PCI

… without resorting to coronary artery bypass surgery (CABG). PCI usually starts by inflating a balloon within the coronary artery stenosis (percutaneous transluminal coronary angioplasty)…

… need for emergency coronary artery bypass surgery… percutaneous coronary interventions to distinguish them from conventional balloon angioplasty (percutaneous transluminal coronary …

… A wide range of patients may be considered for percutaneous coronary intervention. It is essential that the benefits and risks of the procedure, as well as coronary artery bypass graft …

Context Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown. Objective To assess …

Percutaneous coronary intervention (PCI) continues to advance at pace with an ever-broadening indication. In this article we will review the recent technological advances in PCI that have enabled more complex coronary disease to be treated. The choice of revascularisation strategy must take into account the evidence—just because we can treat by PCI does not necessarily mean we should. When PCI is indicated, a safe, precision PCI approach guided by physiology, imaging and optimal lesion preparation should be the goal to obtain complete revascularisation and a durable long-term result. When these standards are adhered to, the outcomes can be excellent, in even complex coronary disease. We provide contemporary trial evidence to justify PCI and treatment algorithms that ensure optimal revascularisation decision making to achieve the best patient outcomes.

… Kaplan–Meier curves are shown for the percutaneous coronary intervention (PCI) group and the coronary-artery bypass grafting (CABG) group for death from any cause (Panel A); death…

… ESC Guidelines for percutaneous coronary interventions (PCI), however, have not been established. It is the purpose of these guidelines to give practically oriented recommendations …

The field of interventional cardiology has evolved significantly since the first percutaneous transluminal coronary angioplasty was performed 40 years ago. This evolution began with a balloon catheter mounted on a fixed wire and has progressed into bare-metal stents (BMS), first-generation drug-eluting stents (DES), second- and third-generation biodegradable polymer-based DES, and culminates with the advent of bioabsorbable stents, which are currently under development. Each step in technological advancement has improved outcomes, while new persisting challenges arise, caused by the stent scaffolds, the polymers employed, and the non-selective cytostatic and cytotoxic drugs eluted from the stents. Despite the promising technological advances made in stent technology, managing the balance between reductions in target lesion revascularization, stent thrombosis, and bleeding remain highly complex issues. This review summarizes the evolution of percutaneous coronary intervention with a focus on vascular dysfunction triggered by the non-selective drugs eluted from various stents. It also provides an overview of the mechanism of action of the drugs currently used in DES. We also discuss the efforts made in developing novel cell-selective drugs capable of inhibiting vascular smooth muscle cell (VSMC) proliferation, migration, and infiltration of inflammatory cells while allowing for complete reendothelialization. Lastly, in the era of precision medicine, considerations of patients’ genetic variance associated with myocardial infarction and in-stent restenosis are discussed. The combination of personalized medicine and improved stent platform with cell-selective drugs has the potential to solve the remaining challenges and improve the care of coronary artery disease patients.

In contemporary practice, more than one in five patients treated with percutaneous coronary intervention (PCI) are aged ≥75 years and the proportion of elderly individuals in the …

In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset…

… The possible benefits of percutaneous coronary intervention (PCI) in the management of stable patients with coronary artery disease (CAD) in nonacute settings have been debated for …

Percutaneous coronary intervention is a well-established symptomatic therapy of stable coronary artery disease. Using a literature search with special emphasis on the newly-published FAME 2 trial data, the author wanted to explore why percutaneous coronary intervention fails to reduce mortality and myocardial infarction in stable coronary artery disease, as opposed to surgical revascularisation. In the FAME 2 trial, fractional flow reserve-guided percutaneous coronary intervention with second generation drug eluting stents showed a significant reduction in the primary composite endpoint of 2-year mortality, myocardial infarction and unplanned hospitalization with urgent revascularisation as compared to medical therapy alone. In addition, landmark analysis showed that after 8 days, mortality and myocardial infarction were significantly reduced. The author concludes that percutaneous coronary intervention involving fractional flow reserve guidance and modern stents offers symptomatic, as well as prognostic benefit. Orv. Hetil., 2014, 155(49), 1952–1959.

In the twenty-six years since Gruntzig introduced a simple balloon angioplasty technique, percutaneous coronary intervention has undergone extraordinary growth and has now …

… Percutaneous coronary intervention was completed successfully without conversion to manual operation, and device technical success was achieved in 162 of 164 patients (98.8%). …

Ever since coronary angioplasty was first undertaken, treatment of coronary bifurcation lesions has posed technical problems.w1 w2 Specific difficulties involving access to the side branch and the snow plough effect, as well as the role of kissing balloon inflation, have been rapidly identified even before the era of near universal stenting. Consequently, until the late 1980s, patients with bifurcation lesions were generally referred for surgery and seldom treated by percutaneous techniques. However, in cases where angioplasty was considered an option, the kissing dilatation technique was widely used in order to avoid recurrent problems of plaque shifting observed when the two branches were dilated separately.w3 The new tools developed in the early 1990s seemed likely at first to facilitate the approach to bifurcation lesions. However, the results achieved with the debulking technique alone (rotative or directional atherectomy) were rather disappointing. Conversely, coronary stenting through its scaffolding properties became the treatment of choice, at least for reducing the risk of acute complications. In the mid 1990s, the question remained as to how to perform optimal stenting of the main branch while preserving the side branch. The data collected from bench test studies proved crucial. They allowed the operators to understand stent behaviour and the effect of empirically implemented strategies, and to develop new concepts such as dedicated stents. Numerous techniques of stent deployment in bifurcation lesions have been described.1–5w4–w21 These techniques have been indexed6 in our institution and evaluated in vitro in a bench test mimicking coronary bifurcations with diameters of 3.5 mm for the main branch and 3.00 mm for the side branch. The pitfalls of such a model are the absence of stenosis, the constant longitudinal diameter of the main branch, and the impossibility to study other branch diameters. Nevertheless, the problem of access …

Complications of percutaneous coronary intervention (PCI) may have significant impact on patient survival and healthcare costs. PCI procedural complexity and patient risk are increasing, and operators must be prepared to recognize and treat complications, such as perforations, dissections, hemodynamic collapse, no-reflow, and entrapped equipment. Unfortunately, few resources exist to train operators in PCI complication management. Uncertainty regarding complication management could contribute to the undertreatment of patients with high-complexity coronary disease. We, therefore, coordinated the Learning From Complications: How to Be a Better Interventionalist courses to disseminate the collective experience of high-volume PCI operators with extensive experience in chronic total occlusion and high-risk PCI. From these conferences in 2018 and 2019, we developed algorithms that emphasize early recognition, effective treatment, and team-based care of PCI complications. We think that an algorithmic approach will result in a logical and systematic response to life-threatening complications. This construct may be useful for operators who plan to perform complex PCI procedures.

