP + GA significantly enhanced the AUC, meanwhile combining AIP and GA levels maximized prognostic accuracy in the baseline risk model., Conclusions: This study found that the combined measurement of AIP and GA significantly enhanced the predictive capability for CVE following PCI in postmenopausal ACS patients. By integrating these two biomarkers, it became possible to more accurately identify high-risk individuals and provided clinicians with new predictive tools for postmenopausal ACS patients in risk assessment and management., (© 2024. The Author(s).)

Background: Cardiogenic shock (CS) occurs in 5-10% of patients with acute myocardial infarction (AMI), and the condition is associated with a 30-day mortality rate of up to 50%. Most of the AMI patients are in SCAI SHOCK stage B upon hospital arrival, but some of these patients will progression through the stages to overt shock (SCAI C-E). Around one third of patients who develop CS are not in shock at the time of hospital admission. Pro-B-type natriuretic peptide (proband) is a biomarker closely related to CS development. The aim of this study is to investigate the potential for preventing progression of hemodynamic instability by early inotropic support with low-dose dobutamine infusion administrated after revascularization in AMI patients with intermediate to high risk of in-hospital CS development., Methods: This investigator-initiated, double-blinded, placebo-controlled, randomized, single-center, clinical trial will include 100 AMI patients (≥ 18 years) without CS at hospital admission and at intermediate-high risk of in-hospital CS development (ORBI risk score ≥ 10). Patients will be randomized in a 1:1 ratio to a 24 h intravenous (IV) infusion of dobutamine (5 μg/kg/min) or placebo (NaCl) administrated after acute percutaneous coronary intervention (PCI) (< 24 h from symptom onset). Blood samples are drawn at time points from study inclusion (before infusion, 12, 24, 36, and 48 h). The primary outcome is peak plasma proBNP within 48 h after infusion as a surrogate-measure for the hemodynamic status. Hemodynamic function will be assessed pulse rate, blood pressure, and lactate within 48 h after infusion and by transthoracic echocardiography (TTE) performed after 24-48 h and at follow-up after 3 months. Markers of cardiac injury (troponin T and creatine kinase MB (CK-MB)) will be assessed., Discussion: Early inotropic support with low-dose dobutamine infusion in patients with AMI, treated with acute PCI, and at intermediate-high risk of in-hospital CS may serve as an intervention promoting hemodynamic stability and facilitating patient recovery. The effect will be assessed using proBNP as a surrogate marker of CS development, hemodynamic measurements, and TTE within the initial 48 h and repeated at a 3-month follow-up., Trial Registration: The Regional Ethics Committee : H-21045751. EudraCT: 2021-002028-19., Clinicaltrials: gov: NCT05350592, Registration date: 2022-03-08. WHO Universal Trial Number: U1111-1277-8523., (© 2024. The Author(s).)

Background: Acute coronary syndrome (ACS) remains one of the leading causes of death worldwide. Smoking may also increase the risk of developing ACS. The most advantageous therapy is percutaneous coronary intervention. However, this therapy may fail because of the no-reflow phenomenon. This case report describes a young male patient admitted to the emergency department due to ST-segment elevation of myocardial infarction (STEMI), with smoking as the only risk factor., Case Description: A 37-year-old male presented to our hospital with a typical chest pain. He was a heavy smoker. Electrocardiography (ECG) revealed extensive anterior STEMI. Coronary angiography revealed total occlusion of the proximal left anterior descending artery (LAD) with a high-burden thrombus. The no-reflow phenomenon occurs during Percutaneous Coronary intervention (PCI). After two days of hospitalization, the patient developed cardiogenic shock and acute decompensated heart failure. The patient was administered ticagrelor, acetylsalicylic acid, enoxaparin for three days, high-dose statins, and optimized heart failure treatment. The patient was discharged on the 7th day after admission., Discussion: Cigarette smoke chemicals may induce atherosclerosis and thickened blood in the arteries. Lipid oxidation leads to plaque formation. If plaque ruptures, it will cause thrombus occlusion. A high-burden thrombus can induce a no-reflow phenomenon, leading to heart failure and cardiogenic shock., Conclusion: Smoking may induce STEMI and tends to result in a high-burden thrombus. The no-reflow phenomenon is an evidence of miscarriage during PCI, which may increase because of smoking., Competing Interests: No competing interests were disclosed., (Copyright: © 2024 Pintaningrum Y et al.)

Background: The CTO-ARC (Chronic Total Occlusion Academic Research Consortium) recognized that a nonstandardized definition of chronic total occlusion (CTO) percutaneous coronary intervention approaches can bias the complications' attribution to each crossing strategy., Objectives: The study sought to describe the numbers, efficacy, and safety of each final CTO crossing strategy according to CTO-ARC recommendations., Methods: In this cross-sectional study, data were retrieved from the European Registry of Chronic Total Occlusions between 2021 and 2022., Results: Out of 8,673 patients, antegrade and retrograde approach were performed in 79.2% and 20.8% of cases, respectively. The antegrade approach included antegrade wiring and antegrade dissection and re-entry, both performed with or without retrograde contribution (antegrade wiring without retrograde contribution: n = 5,929 [68.4%]; antegrade wiring with retrograde contribution: n = 446 [5.1%]; antegrade dissection and re-entry without retrograde contribution: n = 353 [4.1%]; antegrade dissection and re-entry with retrograde contribution: n = 137 [1.6%]). The retrograde approach included retrograde wiring (n = 735 [8.4%]) and retrograde dissection and re-entry (n = 1,073 [12.4%]). Alternative antegrade crossing was associated with lower technical success (70% vs 86% vs 93.1%, respectively; P < 0.001) and higher complication rates (4.6% vs 2.9% vs 1%, respectively; P < 0.001) as compared with retrograde and true antegrade crossing. However, alternative antegrade crossing was applied mostly as a rescue strategy (96.1%)., Conclusions: The application of CTO-ARC definitions allowed the reclassification of 6.7% of procedures as alternative antegrade crossing with retrograde or antegrade contribution which showed higher MACCE and lower technical success rates, as compared with true antegrade and retrograde crossing., Competing Interests: Funding Support and Author Disclosures Dr Bufe has received speaker honoraria from Biotronik and Shockwave Medical. Dr Pyxaras has received consulting/speaker/proctorship honoraria from Abiomed, AstraZeneca, Asahi Intecc, Biotronik, Boston Scientific, and Terumo. Dr Ladwiniec has received consulting/speaker/proctoring honoraria from Abbott, Biotronik, Boston Scientific, Cordis, Shockwave Medical, and SMT. Dr Werner has received speaker honoraria from Abbott, Asahi Intecc, OrbusNeich, Philips, Siemens, and Terumo. Dr Mashayekhi has received consulting/speaker/proctoring honoraria from Abbott, Abiomed, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic, OrbusNeich, Shockwave Medical, Teleflex, and Terumo. Dr Ayoub has received consultant/proctor honoraria from Boston Scientific, Teleflex, Asahi Intecc, Cordis, Terumo, and SIS Medical. Dr Goktekin has received consulting/speaker/proctoring honoraria from Boston Scientific, Medtronik, MicroPort, and Asahi Inc. Dr Agostoni has received consulting honoraria from Abbott, Boston Scientific, Cordis, iVascular, Medtronic, Neovasc, Seven Sons, Teleflex, and Terumo. Dr Diletti has received consultant/proctoring honoraria from Asahi Intecc, Terumo, IMDS, Boston Scientific, Teleflex, and Philips. Dr Rathore has received honoraria for speaker and proctoring from Abbott Vascular and Translumina Therapeutics. Dr Bozinovic has served as a speaker or proctor and/or received honoraria from Orbus Neich and Medtronic. Dr Galassi has received consulting/speaker honoraria from Asahi Intecc and Ivascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Dissection and re-entry techniques are essential to achieve safe and effective chronic total occlusion recanalization. Several studies have demonstrated similar outcomes following extraplaque stenting compared with intraplaque stenting. Dissection techniques most often involve the use of knuckled wires to progress within and beyond the chronic total occlusion segment. In this expert consensus document, the authors compare the properties of different polymer-jacketed wires for their use in dissection techniques. The authors also describe 2 principal knuckle wire behaviors, the rolling and the traveling knuckles. Finally, several adjunctive techniques for safer dissection are described., Competing Interests: Funding Support and Author Disclosures Dr Rinfret has received consulting, speaker, and proctoring honoraria from Abiomed, Boston Scientific, Medtronic, and Teleflex. Dr Khatri has received consulting, speaker, and proctoring honoraria from Abbott, Medtronic, Terumo, Boston Scientific, and Shockwave Medical. Dr Mashayekhi has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Abiomed, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic, OrbusNeich, Shockwave Medical, Teleflex, and Terumo. Dr Alaswad has received consulting, speaker, and proctoring honoraria from Boston Scientific and Teleflex. Dr Azzalini has received consulting fees from Teleflex, Abiomed, GE Healthcare, Abbott Vascular, Reflow Medical, and Cardiovascular Systems; serves on the advisory boards of Abiomed and GE Healthcare; and owns equity in Reflow Medical. Dr Vijayaraghavan has received consulting and proctoring fees from Acist, Abbott, Asahi Intecc, Medtronic, and Biotronik. Dr Frizzell has received consulting and speaker honoraria from Asahi Intecc, Boston Scientific, Medtronic, Reflow Medical, and Shockwave Medical. Dr Avran has received consulting, speaker, and proctoring honoraria from Abbott Vascular, Asahi Intecc, Biotronik, Boston Scientific, Medtronic, Shockwave Medical, Teleflex, and Terumo. Dr McEntegart has received consulting, speaker, and proctoring honoraria from Boston Scientific and Shockwave Medical. Dr Lombardi has received consulting fees from Asahi Intecc, Abiomed, Boston Scientific, Medtronic, Siemens, and Teleflex and has received royalties from Asahi Intecc; his spouse is a Philips employee. Dr Grantham has received speaking fees and honoraria from Boston Scientific, Medtronic, and Asahi Intecc; has received advisory board fees from Teleflex and Boston Scientific; and has received institutional research grants from Asahi Intecc, Abiomed, and Boston Scientific. Dr Brilakis has received consulting and speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, the Cardiovascular Innovations Foundation (Board of Directors), Cardiovascular Systems, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, Teleflex, and Terumo; has received research support from Boston Scientific and GE Healthcare; is the owner or Hippocrates; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Type-D personality is an established predisposing factor for various diseases. Type-D traits have been shown to pose a 26% increased risk of coronary artery disease after controlling for other confounding factors. Significant associations have been reported between type-D personality traits and dyslipidaemia, impaired endothelial function, coronary heart disease (CAD), acute myocardial infarction, and other adverse cardiovascular events., Objective: To assess the association between type-D personality and left-ventricular adverse remodelling in patients treated with percutaneous coronary intervention following index ST-segment elevation myocardial infarction., Methods: All patients hospitalized and treated with percutaneous coronary intervention (PCI) after their index ST-segment elevation myocardial infarction (STEMI) between 1 January 2022 to 31 December 2023 were prospectively enrolled. Type-D personality traits in the study population were determined at baseline using type-D Scale-14 (DS14) instrument, whereas any positive change in left ventricular end diastolic volume (LVEDV) ≥ 20% at follow up period of 12-months from baseline was defined as left-ventricular adverse remodelling (LVAR). Univariate and multivariate analysis was done to establish the independent predictors of LVAR. The area under receiver-operating characteristic curve (AUROC) was employed to assess the sensitivity and specificity of the identified independent predictors., Results: A total of 124 patients were enrolled in the study. The mean age of the study population was 67 ± 10 years and the overall incidence of LVAR was found to be 25%. Multivariate regression analysis revealed that type-D personality is a significant independent predictor of LVAR [Formula: see text] apart from the already established independent predictors Killip Class[Formula: see text], baseline Global Longitudinal strain (GLS)[Formula: see text], and 3-vessel CAD[Formula: see text]. In ROC curve analysis type-D personality as an independent predictor of LVAR achieved a sensitivity of 41.4% and a specificity of 87.1%, p < 0.02., Conclusion: Type-D personality trait is a significant independent predictor of LVAR in patients treated with PCI after their index-STEMI., (© 2024. The Author(s).)

