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Heart failure (HF) is a significant public health concern characterized by notable rates of morbidity and mortality. Multimorbidity, ranging from 43% to 98% among HF patients, significantly impacts prognosis and treatment response. HF management requires a holistic approach, including guideline-directed medical therapy. Sacubitril/valsartan (angiotensin receptor neprilysin inhibitor [ARNI]) is a cornerstone of HF treatment, supported by robust evidence from large-scale clinical trials across different levels of left ventricular ejection fraction. The recommendations presented in this paper have been developed by a group of cardiologists in India who convened in expert opinion meetings to discuss the utilization of ARNI in chronic HF patients with five different comorbid conditions like type 2 diabetes mellitus (T2DM), chronic kidney disease, myocardial infarction (MI), obesity, and hypertension. Key focus areas include initiation, dose titration, and management across different HF phenotypes and comorbidities. Emphasis is placed on the efficacy of ARNI irrespective of glycemic status in the T2DM population, its role in HF patients with obesity, and addressing challenges related to renal function decline and hyperkalemia. Additionally, the document highlights ARNI’s potential benefits in hypertensive and post-MI HF patients, alongside observations on the obesity paradox in HF prognosis. Overall, these recommendations aim to optimize ARNI therapy in HF patient populations with different comorbidities, addressing specific challenges and considerations to improve outcomes and quality of life.

Percutaneous coronary intervention (PCI) of calcified coronary arteries is associated with poor outcomes. Poorly modified calcified lesion hinders the stent delivery, disrupts drug-carrying polymer, impairs drug elution kinetics and results in under-expanded stent (UES). UES is the most common cause of acute stent thrombosis and in-stent restenosis after PCI of calcified lesions. Angiography has poor sensitivity for recognition and quantification of coronary calcium, thereby mandating the use of intravascular imaging. Intravascular imaging, like intravascular ultrasound and optical coherence tomography, has the potential to accurately identify and quantify the coronary calcium and to guide appropriate modification device before stent placement. Available options for the modification of calcified plaque include modified balloons (cutting balloon, scoring balloon and high-pressure balloon), atherectomy devices (rotational atherectomy and orbital atherectomy) and laser atherectomy. Coronary intravascular lithotripsy (IVL) is the newest addition to the tool box for calcified plaque modification. It produces the acoustic shockwaves, which interact with the coronary calcium to cause multiplanar fractures. These calcium fractures increase the vessel compliance and result in desirable minimum stent areas. Coronary IVL has established its safety and efficacy for calcified lesion in series of Disrupt CAD trials. Its advantages over atherectomy devices include ease of use on workhorse wire, ability to modify deep calcium, no debris embolization causing slow flow or no-flow and minimal thermal injury. It is showing promising results in modification of difficult calcified lesion subsets such as calcified nodule, calcified left main bifurcation lesions and chronic total occlusion. In this review, authors will summarize the mechanism of action for IVL, its role in contemporary practice, evidence available for its use, its advantages over atherectomy devices and its imaging insight in different calcified lesion scenarios.

Objective: The present study was designed to establish the correlation between anatomical variables analyzed using optical coherence tomography (OCT) and physiological assessment provided by fractional flow reserve (FFR, ≤0.8) in patients with significant coronary artery stenosis. Materials and Methods: This was a prospective, single-center observation study which included total fifty patients who were diagnosed with coronary artery disease in the presence of significant stenosis (>70%) as per coronary angiography. The FFR ≤0.8 was considered as positive with severe stenosis. Minimal luminal area (MLA), minimal luminal diameter (MLD), percent area stenosis, and percent diameter stenosis were calculated as OCT variables in all patients. Results: The mean age of the patients was 56 ± 7.13 years. The mean FFR was found to be 0.72 ± 0.06. The OCT-derived MLA was 1.97 ± 0.53 mm2 and MLD was 1.35 ± 0.22 mm. The Pearson correlation coefficients of OCT-derived MLA (cutoff: 2 mm2) and MLD (cutoff: 1.24 mm) with FFR were 0.21 (P < 0.05) and 0.03 (P < 0.05) with 67% and 71% diagnostic efficiency, respectively. Conclusion: The study identified a significant correlation between OCT-derived MLA (poor)/MLD (moderate) and FFR (≤0.8). Thus, both the techniques, when performed collectively, provide valuable information regarding coronary artery morphology and physiology.