… first coronary angioplasty by Grüntzig 2 in Zurich, Switzerland—we reflect on the progress in percutaneous coronary … coronary intervention, we focus on balloon angioplasty catheters, …

… In our study, stent implantation resulted in a larger coronary … flow after routine stenting than after primary angioplasty. This trend … in other trials of stenting for acute myocardial infarction. …

… Almost 900,000 coronary angioplasty procedures were performed worldwide in 1995. Since 1994, the use of balloon angioplasty has leveled off, while the use of coronary stents has …

… stent implantation and balloon angioplasty for new lesions in small coronary arteries. … , a prospective comparison of stent placement and balloon angioplasty for small coronary arteries, …

… Coronary-stent placement is a new technique in which a … a coronary stenosis. The purpose of this study was to compare the effects of stent placement and standard balloon angioplasty …

… coronary stenting, as compared with balloon angioplasty, reduces the frequency of restenosis after previously successful balloon angioplasty… of restenosis after coronary stent placement …

… for a second coronary angioplasty in the stent group (relative … the stent group and 2.05 ±0.33 mm in the angioplasty group; … the stent group and 1.73 ±0.55 mm in the angioplasty group (…

Coronary stents are routinely placed in the treatment and prophylaxis of coronary artery disease (CAD). Current coronary stent designs are prone to developing blockages: in-stent thrombosis (IST) and in-stent re-stenosis (ISR). This is a systematic review of the design of current coronary stent models, their structural properties and their modes of application, with a focus on their associated risks of IST and ISR. The primary aim of this review is to identify the best stent design features for reducing the risk of IST and ISR. To review the three major types of stents used in clinical settings today, determining best and relevant clinical practice by exploring which types and features of offer improved patient outcomes regarding coronary angioplasty. This information can potentially be used to increase the success rate of coronary angioplasty and stent technology in the future taking into account costs and benefits. Scientific databases were searched to find studies concerning stents. After the exclusion criteria were applied, 19 of the 3192 searched literature were included in this review. Studies investigating three major types of stent design were found: bare-metal stents (BMS), drug-eluting stents (DES) and bioresorbable stents (BRS). The number of participants varied between 14 and 1264. On average 77.4% were male, with a mean age of 64 years. From the findings of these studies, it is clear that DES are superior in reducing the risk of ISR when compared to BMS. Conflicting results do not clarify whether BRS are superior to DES at reducing IST occurrence, although studies into newer BRS technologies show reducing events of IST to 0, creating a promising future for BRS showing them to be non-inferior. Thinner stents were shown to reduce IST rates, due to better re-endothelialisation. Scaffold material has also been shown to play a role with cobalt alloy stents reducing the risk of IST. This study found that thinner stents that release drugs were better at preventing re-blockages. Some dissolvable stents might be better at stopping blood clots blocking the arteries when compared to metal stents. The method and procedure of implanting the stent during coronary angioplasty influences success rate of these stents, meaning stent design is not the only significant factor to consider. Positive developments in coronary angioplasty could be made by designing new stents that encompass all the most desirable properties of existing stent technology. Further work is needed to investigate the benefits of BRS in reducing the risk of IST compared to DES, as well as to investigate the effects of different scaffold materials on IST and ISR outcomes.

… that the use of coronary-artery stenting as the initial treatment for coronary stenosis is associated with a lower risk of restenosis than is standard coronary angioplasty. We prospectively …

… Coronary artery stenting is associated with lower rates of restenosis compared with PTCA in … patients receiving coronary stents 16 but similar rates of restenosis after coronary stenting in …

… implantation of endoluminal stents for acute vessel closure after coronary balloon angioplasty. Nine patients received one stent, and two patients received two stents during the study …

Objectives—To undertake a systematic review of the clinical effectiveness of routine percutaneous transluminal coronary angioplasty (PTCA) plus stenting vs PTCA alone. Data sources…

… balloon angioplasty in the setting of AMI (13–16). We report the results of the second STENTing … systematic coronary stenting using the Wiktor (Medtronic) stent to conventional balloon …

OBJECTIVE—Coronary artery disease is a significant source of morbidity and mortality in patients with diabetes. Angioplasty has been associated with higher rates of restenosis in patients with diabetes. Numerous studies have been performed to determine whether coronary artery stenting would be useful in decreasing rates of restenosis of coronary vessels in patients with diabetes. This meta-analysis was conducted to determine the effect of diabetes on angiographic restenosis in patients undergoing coronary stenting. RESEARCH DESIGN AND METHODS—Six studies were included comprising 6,236 individuals—1,166 with diabetes and 5,070 without. The relationships between restenosis rates and age, the percentage of the study population that was male, and the percentage of the study population receiving insulin therapy were examined. RESULTS—The average restenosis rates among patients with and without diabetes were 36.7 and 25.9%, respectively. Restenosis rates were higher among older populations and populations in which a greater percentage of patients with diabetes were treated with insulin, but they did not vary according to the percentage of men in the studies. The odds ratio of coronary artery restenosis associated with diabetes was 1.61 (95% CI 1.21–2.14, P = 0.004) in univariate logistic regression models, but decreased to 1.30 (0.99–1.70, P = 0.055) after controlling for age in multivariate models, suggesting that the higher restenosis rates found in patients with diabetes can in good part be explained by the older ages of patients with diabetes in these studies. CONCLUSIONS—Although diabetes is a risk factor for restenosis after coronary angioplasty stenting, the apparent effect of diabetes on restenosis rates in the published literature is overstated and was reduced in this meta-analysis by approximately half after adjusting for differences in age.