Background: Coronary angioscopy (CAS) has 2 unique abilities: direct visualization of thrombi and plaque color. However, in the recent drug-eluting stent (DES) era, serial CAS findings after DES implantation have not been fully elucidated. We investigated the impact of CAS findings after implantation of a polymer-free biolimus A9-coated stent (PF-BCS) or durable polymer everolimus-eluting stent (DP-EES)., Methods and Results: We investigated serial CAS and optical coherence tomography (OCT) findings at 1 and 12 months in 99 patients who underwent PF-BCS or DP-EES implantation. We evaluated factors correlated with angioscopic thrombi and yellow plaque, and the clinical impact of both thrombi and yellow plaque at 12 months (BTY). The BTY group included 17 (22%) patients. The incidence and grade of thrombi and yellow plaque decreased from 1 to 12 months. Although no patients had newly appearing thrombi at 12 months, 2 DP-EES patients had newly appearing yellow plaque at 12 months. Multivariable analysis revealed HbA1c, minimum stent area, and adequate strut coverage were significant factors correlated with 12-month angioscopic thrombi, and DP-EESs were significantly correlated with 12-month yellow plaque. However, BTY was not correlated with clinical events., Conclusions: The management of diabetes, stent area, and adequate stent coverage are important for intrastent thrombogenicity and polymer-free stents are useful for stabilizing plaque vulnerability.

Background: Low-dose prasugrel (3.75 mg) is used as maintenance therapy for percutaneous coronary intervention; however, data on long-term outcomes are scarce., Methods and Results: We analyzed 5,392 participants in the KiCS-PCI registry who were administered low-dose prasugrel or clopidogrel at discharge between 2008 and 2018 and for whom 2-year follow-up data were available. We adjusted for confounders using matching weight analyses and multiple imputations. Similarly, we used inverse probability- and propensity score-weighted analyses. We also performed instrumental variable analyses. The primary outcomes were acute coronary syndrome (ACS) and bleeding requiring readmission. Secondary outcomes were all-cause death and a composite outcome of ACS, bleeding, heart failure, stroke, coronary bypass requiring admission, and all-cause death. In this cohort, 12.2% of patients were discharged with low-dose prasugrel. Compared with clopidogrel, low-dose prasugrel was associated with a reduced risk of ACS (hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.39-0.85), bleeding (HR 0.62; 95% CI 0.40-0.97), and the composite outcome (HR 0.71; 95% CI 0.59-0.86). Inverse probability-weighted analysis yielded similar results; however, matching weight analysis without multiple imputations and propensity score-matched analyses showed similar outcomes in both groups. Instrumental variable analyses showed reduced risks of ACS and composite outcome for those on low-dose prasugrel. All-cause mortality did not differ in all analyses., Conclusions: Low-dose prasugrel demonstrates comparable outcomes to clopidogrel in terms of ACS and bleeding.

Background: Because apolipoprotein-A2 (ApoA2), a key component of high-density lipoprotein cholesterol (HDL-C), lacks clear clinical significance, we investigated its impact on cardiovascular events in patients undergoing percutaneous coronary intervention (PCI)., Methods and Results: We examined 638 patients who underwent PCI with a new-generation drug-eluting stent for acute or chronic coronary syndrome and had their apolipoprotein levels measured between 2016 and 2021. The patients were divided into 2 groups based on the median serum ApoA2 values, and the incidence of major adverse cardiovascular events (MACE) was assessed. Of the 638 patients, 563 (88%) received statin treatment, with a median serum LDL-C level of 93 mg/dL. Furthermore, 137 patients (21.5%) experienced MACE, and Kaplan-Meier analysis revealed that the higher ApoA2 group had a significantly lower incidence of MACE than the lower ApoA2 group (30.9% vs. 41.6%). However, the other apolipoproteins, including ApoA1, ApoB, ApoC2, ApoC3, and ApoE, showed no significant differences in MACE. Multivariable Cox hazard analysis indicated that ApoA2 was an independent predictor of MACEs (hazard ratio, 0.666; 95% confidence interval, 0.465-0.954). Furthermore, ApoA2 levels exhibited the strongest inverse association with high-sensitivity C-reactive protein levels (r s =-0.479)., Conclusions: Among all the apolipoproteins, the serum ApoA2 level may be the strongest predictor of future cardiovascular events and prognosis in patients undergoing PCI.

Background: Proton pump inhibitors (PPIs) reportedly reduce upper gastrointestinal bleeding (UGIB) in patients undergoing percutaneous coronary intervention (PCI). However, whether the benefits of PPIs differ in high-risk subgroups is unknown., Methods and Results: Among 24,563 patients undergoing first PCI in the CREDO-Kyoto registry Cohort-2 and -3, we evaluated long-term effects of PPI for UGIB, defined as GUSTO moderate/severe bleeding, in several potential high-risk subgroups. In the study population, 45.6% of patients were prescribed PPIs. Over a median 5.6-year follow-up, PPIs were associated with lower adjusted risk of UGIB (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.50-0.80; P<0.001) and a non-significant but numerically lower risk of any gastrointestinal bleeding (HR 0.84; 95% CI 0.71-1.01; P=0.06). PPIs were not associated with a lower risk of GUSTO moderate/severe bleeding (HR 1.04; 95% CI 0.94-1.15; P=0.40) or a higher adjusted risk of myocardial infarction or ischemic stroke (HR 1.00; 95% CI 0.90-1.12; P=0.97), but were associated with higher adjusted mortality risk (HR 1.18; 95% CI 1.09-1.27; P<0.001). The effects of PPIs for UGIB, myocardial infarction or ischemic stroke, and all-cause death were consistent regardless of age, sex, acute coronary syndrome, high bleeding risk, oral anticoagulant use, and type of P2Y 12 inhibitor., Conclusions: PPIs were associated with a lower risk of UGIB and a neutral risk of ischemic events regardless of high-risk subgroup.

Background: Few studies have investigated the potential predictive value of glycosylated hemoglobin A (HbA1c) and clinical outcomes in diabetic patients after percutaneous coronary intervention (PCI), and the results of the reports have often been inconclusive and contradictory. We have organized a study to investigate the relationship between HbA1c and the occurrence of major adverse cardiovascular events (MACE) in diabetic patients after PCI., Methods: This case-cohort study was conducted on 563 diabetic patients who underwent PCI. All studied patients had an HbA1c level measured within 24 h before angioplasty. All patients were followed for six months regarding the occurrence of MACE, and the HbA1c level was measured again at the end of the sixth month of follow-up. In the case of MACE, the subjects were considered the case group, and other non-MACE patients were included in the control group., Results: 505 patients remained in the study at the end of follow-up. MACE occurred in 23 (4.6%) patients during the first month and in 57 (11.3%) patients by the end of the sixth month. Baseline HbA1c was an independent predictor of MACE and mortality at the end of month-6 (P = 0.008 and 0.001, respectively)., Conclusions: The level of HbA1c at the time of admission has a significant predictive value for the occurrence of MACE in diabetic patients who undergo PCI. However, post-PCI glycemic control may not effectively reduce the risk of MACE in this population., Clinical Trial Registration: Not applicable., (© 2024. The Author(s).)

Background: Liver dysfunction is a known risk factor in the cardiovascular field. It specifically increases perioperative risk in patients undergoing coronary bypass surgery. Since percutaneous coronary intervention (PCI) is the much less invasive procedure for the treatment of coronary artery disease, we aimed to assess the relationship of liver dysfunction with outcomes in patients undergoing PCI., Methods: Three libraries were searched (MEDLINE, Web of Science and The Cochrane Library). We performed a meta-analysis of all studies in patients who underwent PCI that provided information on the presence or absence of liver dysfunction. Primary outcome was short-term mortality. Secondary outcomes were major adverse cardio- and cerebrovascular events (MACCE), bleeding and acute kidney injury. Random-effects model was applied., Results: Five studies were selected and the data from 10,710,317 patients were included in the final analysis. In comparison with the absence of liver dysfunction, patients with liver dysfunction were associated with higher short-term mortality (OR 2.97, 95%CI 1.23-7.18, p = 0.02), higher MACCE (OR 1.42, 95%CI 1.08-1.87, p = 0.01), and higher bleeding (OR 2.23, 95%CI 1.65-3.00, p < 0.01). There was no significant difference regarding acute kidney injury (OR 1.20, 95%CI 0.50-2.87, p = 0.69)., Conclusions: The analysis suggests that liver dysfunction in patients undergoing PCI is independently associated with higher risk of short-term mortality and increased occurrence of MACCE and bleeding. However, there appears to be no association to acute kidney injury., (© 2024. The Author(s).)

Cardiogenic shock (CS) is a devastating and fatal complication of acute myocardial infarction (AMI). CS can affect the pharmacokinetics and pharmacodynamics of medications. The unique properties of cangrelor make it the optimal P2Y12 inhibitor for CS-AMI, in terms of both efficacy and safety. The DAPT-SHOCK-AMI trial (ClinicalTrials.gov: NCT03551964; EudraCT: 2018-002161-19) will assess the benefits of cangrelor in patients with an initial CS-AMI undergoing primary angioplasty. This randomised, multicentre, placebo-controlled trial of approximately 550 patients (with an allowed 10% increase) in 5 countries using a double-blind design will compare initial P2Y12 inhibitor treatment strategies in patients with CS-AMI of (A) intravenous cangrelor and (B) ticagrelor administered as crushed tablets at a loading dose of 180 mg. The primary clinical endpoint is a composite of all-cause death, myocardial infarction (MI), or stroke within 30 days. The main secondary endpoints are (1) the net clinical endpoint, defined as death, MI, urgent revascularisation of the infarct-related artery, stroke, or major bleeding as defined by the Bleeding Academic Research Consortium criteria; (2) cardiovascular-related death, MI, urgent revascularisation, or heart failure; (3) heart failure; and (4) cardiovascular-related death, all (1-4) within 1 year after study enrolment. A platelet reactivity study that tests the laboratory antiplatelet benefits of cangrelor, when given in addition to standard antiplatelet therapy, will be conducted using vasodilator-stimulated phosphoprotein phosphorylation. The primary laboratory endpoints are the periprocedural rate of onset and the proportion of patients who achieve effective P2Y12 inhibition. The DAPT-SHOCK-AMI study is the first randomised trial to evaluate the benefits of cangrelor in patients with CS-AMI.