… retrospective studies (22-25) suggestiug that stenting of chronic coronary occlusion may … to the stent group, one or more coronary stents were implanted with the aim to stent the entire …

… thrombolytic therapy, primary percutaneous transluminal coronary angioplasty (PTCA) in acute … When used in combination with PTCA, coronary stenting and platelet glycoprotein IIb/IIIa …

… coronary intervention”, and “medical therapy”),8 updated to March 2015. We also drew on our … of coronary angioplasty and medical treatment of patients with stable coronary artery …

… stent implantation with balloon angioplasty in patients with stable angina and a de novo coronary … of restenosis and fewer clinical events in the stent group. It is not established whether …

… total coronary occlusion before stenting. The placement of stents in the right coronary artery … to the LAD (10.1%) and left circumflex coronary artery (7.9%). The paucity of side branches …

The nonsurgical treatment of arteries narrowed by atherosclerosis was introduced in 1964, when Dotter and Judkins performed transluminal angioplasty of femoral arterial stenoses 1 . …

… IN 1979, the National Heart, Lung, and Blood Institute established a voluntary registry of percutaneous transluminal coronary angioplasty to evaluate the safety and efficacy of this new …

… reported short-term results in 50 patients who had undergone coronary angioplasty. The … who are currently treated with percutaneous transluminal coronary angioplasty. Because of the …

… report of complications with percutaneous transluminal coronary angioplasty (abstr). Am J … Percutaneous transiuminal coronary angioplasty: report from the NHLBI PTCA Registry. Am …

… 1988, 4988 percutaneous transluminal coronary angioplasty … after percutaneous transluminal coronary angioplasty included … , prior percutaneous transluminal coronary angioplasty, …

… In percutaneous transluminal coronary angioplasty, a catheter system is introduced through a systemic artery under local anesthesia to dilate a stenotic artery by controlled inflation of a …

… This study sought to compare procedural and clinical outcomes of percutaneous transluminal coronary angioplasty (PTCA) performed with 6F guiding catheters introduced through the …

… When resources limit access to angiography, the magnitude of benefit with angioplasty … percutaneous transluminal coronary angioplasty with medical treatment in non-acute coronary …

… Of 6,500 percutaneous transluminal coronary angioplasty procedures performed … and angioplasty for unstable angina (n = 193, mortality 1.5%), and percutaneous transluminal coronary …

… Percutaneous transluminal coronary angioplasty in patients with stable and unstable angina pectoris: Analysis of early and late results Percutaneous transluminal coronary angioplasty (…

… To date, the baseline status and subsequent outcomes of diabetic coronary angioplasty (percutaneous transluminal coronary angioplasty, or PTCA) patients with advanced …

… PERCUTANEOUS transluminal coronary angioplasty (PTCA) was introduced in 19771 and … ment of selected patients with symptomatic coronary artery occlusive disease. In March 1979…

… Specifically, patients with diabetes mellitus account for approximately 10% to 20% of patients currently undergoing percutaneous transluminal coronary angioplasty (PTCA). Several …

… coronary angioplasty. In 20 … Percutaneous transluminal coronary angioplasty has an established role as a nonsurgical revascularization procedure in selected patients with coronary …

… coronary angioplasty, 1.72 ą 0.52 mm on day 1, 1.86 ą Percutaneous transluminal coronary angioplasty … selected patients with coronary artery disease. Its long-term efficacy is limited by …

… For this reason, percutaneous transluminal coronary angioplasty … coronary angioplasty in patients >65 years of age (6-14), there are few data to guide the clinician regarding angioplasty …

… of 5,400 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures, 12 patients had complicattons resulting in retention of 1 or more PTCA equipment …

… coronary artery in 12 patients undergoing elective percutaneous transluminal coronary angioplasty … second of two periods of coronary artery occlusion during percutaneous transluminal …

Multivessel disease (MVD) affects approximately 50% of patients with acute coronary syndromes (ACS) and is significantly burdened by poor outcomes and high mortality. It represents a clinical challenge in patient management and decision making and subtends an evolving research area related to the pathophysiology of unstable plaques and local or systemic inflammation. The benefits of complete revascularization are established in hemodynamically stable ACS patients with MVD, and guidelines provide some reference points to inform clinical practice, based on an evidence level that is solid for ST-segment elevation myocardial infarction and less robust for non-ST-segment elevation myocardial infarction and cardiogenic shock. However, several areas of uncertainty remain, such as the optimal timing for complete revascularization or the best guiding strategy for intermediate stenoses. We performed a systematic review of current evidence in the field of percutaneous revascularization in ACS and MVD, also including future perspectives from ongoing trials that will directly compare different timing strategies and investigate the role of invasive and noninvasive guidance techniques. (Complete percutaneous coronary revascularization in patients with acute myocardial infarction and multivessel disease; CRD42022383123).

… The concept of complete revascularization arose from the early studies on coronary artery … The development of percutaneous coronary interventions (PCIs) for the treatment of coronary …

… Coronary balloon angioplasty using the percutaneous … Since then, percutaneous coronary revascularization has been … , together now known as percutaneous coronary intervention (PCI)…

Background : Randomized trial data support the superiority of coronary artery bypass grafting (CABG) surgery over percutaneous coronary intervention (PCI) in diabetic patients with …

… There is speculation that the volume of percutaneous coronary interventions (PCIs) has been … This study describes the use of coronary angiography and revascularization methods in …

… had undergone percutaneous coronary revascularization at … During the period from the introduction of coronary balloon … underwent percutaneous coronary revascularization and did not …

… societies, released Appropriate Use Criteria for Coronary Revascularization to critically examine and improve patient selection for percutaneous coronary intervention (PCI) as well as …

BACKGROUND Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI. OBJECTIVES This study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality. METHODS We performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored. RESULTS The analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001). CONCLUSIONS This individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization.

… Through advances in percutaneous interventional techniques and … , current percutaneous coronary intervention may allow appropriate patients to benefit safely from revascularization …

… of revascularization by percutaneous coronary intervention … impact of incomplete revascularization outside of randomized … and subsequent revascularization for percutaneous …

Persistence or recurrence of angina after a percutaneous coronary intervention (PCI) may affect about 20-40% of patients during short-medium-term follow-up. This appears to be true even when PCI is 'optimized' using physiology-guided approaches and drug-eluting stents. Importantly, persistent or recurrent angina post-PCI is associated with a significant economic burden. Healthcare costs may be almost two-fold higher among patients with persistent or recurrent angina post-PCI vs. those who become symptom-free. However, practice guideline recommendations regarding the management of patients with angina post-PCI are unclear. Gaps in evidence into the mechanisms of post-PCI angina are relevant, and more research seems warranted. The purpose of this document is to review potential mechanisms for the persistence or recurrence of angina post-PCI, propose a practical diagnostic algorithm, and summarize current knowledge gaps.

… to percutaneous revascularization in patients with coronary artery … and efficacy of percutaneous coronary intervention (PCI), we … The lack of optimal revascularization observed in half of …

Over the last 4 decades, percutaneous coronary intervention has evolved dramatically and is now an acceptable treatment option for patients with advanced coronary artery disease. However, trialists have struggled to establish the respective roles for percutaneous coronary intervention and coronary artery bypass graft surgery, especially in patients with multivessel disease and unprotected left-main stem coronary artery disease. Several pivotal trials and meta-analyses comparing these 2 revascularization strategies have enabled the relative merits of each technique to be established with regard to the type of ischemic syndrome, the coronary anatomy, and the patient's overall comorbidity. Precision medicine with individualized prognosis is emerging as an important method of selecting treatment. However, the never-ending advancement of technology, in conjunction with the emergence of novel pharmacological agents, will in the future continue to force us to reconsider the evolving question: "Which treatment strategy is better and for which patient?"

… The central finding of the present study is that percutaneous revascularization procedures of coronary vessels with luminal reference diameters of ≤2.5 mm are associated with lower …

… Advances in both the percutaneous and surgical fields have opened opportunities for … durable coronary revascularization strategies. Integrated or hybrid coronary revascularization …

Background Women hospitalized with a non‐ST segment elevation acute coronary syndrome (ACS) have worse clinical outcomes compared with men. An early invasive strategy with prompt coronary revascularization may mitigate sex differences in outcomes. However, few contemporary studies have evaluated whether clinical outcomes differ between women and men presenting with ACS treated with an early invasive strategy. Methods and Results A population‐based cohort of hospitalized ACS patients who received prompt cardiac catheterization from 2008 to 2011 in Ontario, Canada and followed for up to 2 years was studied. Clinical outcomes were compared between men and women, stratified by the use of coronary revascularization. Inverse probability weighting using the propensity score accounted for measured differences in baseline characteristics between men and women. Among the 23 473 ACS patients who received cardiac catheterization during an index hospitalization, 66.1% of men and 51.8% of women received coronary revascularization during the same hospitalization. In the propensity‐weighted cohort of patients who received coronary revascularization, the 1‐year rate of death or recurrent ACS was 10.6% for men (referent) compared with 13.1% for women (hazard ratio 1.24; 95% CI 1.16–1.33). In contrast, outcomes for patients who did not receive coronary revascularization did not differ significantly between women and men at 1 year (17.8% versus 16.9%; hazard ratio 1.06; 95% CI 0.99–1.14) or at longer follow‐up. Conclusions An increased risk of adverse clinical outcomes was observed for women with ACS undergoing an early invasive strategy and coronary revascularization compared with men.

… small MIs with percutaneous coronary revascularization. … surgery, repeat percutaneous revascularization, and cardiac … flag about the percutaneous coronary procedures associated …

… Major technical advances in the field of percutaneous coronary revascularization have … and restenosis rates in patients with diabetes, including coronary stents (31), glycoprotein IIB/IIIA …

… Although elderly patients with coronary artery disease tend to be treated less aggressively than nonelderly patients, the use of percutaneous coronary intervention (PCI) in the elderly is …

… A reduction in hospital admissions for acute coronary syndromes (ACS) has been observed … , formal evaluation of the variation in percutaneous coronary intervention (PCI) rates during …

… Thus, foundations were laid for reperfusion to be given as … -dependent standards to achieve reperfusion. Emphasis is also … in patients with STEMI are early reperfusion therapy and the …

… and without having received any prior reperfusion therapy. There is no standardised … of STEMI in the public or private sector. The key objectives of the SA Heart STEMI Early Reperfusion …

For almost 30 years, urgent revascularization termed primary percutaneous coronary intervention (pPCI) has been a cornerstone of modern care for acute myocardial infarction (AMI). It lowers mortality and improved cardiovascular outcome compared to conservative therapy including thrombolysis. Reperfusion injury, which occurs after successful re-opening of the formerly occluded coronary artery, had been exploited as a potential therapeutic target. When revascularisation became faster and pPCI was successfully performed within 60-90 minutes of symptom onset, the interest in a potential additive effect of targeting reperfusion injury vanished. More recently, several meta-analyses indicated that limiting reperfusion injury prevents microvascular obstruction and reduces final infarct size, thereby lowering the probability of heart failure events and improving quality of life in AMI survivors. Here, we describe the current strategies to limit reperfusion injury and to improve post-AMI outcomes such as systemic or intracoronary hypothermia, left-ventricular unloading, intracoronary infusion of super-saturated oxygen, intermittent coronary sinus occlusion, and C-reactive protein apharesis.

Objective Routine evaluation of performance measures for the system of care for patients with ST-elevation myocardial infarction (STEMI) is needed to improve the STEMI network. We sought to evaluate the current status of reperfusion therapy for STEMI in the capital city of a developing country where a STEMI network was introduced in 2010. Methods Data were obtained from a local registry. A total of 28 812 patients admitted to the emergency department of a national cardiovascular hospital in three different periods (2007, 2010 and 2013) were retrospectively analysed; there were 2703 patients with STEMI. Results In 2013 compared with 2007, there was a major increase in the number of primary percutaneous coronary interventions (PCIs) (35% vs 24%, p<0.001), and the proportion of non-reperfused patients fell (62.8% vs 67.7%, p<0.001). An improvement in the overall STEMI mortality rate was also observed (7.5% vs 11.7%, p<0.001). Conclusions Implementation of a regional system of care for STEMI may improve utilisation of primary PCI. Future organisation of reperfusion therapy in a developing country such as Indonesia strongly calls for a strategy that focuses on prehospital care to minimise delay from the first medical contact to reperfusion therapy, and this may reduce the proportion of non-reperfused patients. These strategies are in concordance with guideline recommendations and may reduce or eliminate gaps in healthcare in developing countries, particularly the underutilisation of evidence-based therapies for patients with STEMI. Trial registration number NCT 02319473, Clinicaltrials.gov.

AIMS Current European Society of Cardiology guidelines state that repetitive monitoring and feedback should be implemented for ST-elevation myocardial infarction (STEMI) treatment, but no evidence is available supporting this recommendation. We aimed to analyze the long-term effects of a formalized data assessment and systematic feedback on performance and mortality within the prospective, multicenter Feedback Intervention and Treatment Times in STEMI (FITT-STEMI) study. METHODS Regular interactive feedback sessions with local STEMI management teams were performed at six participating German percutaneous coronary intervention (PCI) centers over a 10-year period starting from October 2007. RESULTS From the first to the 10th year of study participation, all predefined key-quality indicators for performance measurement used for feedback improved significantly in all 4926 consecutive PCI-treated patients - namely, the percentages of patients with pre-hospital electrocardiogram (ECG) recordings (83.3% vs 97.1%, p < 0.0001) and ECG recordings within 10 minutes after first medical contact (41.7% vs 63.8%, p < 0.0001), pre-announcement by telephone (77.0% vs 85.4%, p = 0.0007), direct transfer to the catheterization laboratory bypassing the emergency department (29.4% vs 64.2%, p < 0.0001), and contact-to-balloon times of less than 90 minutes (37.2% vs 53.7%, p < 0.0001). Moreover, this feedback-related continuous improvement of key-quality indicators was linked to a significant reduction in in-hospital mortality from 10.8% to 6.8% (p = 0.0244). Logistic regression models confirmed an independent beneficial effect of duration of study participation on hospital mortality (odds ratio = 0.986, 95% confidence interval = 0.976-0.996, p = 0.0087). In contrast, data from a nationwide PCI registry showed a continuous increase in in-hospital mortality in all PCI-treated STEMI patients in Germany from 2008 to 2015 (n = 398,027; 6.7% to 9.2%, p < 0.0001). CONCLUSIONS Our results indicate that systematic data assessment and regular feedback is a feasible long-term strategy and may be linked to improved performance and a reduction in mortality in STEMI management.