Background: Whether revascularisation (REV) improves outcomes in patients with three-vessel coronary artery disease (3V-CAD) is uncertain., Aims: Our objective was to evaluate outcomes with REV (percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) versus medical therapy in patients with 3V-CAD., Methods: ISCHEMIA participants with 3V-CAD on coronary computed tomography angiography without prior CABG were included. Outcomes following initial invasive management (INV) with REV (PCI or CABG) versus initial conservative management (CON) with medical therapy alone were evaluated. Regression modelling was used to estimate the outcomes if all participants were to undergo prompt REV versus those assigned to CON. Outcomes were cardiovascular (CV) death/myocardial infarction (MI), death, CV death, and quality of life. Bayesian posterior probability for benefit (Pr [benefit]) for 1 percentage point lower 4-year rates with REV versus CON were evaluated., Results: Among 1,236 participants with 3V-CAD (612 INV/624 CON), REV was associated with lower 4-year CV death/MI (adjusted 4-year difference: -4.4, 95% credible interval [CrI] -8.7 to -0.3 percentage points, Pr [benefit]=94.8%) when compared with CON, with similar results for PCI versus CON (-5.8, 95% CrI: -10.8 to -0.5 percentage points, Pr [benefit]=96.4%) and CABG versus CON (-3.7, 95% CrI: -8.8 to 1.5 percentage points, Pr [benefit]=84.7%). Adjusted 4-year REV versus CON differences were as follows: death -1.2 (95% CrI: -4.7 to 2.2) percentage points, CV death -2.3 (95% CrI: -5.5 to 0.8) percentage points, with similar results for PCI and for CABG. The Pr (benefit) for death with REV (PCI or CABG) versus CON was 49-63%. The adjusted 12-month Seattle Angina Questionnaire-7 summary score differences favoured REV: REV versus CON 4.6 (95% CrI: 2.7-6.4) percentage points; PCI versus CON 3.6 (95% CrI: 1.2-5.8) percentage points and CABG versus CON 4.3 (95% CrI: 1.5-6.9) percentage points with high Pr (benefit)., Conclusions: In participants with 3V-CAD, REV (either PCI or CABG) was associated with a lower 4-year CV death/MI rate and improved quality of life, with similar results for PCI versus CON and CABG versus CON. The differences in all-cause mortality between REV and CON were small with wide confidence intervals. (ClinicalTrials.gov: NCT01471522).

BACKGROUND Recently, the albumin-to-creatinine ratio (ACR) has been suggested as a valuable biomarker for adverse events in acute myocardial infarction. However, the prognostic value of ACR in very elderly patients (≥80 years) with non-ST-elevation acute coronary syndrome (NSTE-ACS) after percutaneous coronary intervention (PCI) remains unclear. MATERIAL AND METHODS A total of 354 very elderly patients with NSTE-ACS who underwent PCI were included in this study and followed up for 1 year. Patients were divided into 3 groups according to ACR tertiles. Logistic regression analysis proportional hazard model was used to determine the prognostic value of ACR. RESULTS Sixty-two patients (17.5%) with 114 major adverse cardiovascular and cerebrovascular events (MACCEs) were recorded during 1-year follow-up. Patients with lower ACR tended to be older and had a lower serum albumin level and higher uric acid and creatinine levels (P<0.05). Moreover, patients with lower ACR levels had elevated all-cause mortality and MACCEs. Kaplan-Meier analysis suggested that patients with a lower ACR had a significantly lower survival rate free of all-cause mortality and MACCEs. Multivariable logistic regression analysis demonstrated that ACR was an independent predictor of all-cause mortality in these patients. ROC analysis showed that when ACR was ≤42.8, sensitivity and specificity were 75.2% and 80.2%, respectively, and the area under the ROC curve was 0.802 (95% CI: 0.745-0.859; P<0.001). CONCLUSIONS A lower ACR was associated with a higher incidence of all-cause mortality in very elderly patients with NSTE-ACS after PCI. The ACR is a promising indicator for risk stratification and prognostic assessment in these individuals.

Background: The utilization of postdilatation in primary percutaneous coronary intervention (PCI) is feared to induce suboptimal coronary blood flow and compromise the outcome of the patients. This meta-analysis sought to verify whether postdilatation during primary PCI is associated with worse angiographic or long-term clinical outcomes., Methods: Systematic literature searches were conducted on PubMed, The Cochrane Library, ClinicalTrials.gov, EBSCO, and Europe PMC on 10 March 2024. Eligible studies reporting the outcomes of postdilatation among ST-segment elevation myocardial infarction patients were included. The primary outcome was no-reflow condition during primary PCI based on angiographic finding. The secondary clinical outcome was major adverse cardiovascular events (MACEs) comprising all-cause death, myocardial infarction, target vessel revascularization (TVR), and stent thrombosis., Results: Ten studies were finally included in this meta-analysis encompassing 3280 patients, which was predominantly male (76.6%). Postdilatation was performed in 40.7% cases. Postdilatation was associated with increased risk of no-reflow during primary PCI [Odd Ratio (OR) = 1.33, 95% Confidence Interval (CI): 1.12-1.58; P = .001)]. Conversely, postdilatation had a tendency to reduce MACE (OR = 0.70, 95% CI: 0.51-0.97; P = .03) specifically in terms of TVR (OR = 0.41, 95% CI: 0.22-0.74; P = .003). No significant differences between both groups in relation to mortality (OR = 0.58, 95% CI: 0.32-1.05; P = .07) and myocardial infarction (OR = 1.5, 95% CI: 0.78-2.89; P = .22)., Conclusions: Postdilatation after stent deployment during primary PCI appears to be associated with an increased risk of no-reflow phenomenon after the procedure. Nevertheless, postdilatation strategy has demonstrated a significant reduction in MACE over the course of long-term follow-up. Specifically, postdilatation significantly decreased the occurrence of TVR. Key messages: What is already known on this topic?  Optimizing stent deployment by performing postdilatation during percutaneous coronary intervention (PCI) is essential for long-term clinical outcomes. However, its application during primary PCI is controversial due to the fact that it may provoke distal embolization and worsen coronary blood flow. What this study adds?  In this systematic review and meta-analysis of 10 studies, we confirm that postdilatation during primary PCI is associated with worse coronary blood flow immediately following the procedure. On the contrary, this intervention proves advantageous in improving long-term clinical outcomes, particularly in reducing target vessel revascularization. How this study might affect research, practice, or policy?  Given the mixed impact of postdilatation during primary PCI, this strategy should only be applied selectively. Future research should focus on identifying patients who may benefit from such strategy., (© The Author(s) 2024. Published by Oxford University Press on behalf of Fellowship of Postgraduate Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Percutaneous coronary intervention (PCI) combined with stent implantation is currently one of the most effective treatments for coronary artery disease (CAD). However, in-stent restenosis (ISR) significantly compromises its long-term efficacy. Mitophagy plays a crucial role in vascular homeostasis, yet its role in ISR remains unclear. This study aims to identify mitophagy-related biomarkers for ISR and explore their underlying molecular mechanisms. Through differential gene expression analysis between ISR and Control samples in the combined dataset, 169 differentially expressed genes (DEGs) were identified. Twenty-three differentially expressed mitophagy-related genes (DEMRGs) were identified by intersecting with mitophagy-related genes (MRGs) from the GeneCards, and functional enrichment analysis indicated their significant involvement in mitophagy-related biological processes. Using Weighted Gene Co-expression Network Analysis (WGCNA) and three machine learning algorithms (Logistic-LASSO, RF, and SVM-RFE), LRRK2, and ANKRD13A were identified as mitophagy-related biomarkers for ISR. The nomogram based on these two genes also exhibited promising diagnostic performance for ISR. Gene Set Enrichment Analysis (GSEA) as well as immune infiltration analyses showed that these two genes were closely associated with immune and inflammatory responses in ISR. Furthermore, potential small molecule compounds with therapeutic implications for ISR were predicted using the connectivity Map (cMAP) database. This study systematically investigated mitophagy-related biomarkers for ISR and their potential biological functions, providing new insights into early diagnosis and precision treatment strategies for ISR., (© 2024. The Author(s).)

Background: A history of hypertensive disorders of pregnancy is associated with at least twice the risk of incident ischemic heart disease. Whether the long-term outcome following treatment with coronary artery stenting is associated to the history of hypertensive disorders of pregnancy is unknown., Methods and Results: We included 8364 women (age ≤65 years) undergoing first coronary artery stenting 2006 to 2022 following their first delivery in 1973 or later, linking nationwide data on percutaneous coronary intervention and delivery history. In total, 1122 women (13.4%) had a history of hypertensive disorders of pregnancy. The main outcome, a major adverse cardiovascular event, was defined as any incident myocardial infarction, ischemic heart disease, cardiac arrest, arrhythmias, angina pectoris, heart failure, cerebral infarction, or sudden death. During a median follow-up time of 5 years, 258 women with a history of hypertensive disorders of pregnancy had a major adverse cardiovascular event, compared with 1465 women without a history of hypertensive disorders of pregnancy (23% versus 20.2%, P =0.028 for log-rank test). Estimates adjusted for patient- and procedural characteristics in proportional hazards regression models suggested that the hazard rate increased only after 4-8 years of follow-up (hazard ratio [HR], 1.36 [95% CI, 1.05-1.78]) and was primarily driven by women with history of gestational hypertension (HR, 2.15 [95% CI, 1.49-3.11])., Conclusions: Women with a history of hypertensive disorders of pregnancy have an increased risk of a major adverse cardiovascular event following coronary artery stenting compared with other parous women. A history of hypertensive disorders of pregnancy warrants further attention in the secondary prevention setting of coronary artery disease.

Background: Optimal duration and choice of antiplatelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention remain controversial., Methods and Results: Digital databases (PubMed, Cochrane, and Embase) were queried to select all randomized controlled trials on a post-percutaneous coronary intervention population with acute coronary syndrome. Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel for 12 months was compared with 4 major strategies: high-potency, high- to low-potency, low-dose, and short-duration DAPT. A network meta-analysis was performed to compare the safety and efficacy of different antiplatelet strategies. This study was the second updated manuscript under the International Prospective Register of Systematic Review registration (CRD42021286552). Thirty-two randomized controlled trials comprising 103 459 (51 750 experimental, 51 709 control) patients were included. Compared with DAPT with aspirin and clopidogrel for 12 months, high- to low-potency DAPT (risk ratio [RR], 0.69 [95% CI, 0.52-0.92]) and aspirin+prasugrel containing DAPT for 12 months (RR, 0.84 [95% CI, 0.72-0.98]) had a significantly lower, whereas DAPT for 1 month followed by clopidogrel only (RR, 1.59 [95% CI, 1.06-2.39]) had a higher, incidence of major adverse cardiovascular events at 1 year (median follow-up). Prasugrel (RR, 1.35 [95% CI, 1.09-1.66]) and ticagrelor (RR, 1.38 [95% CI, 1.17-1.62]) containing DAPT for 12 months had significantly higher rates, whereas high- to low-potency DAPT (RR, 0.85 [95% CI, 0.63-1.15]) had no significant risk of major bleeding., Conclusions: Aspirin and ticagrelor for 3 months, followed by aspirin and clopidogrel for the remaining duration, can be considered the optimal strategy for treating post-percutaneous coronary intervention patients with acute coronary syndrome because of a significantly reduced risk of major adverse cardiovascular events without increasing the risk of bleeding.