BACKGROUND ST-segment-elevation myocardial infarction (STEMI) is uncommon among inpatients already admitted to the hospital for other indications. Prior studies reported significant differences in clinical characteristics and outcomes of patients who develop STEMI while hospitalized versus those who present with out-of-hospital STEMI. However, prior studies were small or not contemporary. METHODS We compared the characteristics and outcomes of patients presenting with STEMI at the time of hospital admission (preadmission STEMI) versus in-hospital STEMI (occurring during the hospitalization) using data from the National Cardiovascular Data Registry Chest Pain-MI Registry from 2019 to 2022. RESULTS A total of 112 590 patients (3.8% in-hospital STEMI, 96.2% preadmission STEMI) from 670 hospitals were included. Patients with in-hospital STEMI were significantly older (median age, 67 versus 63 years), more likely to be diabetic (37.6% versus 29.6%) and have CHF (13.7% versus 6.0%) compared with preadmission STEMI patients (all P<0.001). The median (interquartile range) time from ECG to first device activation (81 minutes [61-110] versus 69 [55-84]; P<0.0001) and time from cath laboratory arrival to first device time (28 minutes [21-39] versus 23 [18-30]; P<0.001) were significantly longer for in-hospital compared with preadmission STEMI patients. The incidence of major bleeding (25.5% versus 7.1%), cardiogenic shock (19.7% versus 7.0%), and cardiac arrest (22.3% versus 7.3%) were all significantly higher in the in-hospital STEMI cohort (all P<0.001), as was mortality (25.9% versus 5.6%; adjusted OR, 5.7 [95% CI, 5.0-6.4]; P<0.001). CONCLUSIONS Patients who experience in-hospital STEMI represent a high-risk group, with significantly longer times from the diagnostic ECG to primary percutaneous coronary intervention, more complications, and higher mortality.

… , no strategy or intervention has been shown to prevent reperfusion injury or enhance … Primary PCI (PPCI) has become the mainstay of reperfusion therapy in patients with STEMI …

… and PCI after successful lysis reperfusion in 24- 48 hours, … associated with different STEMI reperfusion strategies from a “… alternative reperfusion strategies among patients with STEMI …

… coronary intervention is the preferred reperfusion … reperfusion strategies to achieve faster and more effective epicardial vessel and microvascular reperfusion in patients with STEMI and …

BackgroundST Segment Elevation Acute myocardial infarction (STEMI) preferred treatment is culprit artery reperfusion with primary percutaneous coronary intervention (PPCI). We ought to analyze the benefit of early reperfusion vs. optimal medical therapy in STEMI before and after the set-up of a regional STEMI network that prioritizes PPCI.MethodsBetween January 2002 and December 2013, 1268 STEMI patients were consecutively admitted in a University Hospital. Patients were classified in two groups: pre-STEMI Network (January 2002–June 2009; n = 670) and post-STEMI network (July 2009–December 2013; n = 598). Vital status was available at 2-year follow-up.ResultsThe STEMI network increased reperfusion (89.2% vs 64.4%, p < 0.001) mainly using PCI (99.0% vs 43.9%, p < 0.001). In univariate analysis, in-hospital mortality was significantly lower in the post-STEMI network period (2.51% vs. 7.16%, p < 0.001). After multivariate adjustment, including age, sex, comorbidities, severity and reperfusion therapy, a trend to a lower in-hospital mortality was observed (post-Network OR: 0.50, 95% CI:0.16–1.59, p = 0.24); this trend disappeared when optimal medical therapy was included in the model (post-Network OR: 1.14, 95% CI:0.32–4.08, p = 0.840). No differences in 2-year mortality were observed (post-Network HR: 0.83; CI 95%: 0.55–1.25, p = 0.37).ConclusionA STEMI network with PPCI 24/7 improved reperfusion therapy, resulting in an increase on PPCI. Despite in-hospital mortality decreased with a STEMI network, 2-year mortality remained similar in both periods, pre- and post-Network. Optimal medical therapy could be as important as reperfusion therapy in a STEMI reperfusion network.

… In this study, NAC improved myocardial reperfusion markers and coronary blood flow, as revealed by differences in peak hs-TnT and TIMI flow grade 3 levels, respectively. Further …

Background: Guidelines recommend primary percutaneous coronary intervention (PCI) in patients with ST-segment–elevation myocardial infarction (STEMI) presenting ≥12 hours of symptom onset in the presence of ongoing ischemia. However, data supporting this recommendation are limited. We evaluated the effect of primary PCI on reperfusion success, using cardiac magnetic resonance, in STEMI patients with signs of ongoing ischemia presenting 12 to 72 hours after symptom onset compared with STEMI patients presenting <12 hours. Methods and Results: We included 865 STEMI patients who underwent cardiac magnetic resonance just after index PCI and 3 months later. Despite equal area at risk (34±12% versus 33±12%; P=0.370), patients presenting late (n=58) had larger final infarct size (13% [interquartile range, 9–24] versus 11% [interquartile range, 4–19]; P=0.037) and smaller myocardial salvage index (0.58 [interquartile range, 0.39–0.71] versus 0.65 [interquartile range, 0.49–0.84]; P=0.021) compared with patients presenting <12 hours after symptom onset (n=807). However, 65% of late-presenting patients achieved substantial myocardial salvage ≥0.50, and area under the curve for symptom onset to PCI as predictor of a myocardial salvage index ≥0.50 was poor (0.58 [95% CI, 0.53–0.63]; P<0.001). In addition, final infarct size, salvage index and left ventricular function correlated weakly with duration from symptom onset to primary PCI (R2 values <0.05). Conclusions: STEMI patients with signs of ongoing ischemia treated with primary PCI 12 to 72 hours after symptom onset had less myocardial salvage and developed larger infarcts. However, a large proportion achieved substantial myocardial salvage indicating a benefit from primary PCI in late-presenting patients. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01435408 and NCT01960933.