Background: PCI for aorto-ostial CTO remains challenging. The techniques for guidewire in aorto-ostial CTO may differ from those used in non-aorto-ostial CTOs, influenced by clinical and angiographic characteristics., Objectives: This study aimed to assess the technical aspects and outcomes of percutaneous coronary intervention (PCI) in patients with aorto-ostial chronic total occlusion (CTO)., Methods: This analysis included 420 patients with ostial CTO from the Japanese CTO-PCI Expert Registry, spanning January 2014 to December 2022. It examined the strategies and procedural outcomes of CTO PCI., Results: Ostial CTO represented 420 of 10,814 (3.9%) of all CTO PCI cases. Within this subset, aorto-ostial CTO accounted for 218 of 420 (52%) cases. The technical success rate for aorto-ostial CTO was 88% (191/218). Aorto-ostial CTOs exhibited longer lesion lengths and were more likely to present with challenges such as distal target lumen ambiguity, calcification, and tortuosity compared with non-aorto-ostial CTOs. The retrograde approach was more commonly used in aorto-ostial CTO, with retrograde direct crossing being the most successful technique, especially in cases of flush CTO. A multivariate logistic analysis identified several factors significantly associated with unsuccessful aorto-ostial CTO PCI, including difficulties in engaging a guiding catheter, estimating the collateral channel (as assessed by the J-Channel score), and tortuosity., Conclusions: Aorto-ostial CTOs are more complex and frequently require a retrograde approach. The availability of suitable interventional collateral channels is crucial for the success of these procedures., Competing Interests: Funding Support and Author Disclosures Dr Tsuchikane has served as a consultant for Asahi Intecc, Boston Scientific Japan, and Kaneka. Dr Ito has received speaker honorarium from Boston Scientific Japan, Abbott Medical Japan, TERUMO, and Medtronic Japan. Dr Oikawa has received speaker honorarium from Abbott Medical Japan, Boston Scientific Japan, Medtronic Japan, Nipro, TERUMO, Kaneka, and OrbusNeich Medical. Dr Yoshikawa has received speaker honorarium from TERUMO, Abbott Medical Japan, Kaneka, Nipro, and OrbusNeich Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Antithrombotic therapy after cardiac percutaneous interventions is key for the prevention of thrombotic events but is inevitably associated with increased bleeding, proportional to the number, duration, and potency of the antithrombotic agents used. Bleeding complications have important clinical implications, which in some cases may outweigh the expected benefit of reducing thrombotic events. Because the response to antithrombotic agents varies widely among patients, there has been a relentless effort toward the identification of patients at high bleeding risk (HBR), in whom modulation of antithrombotic therapy may be needed to optimize the balance between safety and efficacy. Among patients undergoing cardiac percutaneous interventions, recent advances in technology have allowed for strategies of de-escalation to reduce bleeding without compromising efficacy, and HBR patients are expected to benefit the most from such approaches. Guidelines do not extensively expand upon the topic of de-escalation strategies of antithrombotic therapy in HBR patients. In this review, we discuss the evidence and provide practical recommendations on optimal antithrombotic therapy in HBR patients undergoing various cardiac percutaneous interventions., Competing Interests: Funding Support and Author Disclosures Dr Galli has received consulting fees or honoraria from Terumo, outside the present work. Dr Andreotti has received speaker or consultancy fees from Amgen, Bayer, BMS/Pfizer, Daiichi-Sankyo, and Servier, outside the present work. Dr Capodanno has received personal honoraria from Novo Nordisk, Sanofi, and Terumo; and payment to his institution from Medtronic, outside the present work. Dr Valgimigli has received personal fees from AstraZeneca, Alvimedica/CID, Abbott Vascular, Daiichi-Sankyo, Bayer, CoreFLOW, Idorsia Pharmaceuticals, Universität Basel | Dept. Klinische Forschung, Bristol-Myers Squibb SA, Medscape, Biotronik, and Novartis, outside the submitted work; and grants and personal fees from Terumo. Dr Mehran has received institutional research payments from Abbott, Abiomed, Affluent Medical, Alleviant Medical, Amgen, AM-Pharma, Applied Therapeutics, Arena, AstraZeneca, AtriCure Inc., Biosensors, Biotronik, Boston Scientific, Bristol Myers Squibb, CardiaWave, CeloNova, Chiesi, Concept Medical, CSL Behring, Cytosorbents, Daiichi-Sankyo, Duke, Element Science, Faraday, Humacyte, Idorsia, I-Laser, Janssen, Magenta, MedAlliance, Medscape, Mediasphere, Medtelligence, Medtronic, MJH Healthcare, Novartis, OrbusNeich, Penumbra, PhaseBio, Philips, Pi-Cardia, PLx Pharma, Protembis, RenalPro, RM Global, Shockwave, Transverse Medical, Vivasure, and Zoll; has received personal fees from Affluent Medical, the Cardiovascular Research Foundation, Daiichi-Sankyo Brasil, E.R. Squibb & Sons, Esperion Science/Innovative Biopharma, Europa Group/Boston Scientific, Gaffney Events, Educational Trust, Ionis Pharmaceuticals, J-CalC, Novartis, Novo Nordisk, Vectura, VoxMedia, IQVIA, McVeigh Global, Overcome, Primer Healthcare of New Jersey, Radcliffe, SL Solutions, TARSUS Cardiology, and WebMD, outside the submitted work; owns equity (<1%) in Applied Therapeutics, Elixir Medical, Stel, ControlRad (via her spouse); and has received no fees from the American Medical Association (Scientific Advisory Board) and the Society of Cardiovascular Angiography and Interventions (Women in Innovations Committee Member); has served on the faculty of the Cardiovascular Research Foundation; and has received honoraria from JAMA Cardiology (Associate Editor) and the American College of Cardiology (Board of Trustees Member, Member Clinical Trials Research Program). Dr Angiolillo has received consulting fees or honoraria from Abbott, Amgen, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Faraday, Haemonetics, Janssen, Merck, Novartis, Novo Nordisk, PhaseBio, PLx Pharma, Pfizer, Sanofi, and Vectura, outside the submitted work; and his institution has received research grants from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi-Sankyo, Eisai, Eli Lilly, Faraday, Gilead, Idorsia, Janssen, Matsutani Chemical Industry Co., Merck, Novartis, and the Scott R. MacKenzie Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Cardiovascular disease (CVD) remains one of the major causes of death around the world in which ST elevation MI (STEMI) is in the lead. Although the mortality rate from STEMI seems to decline, this result might not be demonstrated in young adults who basically have different baseline characteristics and outcomes compared with older patients., Methods: Data of the STEMI patients aged 18 years or older who underwent PCI during May 2018 to August 2019 from Thai PCI Registry, a prospective, multi-center, nationwide study, was included and aimed to investigate the predisposing factors and short-term outcomes of patients aged < 40 years compared with age 41-60, and > 61 years., Results: Data of 5,479 STEMI patients were collected. The patients' mean age was 62.6 (SD = 12.6) years, and 73.6% were males. There were 204, 2,154, and 3,121 patients in the youngest, middle, and oldest groups. The young patients were mainly male gender (89.2% vs. 82.4% and 66.6%; p < 0.001), were current smokers (70.6%, 57.7%, 34.1%; p < 0.001), had BMI ≥ 25 kg/m2 more frequently (60.8%, 44.1%, 26.1%; p < 0.001), and had greater family history of premature CAD (6.9%, 7.2%, 2.9%; p < 0.001). The diseased vessel in the young STEMI patients was more often single vessel disease with the highest percentage of proximal LAD stenosis involvement. Interestingly, there were trends of higher events of procedural failure (2.9%, 2.1%, 3.3%; p = 0.028) and procedural complications (8.8%, 5.8%, 9.4%; p < 0.001) in both youngest and oldest groups compared to the middle-aged group. In-hospital death was found in 3.4% in the youngest group compared to 3.3% in the middle-aged patients and 9.2% in the older patients (p < 0.001)., Conclusions: Despite experiencing higher rates of procedural failure and complications during treatment compared to middle-aged and older patients, young STEMI individuals demonstrate a significantly lower risk of death during hospitalization and within one year of the event. Younger patients might have a more robust physiological reserve or benefit from more aggressive post-procedure management. However, the higher prevalence of modifiable risk factors like smoking and obesity in younger individuals underscores the need for preventative measures. Encouraging smoking cessation and weight control in this demographic is crucial not only to prevent STEMI but also to potentially improve their long-term survival prospects., (© 2024. The Author(s).)

Background: Carriers of cytochrome 2C19 (CYP2C19) loss-of-function (LoF) alleles treated with clopidogrel have impaired drug metabolism, resulting in reduced active metabolite levels, high platelet reactivity (HPR), and an increased risk of thrombotic events. Several alternative antiplatelet therapies have been proposed to overcome HPR in these patients, but their comparative effects remain poorly explored., Methods: Randomized controlled trials (RCTs) comparing different oral antiplatelet therapies in carriers of CYP2C19 LoF alleles undergoing percutaneous coronary interventions (PCI) were included. A frequentist network meta-analysis was conducted to estimate mean difference (MD) or odds ratios and 95% confidence intervals (CI). The primary outcome was platelet reactivity assessed by VerifyNow and reported as P2Y12 reaction unit (PRU). The secondary outcome was the rate of HPR. Standard dose of clopidogrel (75 mg daily) was used as a reference treatment., Results: A total of 12 RCTs testing 6 alternative strategies (i.e. clopidogrel 150 mg, prasugrel 3.75 mg, 5 mg, and 10 mg, ticagrelor 90 mg bid, and adjunctive cilostazol 100 mg bid) were included in the network. Compared with standard-dose clopidogrel, the greatest reduction in PRU was observed with prasugrel 10 mg (MD -127.91; 95% CI -141.04; -114.78) and ticagrelor 90 mg bid (MD -124.91; 95% CI -161.78; -88.04), followed by prasugrel 5 mg (MD -76.33; 95% CI -98.01; -54.65) and prasugrel 3.75 mg (MD -73.00; 95% CI -100.28; -45.72). Among other strategies, adjunctive cilostazol (MD -42.64; 95% CI -64.72; -20.57) and high-dose clopidogrel (MD -32.11; 95% CI -51.33; -12.90) were associated with a modest reduction in PRU compared with standard-dose clopidogrel., Conclusion: Among carriers of CYP2C19 LoF alleles undergoing PCI, standard-dose prasugrel or ticagrelor are most effective in reducing platelet reactivity, while double-dose clopidogrel and additional cilostazol showed modest effects. Reduced-dose of prasugrel may represent a balanced strategy to overcome HPR without a significant increase in bleeding. The clinical implications of these pharmacodynamic findings warrant further investigation., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Recent studies have suggested that adverse events associated with lipoprotein(a) [Lp(a)] might be modified by low-density lipoprotein cholesterol (LDL-C) or high-sensitivity C-reactive protein (hs-CRP) levels, but whether LDL-C and hs-CRP jointly mediate the outcome of Lp(a) remains unknown in patients with coronary artery disease., Methods and Results: A prospective study was conducted, enrolling consecutive 10 724 patients with percutaneous coronary intervention (PCI) in 2013. The endpoint event was all-cause death. A total of 10 000 patients with complete baseline data were finally included. During a median follow-up of 5.1 years, Lp(a) ≥ 30 mg/dL was an independent risk factor of all-cause death in the overall population, LDL-C ≥ 70 mg/dL, and hs-CRP ≥ 2 mg/L population, respectively. According to concurrent LDL-C (70 mg/dL) and hs-CRP (2 mg/L) levels, further analysis revealed that when LDL-C < 70 mg/dL regardless of hs-CRP levels, Lp(a) ≥ 30 mg/dL was not an independent predictor of all-cause death. However, when LDL-C ≥ 70 mg/dL, Lp(a) ≥ 30 mg/dL was independently associated with a higher risk of all-cause death in hs-CRP ≥ 2 mg/L (HR: 1.488, 95% CI: 1.059‒2.092), but not in hs-CRP < 2 mg/L (HR: 1.303, 95% CI: 0.914‒1.856)., Conclusion: Among PCI patients, Lp(a)-associated outcome was jointly affected by LDL-C and hs-CRP. As long as LDL-C is well controlled, the adverse effects of increased Lp(a) on cardiovascular risk seem to be weakened, and only when LDL-C and hs-CRP increase at the same time, elevated Lp(a) is associated with poorer long-term outcome., (© 2024 The Author(s). Clinical Cardiology published by Wiley Periodicals, LLC.)

Background: Despite patients with successful revascularization as evidenced by angiographic findings, inadequate clinical management of coronary microcirculatory dysfunction (CMD) may result in preventable adverse outcomes. Therefore, it is imperative to use a multimodal data‑driven predictive model for the occurrence of CMD in patients with acute myocardial infarction (AMI) following emergency percutaneous coronary intervention (PCI)., Methods: A prospective case-control analysis was conducted on a cohort of 77 patients with AMI who underwent PCI. The most informative predictors were selected for the predictive model through the application of LASSO analysis and multi-factor logistic regression. The diagnosis of CMD is based on findings from cardiac magnetic resonance (CMR)., Results: Based on the findings from LASSO analysis and multi-factor logistic regression, variables including sex, neutrophil-to-lymphocyte ratio (NLR), Gensini score, and diabetes mellitus were identified as independent predictors for the development of CMD in AMI patients who underwent emergency PCI. The predictive model was evaluated using bootstrap self-sampling 500 times. The resulting predictive model demonstrated an AUC value of 0.897 (95% CI: 0.827-0.958). The calibration curves exhibited good concordance between the predictions generated by the model and the CMR analysis. Furthermore, decision curve analysis revealed that the predictive model provided valuable clinical benefit in predicting CMD., Conclusions: The multivariate predictive model, constructed using readily available clinical variables in patients with AMI who underwent PCI, demonstrates satisfactory predictability for identifying comorbid CMD, thereby facilitating the identification of high-risk patients., (© 2024 The Author(s). Clinical Cardiology published by Wiley Periodicals, LLC.)

Competing Interests: Unrelated to this work, Dr Bortnick served as a site principal investigator for sponsored clinical trials by CSL-Behring Inc and Amgen Inc in the past year for which Montefiore received compensation, received honoraria from Zoll and Getinge (to Montefiore), and meeting travel support from Getinge.

Background: Coronary artery disease remains the largest contributor to cardiac arrests worldwide; yet, long-term outcomes are often driven by neurological status after resuscitation. We examined the association between pre-percutaneous coronary intervention (PCI) level of consciousness (LOC) and outcomes among patients with cardiac arrest who underwent PCI., Methods: The study cohort included patients undergoing PCI after cardiac arrest between April 2018 and March 2022 at 48 hospitals in the state of Michigan. Pre-PCI LOC was categorized as mentally alert, partially responsive, unresponsive, and unable to assess. In-hospital outcomes included mortality, bleeding, and acute kidney injury., Results: Among 3021 patients who underwent PCI after cardiac arrest, 1394 (49%) were mentally alert, 132 (5%) were partially responsive, 698 (24%) were unresponsive, and 631 (22%) were unable to assess. The mentally alert cohort had lower mortality (4.59%) compared with the partially responsive (17.42%), unresponsive (50.14%), and unable to assess cohorts (38.03%; P <0.001). After adjusting for baseline differences, compared with mentally alert patients, the odds of mortality were markedly elevated in patients who were partially responsive (adjusted odds ratio, 4.63 [95% CI, 2.67-8.04]; P <0.001), unable to assess (adjusted odds ratio, 13.95 [95% CI, 9.97-19.51]; P <0.001), and unresponsive (adjusted odds ratio, 24.36 [17.34-34.23]; P <0.001). After adjustment, patients with impaired LOC also had higher risks of acute kidney injury and bleeding compared with mentally alert patients., Conclusions: Pre-PCI LOC is a strong predictor of in-hospital outcomes after PCI among cardiac arrest patients. A patient's pre-PCI LOC should be considered an important factor when weighing treatment options, designing clinical trials, and counseling patients and their families regarding prognosis after PCI., Competing Interests: There are no conflicts directly related to this work. Outside this work, Dr Gurm receives research support from Blue Cross and Blue Shield of Michigan paid to his institution. He is the co-founder of, owns equity in, and is a consultant to Amplitude Vascular Systems. He also owns equity in Jiaxing Bossh Medical Technology Partnership and is a consultant for Osprey Medical. He is the chair of the Clinical Events Committee for the PERFORMANCE trial (Protection Against Emboli Using a 3-In‐1 Delivery System Comprising an Integrated Filter, Normal Angioplasty Balloon and Novel Carotid Stent) sponsored by Contego Medical. Dr Sukul receives salary support from the Blue Cross Blue Shield of Michigan for his role in quality improvement within the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. The other authors report no conflicts.

Background: Patients with an indication for oral anticoagulation who undergo percutaneous coronary intervention require a combination of oral anticoagulation and antiplatelet therapy. The use of a coronary stent with a thromboresistant and pro-healing coating may allow an abbreviated duration of dual antiplatelet therapy (DAPT) without an increase in the risk of thromboembolic events., Methods: Patients with an indication for oral anticoagulation undergoing percutaneous coronary intervention were randomized to treatment with the COBRA polyzene F (PzF) stent followed by 14 days of DAPT or a Food and Drug Administration-approved new-generation drug-eluting stent followed by 3 or 6 months of DAPT. The bleeding coprimary end point was Bleeding Academic Research Consortium type ≥2 beyond 14 days (or after hospital discharge) until 6 months. The thromboembolic coprimary end point was the composite of all-cause death, myocardial infarction, definite or probable stent thrombosis, or ischemic stroke at 6 months. The trial hypothesis was that the COBRA PzF stent strategy would be superior with respect to bleeding events and noninferior with respect to thromboembolic events., Results: A total of 996 patients underwent randomization. The bleeding end point occurred in 37 of 475 patients (7.8%) in the COBRA PzF group and 47 of 482 patients (9.8%) in the control group (difference, -2.0 [95% CI, -5.6 to 1.6]; P =0.14). The thromboembolic end point occurred in 37 of 492 patients (7.5%) in the COBRA PzF group and 24 of 490 patients (4.9%) in the control group (difference, 2.6%; prespecified noninferiority margin 5%, upper limit of 1-sided 95% CI of the difference, 5.2%; P noninferiority =0.07)., Conclusions: In patients with an indication for oral anticoagulation undergoing percutaneous coronary intervention, treatment with the COBRA PzF stent plus 14 days of DAPT was not superior with respect to bleeding events and was not noninferior with respect to thromboembolic events at 6 months compared with treatment with standard Food and Drug Administration-approved drug-eluting stent plus 3 to 6 months of DAPT., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02594501., Competing Interests: Dr Byrne reports research or educational funding to the institution of current employment from Abbott Vascular, Biosensors, Boston Scientific, and Translumina. Dr Maeng is supported by a grant from the Novo Nordisk Foundation (grant number NNF22OC0074083), has received lecture and advisory board fees from Astra-Zeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, and Novo Nordisk, has received research grants from Philips, Bayer, and Novo Nordisk, has ongoing research contracts with Novo Nordisk and Philips, and is a minor shareholder in Eli Lilly and Novo Nordisk. Dr Brunner is a previous employee of CeloNova. Dr Urban reports personal consulting fees from and is a shareholder of MedAlliance, Nyon, Switzerland, outside of the submitted work. Dr Cutlip reports contracted research support paid to institution of current employment from Celonova. Dr Kirtane reports Institutional funding to Columbia University and/or Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Amgen, CathWorks, Cardiovascular Systems Inc, Philips, ReCor Medical, Neurotronic, Biotronik, Chiesi, Bolt Medical, Magenta Medical, Canon, SoniVie, and Shockwave Medical. In addition to research grants, institutional funding includes fees paid to Columbia University and/or Cardiovascular Research Foundation for consulting and/or speaking engagements in which Dr Kirtane controlled the content. Personal: Travel Expenses/Meals from Amgen, Medtronic, Biotronik, Boston Scientific, Abbott Vascular, CathWorks, Edwards, Cardiovascular Systems Inc, Novartis, Philips, Abiomed, ReCor Medical, Chiesi, Zoll, Shockwave, and Regeneron. The other authors report no conflicts.

Objective: To explore the association between in-hospital haemoglobin decline and long-term mortality and major adverse cardiovascular and cerebrovascular events (MACCE) among ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI)., Methods: This retrospective analysis included adult patients who underwent primary PCI for STEMI. Haemoglobin levels were recorded at admission and 48-72 h later. Patients were divided into two groups based on the extent of haemoglobin decline: low (<3 g/dl or no decline) and high (≥3 g/dl). The primary endpoint was all-cause mortality at long-term follow-up. The secondary endpoint was MACCE., Results: Patients were divided into two groups: low group ( n  = 665) and high group ( n  = 111). The mortality rate was significantly higher in the high group (72 of 111 patients; 65%) than in the low group (185 of 655 patients; 28%). Propensity score matching confirmed this association, with higher mortality (41 of 79 patients [52%] versus 25 of 79 patients [32%]) and MACCE rates (56 of 79 patients [71%] versus 41 of 79 patients [52%]) in the high group compared with the low group, respectively., Conclusion: There was a significant association between in-hospital haemoglobin decline, even without visible bleeding, and increased long-term mortality and MACCE in STEMI patients undergoing primary PCI., Competing Interests: Declaration of conflicting interestThe authors declare that there are no conflicts of interest.

Background: Percutaneous coronary intervention (PCI) might improve outcome at severe stages of cardiac allograft vasculopathy (CAV) among patients after heart transplantation (HTx). Yet, risk stratification of HTx patients after PCI remains challenging., Aims: To assess whether the International Society for Heart and Lung Transplantation (ISHLT) CAV classification remains prognostic after PCI and whether risk-stratification models of non-transplanted patients extend to HTx patients with CAV., Methods: At 2 European academic centers, 203 patients were stratified in cohort 1 (ISHLT CAV1, without PCI, n = 126) or cohort 2 (ISHLT CAV2 and 3, with PCI). At first diagnosis of CAV or first PCI, respectively, ISHLT CAV grades, SYNTAX scores I and II (SXS-I, SXS-II) were used to quantify baseline and residual CAV (rISHLT, rSXS-I, rSXS-II). RSXS-I > 0 defined incomplete revascularization (IR)., Results: SXS-II predicted mortality in cohort 1 (P = 0.004), whereas SXS-I (P = 0.009) and SXS-II (P = 0.002) predicted mortality in cohort 2. Post-PCI, IR (P = 0.004), high rISHLT (P = 0.02) and highest tertile of rSXS-II (P = 0.006) were associated with higher 5-year mortality. In bivariable Cox analysis, baseline SXS-II, IR and rSXS-II remained predictors of 5-year mortality post-PCI. There was a strong inverse relationship between baseline and rSXS-I (r = -0.55; P < 0.001 and r = -0.50; P = 0.003, respectively) regarding the interval to first reintervention., Conclusion: People with ISHLT CAV classification could apply for risk stratification after PCI. SYNTAX scores could be complemental for risk stratification and individualization of invasive follow-up of HTx patients with CAV., Competing Interests: Disclosures DB reports speaker honoraria from Abbott Vascular outside the submitted work. JH reports grants and personal fees from Abbott Vascular and Edwards Lifescience outside the submitted work. A-CM reports grants and consulting fees from Bristol Myers Squibb, Bayer outside the submitted work. SU reports grants from Novartis and Astellas Pharma outside the submitted work. JM reports lecture fees from Daiichi Sankyo, SIS Medical, Biotronik, Astra Zeneca, and Bristol Myers Squibb outside the submitted work. SM reports grants from German Federal Ministry of Education and Research/German Centre for Cardiovascular Research, grants from German Research Foundation, grants from Boston Scientific and Foundation Leducq Transatlantic Network of Excellence outside the submitted work. All other authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Cardiac rehabilitation (CR) improves outcomes following percutaneous coronary intervention (PCI) but remains underutilized. A liaison-mediated referral (LMR), where a health care professional explains CR's benefits, addresses barriers to participation, and places a referral before discharge, may promote CR use. Our objective was to assess the impact of an LMR on CR participation after PCI., Methods: This was a retrospective study of patients who underwent PCI across 48 hospitals in Michigan between January 2021 and April 2022 and referred to CR before discharge. Clinical registry data were linked to administrative claims to identify the primary outcome, CR participation, defined as ≥1 CR session within 90 days of discharge. Bayesian hierarchical logistic regression was used to compare CR participation between patients with and without an LMR. For the secondary outcome, frailty proportional hazard modeling compared days elapsed between discharge and first CR session between liaison cohorts., Results: Among 9023 patients referred to CR after PCI, 4323 (47.9%) underwent an LMR (mean age, 69.3 [SD=11] years; 68.3% male) and 3390 (36.7%) attended ≥1 CR session within 90 days of discharge. The LMR cohort had a higher unadjusted CR participation rate (43.1% [95% CI, 41.5%-44.6%] versus 32.4% [95% CI, 31.1%-33.8%]; P <0.001), a higher adjusted odds ratio of attending ≥1 CR session (adjusted odds ratio, 1.21; 95% credible interval, 1.07-1.38), and a shorter delay in attending the first CR session compared with the non-LMR cohort (28 [interquartile range, 19-42] versus 33 [interquartile range, 21-47] days; P <0.001)., Conclusions: An LMR was associated with higher odds of CR participation and may mitigate delays in CR enrollment. This referral strategy may improve CR participation and patient outcomes after PCI., Competing Interests: Dr Sukul receives support from Blue Cross Blue Shield of Michigan for his role in quality improvement for the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Dr Gurm receives research support from Blue Cross Blue Shield of Michigan. He is the cofounder of, owns equity in, and is a consultant at Amplitude Vascular Systems. He also owns equity in Jiaxing Bossh Medical Technology Partnership. He is the chair of the Clinical Events Committee for the PERFORMANCE trial sponsored by Contego Medical. Dr Keteyian receives research support from the National Heart, Lung, Blood Institute (HL 143099). Dr Thompson receives support from Blue Cross Blue Shield of Michigan for his role as codirector of the Michigan Value Collaborative and receives grant funding from the Agency for Healthcare Research and Quality (K01HS027839 and R01HS028397). The other authors report no conflicts.