Ischaemic heart disease (IHD) remains the leading cause of death and disability in Europe and worldwide. A major cause of morbidity and mortality in IHD patients is an acute ST-segment elevation myocardial infarction (STEMI), which despite prompt reperfusion by primary percutaneous coronary intervention (PPCI) has significant mortality (7% death at 1 year) and morbidity (22% prolonged or new hospitalization for heart failure at 1 year) in patients with large infarcts.1 When high-risk STEMI patients presenting with cardiogenic shock are not excluded, mortality at 1 year is even higher, at 12% after 1 year.2 As such, there remains an urgent need to discover novel therapies which can be given prior to or at the time of PPCI to reduce myocardial infarct (MI) size in order to preserve left ventricular (LV) systolic function, prevent the onset of heart failure, and improve survival in reperfused STEMI patients. In patients presenting with STEMI, rapid access to the emergency medical services and timely reperfusion by PPCI minimize the total ischaemic time, a major determinant of MI size. Although myocardial reperfusion is essential to salvage myocardium following a STEMI, the process of restoring coronary blood flow to the ischaemic tissue can, in itself, induce myocardial injury and cardiomyocyte death, a phenomenon which is known as ‘myocardial reperfusion injury’.3,4 Crucially, there is currently no effective therapy for reducing myocardial reperfusion injury in STEMI patients, and therefore, it remains a valid target for cardioprotection. However, the search for an effective therapy capable of targeting myocardial reperfusion injury and reducing MI size has been quite challenging, with a large number of failures to translate novel cardioprotective therapies into the …

There is a continuing controversy about the acceptable time-window for primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI). Recent American and European guidelines recommend PPCI if the delay in performing PPCI instead of administering fibrinolysis (PCI-related delay) is &lt;60 min and the presentation delay is more than 3 h. Based on a review of the literature, this viewpoint recommends a revision of the guidelines. The evidence supports an acceptable PCI-related delay of 80–120 min and PPCI as the better reperfusion strategy also in the early incomers. Furthermore, the previous assumption that PPCI is less time-dependent than fibrinolysis is questioned. To maximise the number of patients with STEMI eligible for PPCI the optimal logistic may be to establish the diagnosis in the prehospital phase, to bypass local hospitals and re-route patients directly to catheterisation laboratories running 24/7.

… interventions to improve timely reperfusion for patients presenting to emergency departments with STEMI. … to describe and classify interventions to reduce door to reperfusion time, and …

Contemporary management of ST-segment–elevation myocardial infarction (STEMI) is built around timely reperfusion therapies that aim to reduce infarct size and optimize patient outcome.1 Duration of ischemia, as a key determinant of infarct size, has been recognized since the 1970s, guided by the wave front phenomenon, whereby myocyte death is proportionate to the duration of coronary artery occlusion and starts from the endocardium.2 This knowledge has pushed pharmacological and catheter-based coronary interventions to minimize delay to reperfusion. Nonetheless, the relationship between the probability of death and ischemia time (defined as time from symptoms onset to reperfusion therapy) is nonlinear.3 In trials of thrombolysis, the maximal benefit was delivered within the first 2 hours.4 Therefore, the survival benefit from opening occluded artery is crucially related to time in the very early course of STEMI presentation; however, this relationship breaks down in patients presenting late.3,5 Remarkably, a time threshold to define late presentation (>12 hours) for primary percutaneous coronary intervention (PCI) was inferred from data derived from outcomes with lytic therapies, generating debate as to whether such an approach is appropriate.6 The LATE study (Late Assessment of Thrombolytic Efficacy) showed no morality benefits in patients presenting beyond 12 hours using thrombolytic therapy.7 Yet, mechanical recanalization of the infarct-related artery in the BRAVE-2 trial (Beyond 12 Hours Reperfusion Alternative Evaluation), albeit underpowered, showed prognostic benefit in patients with late STEMI presentation up to 48 hours.8 On the contrary, establishing flow in the epicardial coronary artery with PCI in very late presenters (3–28 days) in the OAT (Occluded Artery Trial) did not improve mortality or left ventricle ejection fraction during 4-year follow-up compared with medical therapy.5 It seems likely that time from symptom onset is, in part, a proxy for the downstream status of the myocardium. Duration of ischemia is related to extent of infarction and its complications, such as intramyocardial hemorrhage.9 However, time from symptom onset relies on accurate recollection and does not take into account individual variations such as intermittent or partial coronary occlusion, the extent of collateral circulation, degree of ischemic preconditioning, and the metabolic status within the ischemic myocardium.10 These deficiencies could be potentially be addressed if the myocardium could be accurately and promptly characterized, for example, by imaging. Imaging studies have consistently shown that substantial salvageable myocardium can occur in some patients, even with time onset from symptoms >48 hours.11 More importantly, the relationship between time from onset of symptoms and imaging surrogates of infarct severity was weak at most, highlighting the Mohammad Alkhalil, MRCP Robin P. Choudhury, DM EDITORIAL

Despite the current evidence supporting clinical benefits of fractional flow reserve (FFR), its uptake in the cardiac catheterization laboratory has been slow due to procedural cost and increased time with the need for maximum hyperemia. Recently, novel physiological indices derived from coronary angiography and intracoronary imaging have emerged to overcome issues with a wire-based FFR. Angiography-based FFR can be measured without vessel instrumentation and has shown excellent diagnostic performance using wire-based FFR as the reference standard. Thus, angiography-based FFR may facilitate coronary functional assessment before and after percutaneous coronary intervention (PCI). Angiography-based index of microcirculatory resistance (IMR) is another new computational index for assessing the coronary microcirculation. Although angiography-derived IMR remains in an early phase of development and requires further validation, its less-invasive nature may help broaden the adoption of microvascular functional assessment in various conditions such as myocardial infarction and cardiac allograft vasculopathy. Lastly, computational FFR based on intravascular ultrasound and optical coherence tomography allows detailed lesion assessment from both morphological and functional standpoints. Given a growing interest in physiology-guided PCI optimization strategies, intravascular imaging-based FFR may become the main assessment tool to confirm successful PCI.