Background: Dyslipidemia is prominently associated with adverse outcomes in patients with coronary artery disease (CAD). The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is a novel comprehensive lipid index. However, limited evidence exists on the relationship of the NHHR with the risk of adverse outcomes in patients with CAD. This study aimed to explore the associations between the NHHR and adverse outcomes and identify the optimal NHHR ranges linked to the lowest adverse outcome risk in patients with CAD undergoing percutaneous coronary intervention (PCI)., Methods: Among 2253 patients with CAD undergoing PCI, 2251 with available total cholesterol and HDL-C levels were analyzed. Furthermore, all patients were classified into quintiles based on the NHHR. The primary outcome was the incidence of MACCEs, comprising cardiac mortality, acute myocardial infarction, stroke, and repeat revascularization. Multivariable logistic regression analysis was used to assess the relationship between the NHHR and MACCEs. Moreover, restricted cubic spline (RCS) analysis was performed to quantify nonlinearity. Lastly, the consistency between these associations was confirmed by conducting subgroup and interaction analyses., Results: A total of 270 patients experienced MACCEs over a median follow-up of 29.8 months (interquartile range, 25.6-34 months). After adjustment for confounding variables, the adjusted ORs (95% CIs) of the patients in quintiles 2, 3, 4, and 5 were 0.79 (0.52-1.20), 0.64 (0.42-0.99), 1.00 (0.67-1.48), and 1.17 (0.74-1.64), respectively (reference group: quintile 1). Additionally, RCS analysis demonstrated a U-shaped relationship between the NHHR and MACCEs, with an inflection point at an NHHR of 3.119 using a two-piecewise regression model. This relationship was consistent across the various subgroups, while significant interactions were not observed in these associations.The ORs and 95% CIs to the left and right of the inflection point were 0.734 (0.551-0.978) and 1.231 (1.038-1.460), respectively., Conclusions: This study reveals a U-shaped association between baseline NHHR and MACCE incidence in patients with CAD undergoing PCI., (© 2024. The Author(s).)

Background: No randomized data exist on ultrathin-strut stents in patients at high bleeding risk (HBR) undergoing an abbreviated dual antiplatelet therapy after coronary stenting. The aim of this study was to compare the safety and effectiveness of the ultrathin-strut biodegradable-polymer sirolimus-eluting Supraflex Cruz stent with the thin-strut biodegradable-polymer sirolimus-eluting Ultimaster Tansei stent in patients at HBR with abbreviated dual antiplatelet therapy after stenting., Methods: In the investigator-initiated, randomized, open-label COMPARE 60/80 HBR trial (Comparison of the Supraflex Cruz 60 Micron Stent Strut Versus the Ultimaster Tansei 80 Micron Stent Strut in HBR Percutaneous Coronary Intervention Population), 741 patients at HBR according to the Academic Research Consortium HBR criteria were randomized to receive either the ultrathin-strut biodegradable-polymer sirolimus-eluting Supraflex Cruz stent or thin-strut biodegradable-polymer sirolimus-eluting Ultimaster Tansei stent. Dual antiplatelet therapy was recommended according to the applicable guidelines and trial data for patients at HBR. The primary outcome was net adverse clinical events, the composite of cardiovascular death, myocardial infarction, target vessel revascularization, stroke, and major bleeding, and was powered for noninferiority with an absolute margin of 4.0% at 1-sided 2.5% alpha., Results: Between September 2020 and August 2022, 371 patients were randomized to the ultrathin-strut biodegradable-polymer sirolimus-eluting Supraflex Cruz stent and 370 patients to the thin-strut biodegradable-polymer sirolimus-eluting Ultimaster Tansei stent at 11 sites in the Netherlands. At 1 year, the primary outcome was observed in 56 (15.4%) patients in the ultrathin-strut biodegradable-polymer sirolimus-eluting Supraflex Cruz stent group and 61 (17.1%) in the thin-strut biodegradable-polymer sirolimus-eluting Ultimaster Tansei stent group (risk difference, -1.65%; upper boundary of the 1-sided 95% CI, 3.74; P =0.02 for noninferiority at a 0.025 significance level and P =0.55 for 2-sided superiority at a 0.05 significance level)., Conclusions: Among patients at HBR with abbreviated dual antiplatelet therapy post-stenting, the use of an ultrathin-strut biodegradable-polymer sirolimus-eluting Supraflex Cruz stent was noninferior compared with the use of a thin-strut biodegradable-polymer sirolimus-eluting Ultimaster Tansei stent., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04500912., Competing Interests: Dr Smits reports personal fees from Terumo and Abiomed, institutional grants and personal fees from Abbott Vascular and Microport, and institutional grants from SMT. Dr Hofma reports an institutional grant from Terumo. Dr Oemrawsingh reports speaker fees from Abbott Vascular and Philips. Dr Paradies reports speaker fees from Boston Scientific and Abbott Vascular and institutional grants from Abbott Vascular. The other authors report no conflicts.

Background: After coronary stent implantation, prolonged dual antiplatelet therapy (DAPT) increases bleeding risk, requiring personalization of DAPT duration. The aim of this study was to develop and validate a machine learning model to predict optimal DAPT duration after contemporary drug-eluting stent implantation in patients with coronary artery disease., Methods and Results: The One-Month DAPT, RESET (Real Safety and Efficacy of 3-Month Dual Antiplatelet Therapy Following Endeavor Zotarolimus-Eluting Stent Implantation), and IVUS-XPL (Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesion) trials provided a derivation cohort (n=6568). Using the X-learner approach, an individualized DAPT score was developed to determine the therapeutic benefit of abbreviated (1-6 months) versus standard (12-month) DAPT using various predictors. The primary outcome was major bleeding; the secondary outcomes included 1-year major adverse cardiac and cerebrovascular events and 1-year net adverse clinical events. The risk reduction with abbreviated DAPT (3 months) in the individualized DAPT-determined higher predicted benefit group was validated in the TICO (Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome) trial (n=3056), which enrolled patients with acute coronary syndrome treated with ticagrelor. The validation cohort comprised 1527 abbreviated and 1529 standard DAPT cases. Major bleeding occurred in 25 (1.7%) and 45 (3.0%) patients in the abbreviated and standard DAPT groups, respectively. The individualized DAPT score identified 2582 (84.5%) participants who would benefit from abbreviated DAPT, which was significantly associated with a lower major bleeding risk (absolute risk difference [ARD], 1.26 [95% CI, 0.15-2.36]) and net adverse clinical events (ARD, 1.59 [95% CI, 0.07-3.10]) but not major adverse cardiac and cerebrovascular events (ARD, 0.63 [95% CI, -0.34 to 1.61]), compared with standard DAPT in the higher predicted benefit group. Abbreviated DAPT had no significant difference in clinical outcomes of major bleeding (ARD, 1.49 [95% CI, -1.74 to 4.72]), net adverse clinical events (ARD, 2.57 [95% CI, -1.85 to 6.99]), or major adverse cardiac and cerebrovascular events (ARD, 1.54 [95% CI, -1.26 to 4.34]), compared with standard DAPT in the individualized DAPT-determined lower predicted benefit group., Conclusions: Machine learning using the X-learner approach identifies patients with acute coronary syndrome who may benefit from abbreviated DAPT after drug-eluting stent implantation, laying the groundwork for personalized antiplatelet therapy.

Background: Lipid content in untreated nonobstructive coronary artery lesions is associated with adverse clinical outcomes, and residual in-stent or stent edge lipid may worsen outcomes after percutaneous coronary intervention (PCI)., Methods: Near-infrared spectroscopy-intravascular ultrasound was performed before and after PCI in patients with myocardial infarction. We evaluated the impact of lipid assessed by near-infrared spectroscopy (maximal lipid core burden index over 4 mm [maxLCBI 4mm ]) along with intravascular ultrasound information including residual plaque burden on in-stent or edge-related major adverse cardiac events (MACE) in de novo PCI-treated culprit coronary artery lesions. The primary end point was culprit lesion-related MACE (CL-MACE), defined as cardiac death, myocardial infarction, or unstable or progressive angina either requiring revascularization or with rapid lesion progression and classified as in-stent or stent edge-related., Results: During a median follow-up of 3.8 years, 25 CL-MACE (11 stent edge-related, 13 in-stent, and 1 in-lesion without a stent) occurred in 1041 PCI-treated lesions in 768 patients. Pre-PCI or post-PCI measures of lipid content were not related to in-stent CL-MACE. However, stent edge-related CL-MACE was increased if both the post-PCI stent edge maxLCBI 4mm was greater than the upper quartile (108.7) and the stent edge plaque burden was >50% (adjusted odds ratio, 4.11 [95% CI, 1.12-15.2]; P =0.03)., Conclusions: In PROSPECT II (Providing Regional Observations to Study Predictors of Events in the Coronary Tree), CL stent implantation leaving behind greater stent edge-related lipid and uncovered plaque burden was associated with an increased risk of stent edge-related CL-MACE during follow-up. In contrast, CL lipid content was not related to in-stent CL-MACE., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02171065., Competing Interests: Dr Maehara is a consultant to Boston Scientific, Philips, and SpectraWave; and speaker honoraria from Nipro. Dr Matsumura is a consultant to Boston Scientific and Terumo. Dr Maeng is supported by a grant from the Novo Nordisk Foundation (grant number NNF22OC0074083); has received lecture and advisory board fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, and Novo Nordisk; has received research grants from Philips, Bayer, and Novo Nordisk; has research contracts with Novo Nordisk, Janssen, and Philips; and is a minor shareholder in Verve Therapeutics, Eli Lilly, and Novo Nordisk. Dr Engstrøm has received advisory board fees from Novo Nordisk, Abbot Vascular, and Opsens; and speakers fee from Abbott Vascular. Dr Fröbert has received grants from Sanofi Pasteur. Dr Persson has received unrestricted grants from Abbott. Dr Jensen has received institutional unrestricted research grants from Biotronik, BioSensors, and OrbusNeich. Dr Held has received Advisory board fees from Novo Nordisk, AstraZeneca, Boehringer Ingelheim, Coala Life, and Pharmacosmos; research grants from Pfizer; and lecture fees from Bayer. Dr Mintz has received honoraria from Boston Scientific, Philips, Abbott, SpectraWave, and Gentuity. Dr Ali has received institutional grant support from Abbott, Abiomed, Acist Medical, Amgen, Boston Scientific, Cathworks, Canon, Conavi, Heartflow, Inari, Medtronic Inc, National Institutes of Health, Nipro, Opsens Medical, Medis, Philips, Shockwave, Siemens, Spectrawave, and Teleflex Inc; consultant honoraria from Abiomed, AstraZeneca, Boston Scientific, Cathworks, Opsens, Philips, and Shockwave; and equity in Elucid, Lifelink, Spectrawave, Shockwave, and VitalConnect. Dr Stone has received speaker honoraria from Medtronic, Pulnovo, Infraredx, Abiomed, Amgen, and Boehringer Ingelheim; has served as a consultant to Abbott, Daiichi Sankyo, Ablative Solutions, CorFlow, Cardiomech, Robocath, Miracor, Vectorious, Apollo Therapeutics, Elucid Bio, Cardiac Success, Valfix, TherOx, HeartFlow, Neovasc, Ancora, Occlutech, Impulse Dynamics, Adona Medical, Millennia Biopharma, Oxitope, HighLife, Elixir, Remote Cardiac Enablement, and Aria; and has equity/options from Cardiac Success, Ancora, Cagent, Applied Therapeutics, Biostar family of funds, SpectraWave, Orchestra Biomed, Aria, Valfix, and Xenter. Dr Stone’s employer, Mount Sinai Hospital, receives research grants from Shockwave, Abbott, Abiomed, Bioventrix, Cardiovascular Systems Inc, Phillips, Biosense-Webster, Vascular Dynamics, Pulnovo, and V-wave. Dr Erlinge has received speakers fees from Amgen, AstraZeneca, Bayer, and Chiesi; and advisory board fees from Bayer, Boehringer Ingelheim, and Sanofi. The other authors report no conflicts.