Intermediate coronary artery stenosis, defined as visual angiographic stenosis severity of between 30-70%, is present in up to one quarter of patients undergoing coronary angiography. Patients with this particular lesion subset represent a distinct clinical challenge, with operators often uncertain on the need for revascularization. Although international guidelines appropriately recommend physiological pressure-based assessment of these lesions utilizing either fractional flow reserve (FFR) or quantitative flow ratio (QFR), there are specific clinical scenarios and lesion subsets where the use of such indices may not be reliable. Intravascular imaging, mainly utilizing intravascular ultrasound (IVUS) and optical coherence tomography (OCT) represents an alternate and at times complementary diagnostic modality for the evaluation of intermediate coronary stenoses. Studies have attempted to validate these specific imaging measures with physiological markers of lesion-specific ischaemia with varied results. Intravascular imaging however also provides additional benefits that include portrayal of plaque morphology, guidance on stent implantation and sizing and may portend improved clinical outcomes. Looking forward, research in computational fluid dynamics now seeks to integrate both lesion-based physiology and anatomical assessment using intravascular imaging. This review will discuss the rationale and indications for the use of intravascular imaging assessment of intermediate lesions, while highlighting the current limitations and benefits to this approach.

… fractional flow reserve (FFR), and resting measures such as instantaneous wave-free ratio (iFR), as well as other measures [27,28,29,30,31,32]. FFR … The clinical utility of FFR has been …

… FFR, leading to lively scientific debate about this index. In this review article, the concept, clinical value of FFR … -line comparison between iFR and FFR, in which FFR was measured with …

… characteristics of patients with moderate CAD and discordant FFR and CFR through comprehensive intracoronary imaging and coronary and microvascular physiological assessment. …

Intracoronary imaging has brought new insight in the field of interventional cardiology. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are the most commonly used imaging modalities. Regarding their technical characteristics IVUS and OCT have similarities as well as differences, a fact that could have significant clinical implications. Both techniques play an important role in percutaneous coronary intervention (PCI) guidance and demonstrated superiority compared to intravascular coronary angiography (ICA) guidance alone. Furthermore, their use can notably assist coronary plaque evaluation; both provide additional information of plaque characteristics, which can lead to a better understanding of the cause of an acute coronary syndrome (ACS) and better clinical outcomes. However, there is not enough clinical evidence for the superiority of one method compared to the other, something that is, also, reflected in the guidelines. In this review, we aim to compare role of IVUS and OCT in the different aspects of coronary artery disease (CAD), according to the latest scientific data. In addition, we present the future perspectives regarding the IVUS and OCT, with co-registration of the two methods or hybrid OCT-IVUS catheters.

### Learning objectives Although it is the tool used by most interventional cardiologists to assess the severity of coronary artery disease and guide treatment, coronary angiography has many limitations because it is a lumenogram depicting shadowgraph, planar projections of the contrast-filled lumen that are often foreshortened rather than imaging the diseased vessel itself. Intravascular imaging (IVI)—first intravascular ultrasound (IVUS) and recently optical coherence tomography (OCT) and near infrared spectroscopy (NIRS) and even combined modalities that are now available—provides tomographic or cross-sectional images of the coronary arteries. These techniques aid in physician decision-making, selection of treatment strategies, stent optimisation and answering questions that arise during percutaneous coronary interventions (PCI). Randomised controlled trials, registries and meta-analyses consistently support procedural and long-term benefits of IVI-guided PCI especially drug-eluting stent (DES) implantation. ### IVUS versus OCT An IVUS image is formed when ultrasound bounces off the layers of the artery and returns to the transducer that both emits and receives the ultrasound. There are two types of IVUS: (1) mechanical and (2) synthetic aperture array. The mechanical catheter has a single transducer mounted at the tip of a flexible drive shaft that is rotated and advanced or withdrawn within a stationary, short-monorail imaging sheath to scan the artery; current mechanical transducer frequencies range from 40 MHz to 60 MHz. The 20 mHz synthetic aperture array catheter has multiple, tiny transducer elements permanently affixed around the circumference of the catheter tip; they are fired sequentially to produce cross-sectional images, and the entire catheter must be withdrawn or advanced to scan the vessel. The synthetic aperture array has the lowest transducer frequency and temporal and …

… Intracoronary nitroglycerin (100 to 250 μg) was given before … However, in this study, FFR guidance in patients being … We cannot exclude that the use of uncaptured PCI guidance …

… Among 167 consecutive patients (177 lesions), 83 lesions were assessed by FFR and 94 lesions by IVUS. Intracoronary adenosine was used in 79 lesions to induce maximal hyperemia…

… technological advances, including the advent of intracoronary imaging (ICI) techniques. ICI … Even if an upgrade of guidelines is still uncertain, intracoronary imaging will certainly exert …

Percutaneous coronary intervention (PCI) guided by coronary physiology provides symptomatic benefit and improves patient outcomes. Nevertheless, over one-fourth of patients still experience recurrent angina or major adverse cardiac events following the index procedure. Coronary angiography, the current workhorse for evaluating PCI efficacy, has limited ability to identify suboptimal PCI results. Accumulating evidence supports the usefulness of immediate post-procedural functional assessment. This review discusses the incidence and possible mechanisms behind a suboptimal physiology immediately after PCI. Furthermore, we summarize the current evidence base supporting the usefulness of immediate post-PCI functional assessment for evaluating PCI effectiveness, guiding PCI optimization, and predicting clinical outcomes. Multiple observational studies and post hoc analyses of datasets from randomized trials demonstrated that higher post-PCI functional results are associated with better clinical outcomes as well as a reduced rate of residual angina and repeat revascularization. As such, post-PCI functional assessment is anticipated to impact patient management, secondary prevention, and resource utilization. Pre-PCI physiological guidance has been shown to improve clinical outcomes and reduce health care costs. Whether similar benefits can be achieved using post-PCI physiological assessment requires evaluation in randomized clinical outcome trials.

This systematic review and network meta‐analysis aimed to compare the accuracy of coronary angiographic‐derived fractional flow reserve (Angio‐FFR), optical coherence tomography (OCT)‐FFR, and intravascular ultrasound (IVUS)‐FFR in evaluating the severity of coronary artery stenosis.