Background: Quantitative flow ratio (QFR)-based virtual percutaneous coronary intervention (PCI) is associated with improved post-PCI physiological results. Murray law-based QFR (μQFR) is a new method for physiological assessment that has higher feasibility and efficiency. The purpose of this study was to investigate the performance of μQFR-guided virtual PCI in improving post-PCI outcomes., Methods: The QUITE RIGHT study (Quantitative Flow Ratio Virtual Stenting and Angiography Guided Percutaneous Coronary Intervention) is a prospective, multicenter, blinded, randomized, controlled superiority study. Eligible patients were randomized 1:1 to either the μQFR-guided virtual PCI group or the angiography-guided PCI group. The primary end point was the proportion of the target vessels with a post-PCI μQFR ≥0.90, accepted as an optimal post-PCI physiological outcome., Results: A total of 622 patients with 666 vessels were enrolled. The optimal physiological outcome was reached more often in the μQFR-guided virtual PCI group (absolute difference, 9.1% [95% CI, 4.53-13.76]; P <0.001). The μQFR-guided virtual PCI group had a better QFR value, a lower contrast agent dose and x-ray dose, and a more appropriate stent length than the angiography-guided group., Conclusions: The QUITE RIGHT study showed that the μQFR-guided virtual PCI strategy is superior to angiography-guided PCI in terms of physiological outcomes. The μQFR-guided virtual PCI strategy is associated with lower contrast and x-ray doses and a more appropriate stent length., Registration: URL: https://www.chictr.org.cn/; Unique identifier: ChiCTR2100045452., Competing Interests: Dr Tu reports research grants and consultancy from Pulse Medical. The other authors report no conflicts.

Background: The ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) demonstrated greater health status benefits with an initial invasive strategy, as compared with a conservative one, for patients with chronic coronary disease and moderate or severe ischemia. Whether these benefits vary globally is important to understand to support global adoption of the results., Methods: We analyzed participants' disease-specific health status using the validated 7-item Seattle Angina Questionnaire (SAQ: >5-point differences are clinically important) at baseline and over 1-year follow-up across 37 countries in 6 international regions. The average effect of initial invasive versus conservative strategies on 1-year SAQ scores was estimated using Bayesian proportional odds regression and compared across regions., Results: Considerable regional variation in baseline health status was observed among 4617 participants (mean age=64.4±9.5 years, 24% women), with the mean SAQ summary scores of 67.4±19.5 in Eastern Europe participants (17% of the total), 71.4±15.4 in Asia-Pacific (18%), 74.9±16.7 in Central and South America (10%), 75.5±19.5 in Western Europe (26%), and 78.6±19.2 in North America (28%). One-year improvements in SAQ scores were greater in regions with lower baseline scores with initial invasive management (17.7±20.9 in Eastern Europe and 11.4±19.3 in North America), but similar in the conservative arm. Adjusting for baseline SAQ scores, similar health status benefits of an initial invasive strategy on 1-year SAQ scores were observed (ranging from 2.38 points [95% CI, 0.04-4.50] in North America to 4.66 points [95% CI, 2.46-6.94] in Eastern Europe), with an 88.3% probability that the difference in benefit across regions was <5 points., Conclusions: In patients with chronic coronary disease and moderate or severe ischemia, initial invasive management was associated with a consistent health status benefit across regions, with modest regional variability, supporting the international generalizability of health status benefits from invasive management of chronic coronary disease., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522., Competing Interests: Dr Ikemura received an unrestricted research grant for the Department of Cardiology, Keio University School of Medicine from Bristol Myer Squibb. Dr Spertus discloses providing consultative services on patient-reported outcomes and evidence evaluation to Alnylam, AstraZeneca, Bayer, Merck, Janssen, Bristol Meyers Squibb, Edwards, Kineksia, 4DT Medical, Terumo, Cytokinetics, Imbria, and United Healthcare. He holds research grants from Bristol Meyers Squibb, Abbott Vascular, and Janssen. He owns the copyright to the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire and serves on the Board of Directors for Blue Cross Blue Shield of Kansas City. Dr Nguyen is currently supported by the National Heart, Lung, and Blood Institute under Award Number T32HL110837. Dr Reynolds reports grants from National Heart, Lung, and Blood Institute, during the conduct of the study, she received support from Abbott Vascular (donation of optical coherence tomography catheters for an unrelated research study) and Biotelemetry Inc (donation of telemetry monitors for an unrelated research study). Dr Bangalore reports grants from the National Heart, Lung, and Blood Institute, during the conduct of the study; grants and personal fees from Abbott Vascular; personal fees from Biotronik, Pfizer, Amgen, and Reata outside the submitted work. Dr Bhargava reports grants from the National Heart, Lung and Blood Institute, during the conduct of the study. Dr Senior reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study and speaker fees from Bracco, Lantheus Medical Imaging Boston USA, and Philips Healthcare outside the submitted work. A. Elghamaz reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Goodman reports research grant support (eg, steering committee or data and safety monitoring committee) and speaker/consulting honoraria (eg, advisory boards) from Amgen, Anthos Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, CSL Behring, CYTE Ltd., Daiichi-Sankyo/American Regent, Eli Lilly, Esperion, Ferring Pharmaceuticals, HLS Therapeutics, JAMP Pharma, Merck, Novartis, Novo Nordisk A/C, Pendopharm/Pharmascience, Pfizer, Regeneron, Sanofi, Servier, Tolmar Pharmaceuticals, Valeo Pharma; and salary support/honoraria from the Heart and Stroke Foundation of Ontario/University of Toronto (Polo) Chair, Canadian Heart Failure Society, Canadian Heart Research center and MD Primer, Canadian VIGOUR center, Cleveland Clinic Coordinating Center for Clinical Research, Duke Clinical Research Institute, New York University Clinical Coordinating center, PERFUSE Research Institute, TIMI Study Group (Brigham Health). Dr Lopes reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study; other from Bayer and Boehringer Ingelheim; grants and other from Bristol-Myers Squibb; other from Daiichi Sankyo; grants and other from GlaxoSmithKline and Medtronic; other from Merck; grants and other from Pfizer; other from Portola; and grants and other from Sanofi, outside the submitted work. Dr Pracon reports grants from National Heart, Lung, and Blood Institute, during the conduct of the study and research grant honoraria from NYU. Dr Lopez-Sendon reports grants from National Heart, Lung and Blood Institute, during the conduct of the study; other from Bayer, other from Boehringer Ingleheim, grants and other from Bristol-Myers Squibb, other from Daiichi Sankyo, grants and other from Glaxo Smith Kline, grants and other from Medtronic, other from Merck, grants and other from Pfizer, other from Portola, grants and other from Sanofi, outside the submitted work. Dr Maggioni reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study; and personal fees from Bayer, AstraZeneca, Sanofi and Novartis, outside the submitted work. Dr Kohsaka has received grant support paid to the institution and fees from Novartis and AstraZeneca. Dr White has received grant support paid to the institution and fees for serving on Steering Committees of the ODYSSEY trial from Sanofi and Regeneron Pharmaceuticals, the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) and MINT study from the National Institutes of Health, the STRENGTH trial from Omthera Pharmaceuticals, the HEART-FID study from American Regent, the DAL-GENE study from DalCor Pharma UK Inc., the AEGIS-II study from CSL Behring, the CLEAR OUTCOMES study from Esperion Therapeutics Inc, and the SOLIST-WHF and SCOREDS trials from Sanofi Aventis Australia Pty Ltd. Dr Mavromatis reports grants from the National Heart, Lung, and Blood Institute; grants from National Heart, Blood, and Lung Institute (CV Inflammation Reduction Trial and GMCSF in PAD-3 Trial), grants from CSL Behring, St Jude’s Medical, Medtronic, DalCor Pharmaceuticals, AstraZeneca, Novartis, Regeneron, and Member of American College of Cardiology and Society of Cardiovascular Angiography and Interventions. Dr Boden reports grants from the National Heart, Lung, and Blood Institute, during the conduct of the study; grants from Abbvie, grants from Amarin, grants from Amgen, personal fees from Amgen, personal fees from Cleveland Clinic Clinical Coordinating Center, personal fees from Janssen, outside the submitted work. Dr Fatima Rodriguez reports consulting fees from Novartis, NovoNordisk, AstraZeneca, and Health Pals, and research support from the National Institutes of Health, the American Heart Association, and the Doris Duke Foundation. Dr Hochman is PI for the ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) for which, in addition to support by the National Heart, Lung, and Blood Institute grant, devices and medications were provided by Abbott Vascular; Medtronic Inc.; Abbott Laboratories (formerly St. Jude Medical Inc); Royal Philips NV (formerly Volcano Corporation); Arbor Pharmaceuticals, LLC; AstraZeneca Pharmaceuticals, LP; Merck Sharp & Dohme Corp.; Omron Healthcare Inc, and financial donations from Arbor Pharmaceuticals LLC and AstraZeneca Pharmaceuticals LP. She is also the PI for ISCHEMIA-EXTEND. Dr Maron reports grants from National Heart, Lung, and Blood Institute, during the conduct of the study. The other authors report no conflicts.

Background: Among ST-elevation myocardial infarction (STEMI) patients, those with no standard modifiable risk factors (SMuRFs: hypertension, diabetes mellitus, hypercholesterolemia, and smoking) have higher 30-day mortality than those with SMuRFs. Differences in coronary lesion characteristics remain unclear., Methods: Data from STEMI patients aged ≤60 years from the Asia Pacific Evaluation of Cardiovascular Therapies Network (Australia, Hong Kong, Malaysia, Singapore, and Vietnam) was retrospectively analysed. Exclusion criteria included incomplete SMuRF data, prior myocardial infarction, or prior coronary revascularisation. Lesion type was defined using the American College of Cardiology criteria. Major adverse cardiovascular events (MACE) were defined as peri-procedural myocardial infarction, emergency coronary artery bypass surgery, cerebrovascular event, or mortality. Multiple logistic regressions were used., Results: Of 4404 patients, 767 (17.4%) were SMuRFless. SMuRFless patients were more frequently younger (median age 51 vs. 53 years; p < 0.001), female (22.6% vs. 15.5%; p < 0.001), thrombolysed (20.1% vs. 12.5%; p < 0.001), and in cardiogenic shock (11.2% vs. 8.6%; p = 0.020). SMuRFless patients had significantly higher in-hospital MACE (7.2% vs. 4.3%; adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 1.24-4.08; p = 0.008) but 1-year mortality was not significantly different (3.6% vs. 5.7%, aOR 0.58; 95% CI 0.06-6.12; p = 0.549). Compared with patients with SMuRFs (4918 lesions), the SMuRFless (940 lesions) had fewer type B2/C lesions (60.8% vs. 65.6%; p = 0.020) and fewer lesions ≥20 mm (51.1% vs. 57.1%; p = 0.002) but more procedural complications (5.1% vs. 2.7%; p < 0.001)., Conclusions: Among young STEMI patients, the SMuRFless have shorter and less complex lesions, but worse procedural and short-term MACE outcomes., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: Cardiac tamponade or pericardial tamponade (PT) can be a complication following invasive cardiac procedures., Methods: Patients who underwent various procedures in the cardiac catheterization lab (viz. coronary interventions) were identified using the International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification (International classification of diseases [ICD]-9-Clinical modification [CM] and ICD-10-CM, respectively) from the Nationwide Inpatient Sample (NIS) database. Patient demographics, presence of comorbidities, PT-related events, and in-hospital death were also abstracted from the NIS database., Results: The frequency of PT-related events in the patients undergoing CI from 2010 to 2017 ranged from 3.3% to 8.4%. Combined in-hospital mortality/morbidity of PT-related events were higher with increasing age (odds ratio [OR] [95% CI]: chronic total occlusion (CTO) = 1.19 [1.10-1.29]; acute coronary syndrome (ACS) = 1.21 [1.11-1.33], both p < 0.0001) and female sex (OR [95%CI]: CTO = 1.70 [1.45-2.00]; ACS = 1.72 [1.44-2.06], both p < 0.0001). In-hospital mortality related to PT-related events was found to be 8.5% for coronary procedures. In-hospital mortality was highest amongst the patients undergoing percutaneous transluminal coronary angioplasty (PTCA) for ACS (ACS vs. non-CTO PTCA vs. CTO PTCA: 15.7% vs. 10.4% and 14.4%, p < 0.0001 and ACS vs. non-CTO PTCA vs. CTO PTCA: 12.1% vs. 8.1% and 5.6%, p = 0.0001, respectively)., Conclusions: In the real-world setting, PT-related events in CI were found to be 3.3%-8.4%, with in-hospital mortality of 8.5%. The patients undergoing PTCA for ACS were found to have highest mortality. Older patients undergoing CTO PTCA independently predicted higher mortality., (© 2024 Wiley Periodicals LLC.)

Percutaneous coronary and structural heart interventions are increasingly preferred over cardiac surgery due to reduced rates of periprocedural complications and faster recovery but often require postprocedural antithrombotic therapy for the prevention of local thrombotic events. Antithrombotic therapy is inevitably associated with increased bleeding, the extent of which is proportional to the number, duration, and potency of the antithrombotic agents used. Bleeding complications have important clinical implications, which may outweigh the expected benefit of reducing thrombotic events. Herein, we provide a comprehensive description of the classification and clinical relevance of high bleeding risk in patients undergoing coronary and structural heart interventions., Competing Interests: Disclosure M. Galli declares that he has received honoraria from Terumo, outside the present study. D. D’Amario reports no disclosures for the present study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Although data suggests ad hoc percutaneous coronary intervention (PCI) results in similar patient outcomes compared to planned PCI in nonselected patients, data for ad hoc unprotected left main stem PCI (uLMS-PCI) are lacking., Aim: To determine if in-hospital outcomes of uLMS-PCI vary by ad hoc versus planned basis., Methods: Data were analyzed from all patients undergoing uLMS-PCI in the United Kingdom 2006-2018, and patients grouped into uLMS-PCI undertaken on an ad hoc or a planned basis. Patients who presented with ST-segment elevation, cardiogenic shock, or with an emergency PCI indication were excluded., Results: In total, 8574 uLMS-PCI procedures were undertaken with 2837 (33.1%) of procedures performed on an ad hoc basis. There was a lower likelihood of intervention for stable angina (28.8% vs. 53.8%, p < 0.001) and a higher rate of potent P2Y12 inhibitor use (16.4% vs. 12.1%, p < 0.001) in the ad hoc PCI group compared to the planned PCI group. Patients undergoing uLMS-PCI on an ad hoc basis tended to undergo less complex procedures. Acute procedural complications including slow flow (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.01-2.86), coronary dissection (OR: 1.41, 95% CI: 1.12-1.77) and shock induction (OR: 2.80, 95% CI: 1.64-4.78) were more likely in the ad hoc PCI group. In-hospital death (OR: 1.65, 95% CI: 1.19-2.27) and in-hospital major adverse cardiac or cerebrovascular events (OR: 1.50, 95% CI: 1.13-1.98) occurred more frequently in the ad hoc group. In sensitivity analyses, these observations did not differ when several subgroups were separately examined., Conclusions: Ad hoc PCI for uLMS disease is associated with adverse outcomes compared to planned PCI. These data should inform uLMS-PCI procedural planning., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: Non-eruptive calcium nodules (CNs) are commonly seen in heavily calcified coronary artery disease. They are the most difficult subset for modification, and may result in stent damage, malapposition and under-expansion. There are only limited options available for non-eruptive CN modification. Intravascular lithotripsy (IVL) is being explored as a potentially safe and effective modality in these lesions., Aims: This study aimed to investigate the safety and efficacy of the use of IVL for the modification of non-eruptive CNs. The study also explored the OCT features of calcium nodule modification by IVL., Methods: This is a single-center, prospective, observational study in which patients with angiographic heavy calcification and non-eruptive CN on OCT and undergoing PCI were enrolled. The primary safety endpoint was freedom from perforation, no-reflow/slow flow, flow-limiting dissection after IVL therapy, and major adverse cardiac events (MACE) during hospitalization and at 30 days. MACE was defined as a composite of cardiac death, myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR). The primary efficacy endpoint was procedural success, defined as residual diameter stenosis of <30% on angiography and stent expansion of more than 80% as assessed by OCT., Results: A total of 21 patients with 54 non-eruptive CNs undergoing PCI were prospectively enrolled in the study. Before IVL, OCT revealed a mean calcium score of 3.7 ± 0.5 and a mean MLA at CN of 3.9 ± 2.1 mm 2 . Following IVL, OCT revealed calcium fractures in 40 out of 54 (74.1%) CNs with an average of 1.05 ± 0.72 fractures per CN. Fractures were predominantly observed at the base of the CN (80%). Post IVL, the mean MLA at CN increased to 4.9 ± 2.3 mm 2 . After PCI, the mean MSA at the CN was 7.9 ± 2.5 mm 2 . Optimal stent expansion (stent expansion >80%) at the CN was achieved in 85.71% of patients. All patients remained free from MACE during hospitalization and at the 30-day follow-up. At 1-year follow-up, all-cause death had occurred in 3 (14.3%) patients., Conclusions: This single-arm study demonstrated the safety, efficacy, and utility of the IVL in a subset of patients with non-eruptive calcified nodules. In this study, minimal procedural complications, excellent lesion modifications, and favorable 30-day and 1-year outcomes were observed., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: Patients with chronic kidney disease and CAD have been denied revascularization because of fear of precipitating acute renal failure from contrast exposure. Skepticism on whether Ultra-Low contrast percutaneous coronary intervention (PCI) or Zero contrast PCI (ULC/ZC PCI) can be safely performed has limited its adoption., Methods: This observational registry enrolled 200 consecutive patients referred for elective PCI at a single center from June 2021 to December 2022. The study investigated whether the clinical outcomes of PCI performed with UL/ZC-PCI (n-48) were comparable to outcomes following standard PCI (n-152)., Results: Both groups were well matched in baseline and procedural characteristics. The groups had a highly statistical difference in the use of CV. Mean CV was 19.17 ± 7.29 cc in the ULC/ZC-group and 147.14 ± 73.55 cc in the control arm. The principal findings of the study were that the incidence of ontrast-induced acute kidney injury (AKI) was eightfold lower in patients receiving UL/ZC compared to the control group that received standard PCI. The incidence of all-cause mortality, myocardial infarction and major bleeding were similar in both groups. At 6 months, the decrement in renal function was lower in the group that received lower volumes of contrast., Conclusions: This single center observational registry demonstrated that UL-C/ZC-PCI is safe and effective in a broad spectrum of complex lesions. The skillsets needed to perform this are teachable, widely applicable and do not require a large upgrade of capital equipment. AKI rates and decrement in renal function at 6 months were both significantly lower in the UL-ZC group., (© 2024 Wiley Periodicals LLC.)

Background: Calcification within chronic total occlusions (CTO) is strongly associated with worse outcomes. Despite the excellent success and safety of intravascular lithotripsy (IVL) in heavily calcified lesions, evidence in CTO remains scarce., Aim: This study aimed to evaluate the procedural and long-term clinical outcomes of IVL in heavily calcified CTO., Methods: Patients who underwent IVL between 2019 and 2024 from an ongoing prospective multicenter registry were eligible for inclusion. Patients were therefore classified in CTO and non-CTO groups. The efficacy and safety endpoints of CTO percutaneous coronary interventions were defined according to the CTO-ARC consensus. In-hospital major adverse cardiovascular events (MACE) included cardiac death, nonfatal myocardial infarction and target lesion revascularization (TVR)., Results: A total of 404 patients underwent IVL, of which the treated lesion was a CTO in 33 (8.2%). The mean J-CTO score was 2.3 ± 1.1. Device success showed no significant difference between CTO and non-CTO groups (100% vs 98.4%; p = 0.35). Comparable technical success with residual stenosis <30% was observed in both groups (90.1% in CTO vs 89.2% in non-CTO, p = 0.83). The incidence of MACE was similar across groups during hospital stays (CTO 6.0% vs. non-CTO 1.9%, p = 0.12), at 30-day (CTO 9.1% vs. non-CTO 3.0%, p = 0.07), and at 12-month follow-up (CTO 9.1% vs. non-CTO 7.3%, p = 0.70)., Conclusion: IVL provides high procedural success and consistent clinical outcomes in both CTO and non-CTO cases, reinforcing its role in managing heavily calcified coronary lesions., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Dual antiplatelet therapy (DAPT), comprising both aspirin and the P2Y 12 receptor inhibitor, is crucial in managing patients with coronary artery disease following percutaneous coronary intervention (PCI). The optimal duration for DAPT in patients with angiography-detected moderate-to-severe calcified coronary (MSCC) lesions who underwent PCI with drug-eluting stents (DES) implantation remains uncertain. We recruited patients with angiography-detected MSCC lesions who received DES implantation from the prospective Fuwai Percutaneous Coronary Intervention Registry. Patients were classified into two groups according to the duration of DAPT: those with a DAPT duration of one year or less, and those with a DAPT duration of more than one year. The primary endpoint was the major adverse cardiovascular and cerebrovascular event, which was defined as composed of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. The key-safety endpoint was bleeding type 2, 3, or 5 according to the Bleeding Academic Research Consortium criteria. There were 1730 patients included in the study, and 470 (27.17 %) continued DAPT for more than one year after undergoing MSCC-PCI with DES implantation. The median follow-up time was 2.5 years. DAPT>1-year versus ≤1-year DAPT was significantly associated with a reduced risk of the primary outcome (1.59 % versus 3.19 %; adjusted hazard ratio=0.44; 95 % CI: 0.22-0.88). Similar trends were observed for all-cause death (0.16 % versus 1.91 %; P<0.001) and cardiovascular death (0.08 % versus 1.06 %; P=0.001). There was no significant difference in the key-safety endpoint between 2 regimens (1.75 % versus 0.85 %; adjusted hazard ratio=1.95; 95 % CI: 0.65-5.84). In conclusion, long-term DAPT after DES implantation in patients with MSCC lesions resulted in improved clinical outcomes at 2.5 years. This was achieved by reducing the risk of ischemia without increasing clinically significant bleeding., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)