Background Multiple coronary guidance strategies including angiography, physiology-based assessment, and intracoronary imaging are used to optimize percutaneous coronary intervention, yet their comparative effectiveness across clinical outcomes remains uncertain. Methods A comprehensive network meta-analysis incorporated fifty randomized studies evaluating angiography, FFR, iFR, IVUS, and OCT. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included all-cause mortality, cardiac death, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization. Random effects models were applied and interventions were ranked using SUCRA. Results A total of 50 studies involving 39,863 patients were included, of whom 29,571 were male and 10,031 were female. Across guidance modalities, 15,463 patients underwent angiography-guided PCI, 10,728 IVUS-guided, 6,001 FFR-guided, 3,512 iFR-guided, and 3,849 OCT-guided PCI. In the network meta-analysis, intravascular imaging strategies demonstrated favorable outcomes across evaluated endpoints. Compared with IVUS, angiography-guided PCI was associated with higher rates of major adverse cardiovascular events (RR 1.28, 95% CI 1.13–1.46), all-cause mortality (RR 1.30, 95% CI 0.98–1.63), myocardial infarction (RR 1.73, 95% CI 1.28–2.40), target lesion failure (RR 1.50, 95% CI 1.19–1.93), and stent thrombosis (RR 1.80, 95% CI 1.25–2.70). Physiology-guided PCI using iFR was associated with higher risk estimates for all-cause mortality (RR 1.72, 95% CI 1.06–2.79) and cardiac death (RR 2.21, 95% CI 1.24–4.24) compared with IVUS. OCT demonstrated outcomes comparable to IVUS, with no statistically significant differences in major adverse cardiovascular events (RR 1.00, 95% CI 0.80–1.28) or cardiac death (RR 0.86, 95% CI 0.47–1.59). Sensitivity analyses yielded similar estimates. Overall, probabilistic ranking analyses favored intravascular imaging strategies, although effect estimates among non-angiographic modalities overlapped. Conclusions Advanced PCI guidance strategies using intravascular imaging or invasive physiological assessment are associated with improved clinical outcomes compared with angiography alone. However, no single non-angiographic modality demonstrates definitive superiority, supporting individualized selection of guidance strategies based on clinical and procedural context. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251238909, identifier CRD420251238909.

Today, coronary artery disease (CAD) continues to be a prominent cause of death worldwide. A reliable assessment of coronary stenosis represents a prerequisite for the appropriate management of CAD. Nevertheless, there are still major challenges pertaining to some limitations of current imaging and functional diagnostic modalities. The present review summarizes the current data on invasive functional and intracoronary imaging assessment using optical coherence tomography (OCT), and intravascular ultrasound (IVUS). Amongst the functional parameters—on top of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR)—we point to novel angiography-based measures such as quantitative flow ratio (QFR), vessel fractional flow reserve (vFFR), angiography-derived fractional flow reserve (FFRangio), and computed tomography-derived flow fractional reserve (FFR-CT), as well as hybrid approaches focusing on optical flow ratio (OFR), computational fluid dynamics and attempts to quantify the forces exaggerated by blood on the coronary plaque and vessel wall.

… role of intracoronary imaging to … intracoronary imaging guidance on cardiovascular outcomes is summarized, and patients or lesions most likely to derive clinical benefit from an imaging-…

BACKGROUND Ultrasonic flow ratio (UFR) is a novel method for fast computation of fractional flow reserve (FFR) from intravascular ultrasound images. The objective of this study is to evaluate the diagnostic performance of UFR using wire-based FFR as the reference. METHODS Post hoc computation of UFR was performed in consecutive patients with both intravascular ultrasound and FFR measurement in a core lab while the analysts were blinded to FFR. RESULTS A total of 167 paired comparisons between UFR and FFR from 94 patients were obtained. Median FFR was 0.80 (interquartile range, 0.68-0.89) and 50.3% had a FFR≤0.80. Median UFR was 0.81 (interquartile range, 0.69-0.91), and UFR showed strong correlation with FFR (r=0.87; P<0.001). The area under the curve was higher for UFR than intravascular ultrasound-derived minimal lumen area (0.97 versus 0.89, P<0.001). The diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for UFR to identify FFR≤0.80 was 92% (95% CI, 87-96), 91% (95% CI, 82-96), 96% (95% CI, 90-99), 96% (95% CI, 89-99), 91% (95% CI, 93-96), 25.0 (95% CI, 8.2-76.2), and 0.10 (95% CI, 0.05-0.20), respectively. The agreement between UFR and FFR was independent of lesion locations (P=0.48), prior myocardial infarction (P=0.29), and imaging catheters (P=0.22). Intraobserver and interobserver variability of UFR analysis was 0.00±0.03 and 0.01±0.03, respectively. Median UFR analysis time was 102 (interquartile range, 87-122) seconds. CONCLUSIONS UFR had a strong correlation and good agreement with FFR. The fast computational time and excellent analysis reproducibility of UFR bears the potential of a wider adoption of integration of coronary imaging and physiology in the catheterization laboratory.

… -QP2 stent emphasize that late neointimal regrowth cannot be ruled out a priori with any drug-eluting stent. Furthermore, the histology of restenotic tissue from QuaDS-QP2 stents is …

… drug-eluting stents were analyzed (as specified in the study protocol) as having received a drug-eluting stent … bare-metal stents only and 48 (0.9%) in whom no stent could be implanted …

… landmark time and study outcomes in terms of their … : drug-eluting stent with clopidogrel, drug-eluting stent without clopidogrel, bare-metal stent with clopidogrel, and bare-metal stent …

… data on the rate of neointimal coverage of drug-eluting stents (DES) that complement recent … stent thrombosis (LST). They evaluated 25 patients (37 stents, 15 DES, 22 bare-metal stents […

… Our study compared the long-term outcome of drug-eluting stents versus bare-metal stents in a large cohort of unselected consecutive patients treated with coronary stents at all …

… In conclusion, the incidence of stent thrombosis at 9 months after successful drug-eluting stent implantation in consecutive real-world patients was 1.3%. Premature antiplatelet therapy …

… In this study, the frequency and outcomes of off-label or untested use of drug-eluting stents compared with standard use were evaluated from a large, multicenter, prospective PCI …

OBJECTIVES We compared the angiographic and long-term clinical outcomes of patients with and without overlap of drug-eluting stents (DES). BACKGROUND DES overlap has been associated with delayed healing and increased inflammation in experimental studies, but its impact on clinical outcome is not well established. METHODS We analyzed the angiographic and clinical outcomes of 1,012 patients treated with DES in the SIRTAX (Sirolimus-Eluting Versus Paclitaxel-Eluting Stents for Coronary Revascularization) trial according to the presence or absence of stent overlap and the number of stents per vessel: 134 (13.2%) patients with multiple DES in a vessel with overlap, 199 (19.7%) patients with multiple DES in a vessel without overlap, and 679 (67.1%) patients with 1 DES per vessel. RESULTS Angiographic follow-up at 8 months showed an increased late loss in DES overlap patients (0.33 +/- 0.61 mm) compared with the other groups (0.18 +/- 0.43 mm and 0.15 +/- 0.38 mm, p < 0.01). The smallest minimal lumen diameter was located at the zone of stent overlap in 17 (68%) of 25 patients with stent overlap who underwent target lesion revascularization. Major adverse cardiac events were more common in patients with DES overlap (34 events, 25.4%) than in the other groups (42 events, 21.1% and 95 events, 14.0%) at 3 years (p < 0.01). Both the risk of target lesion revascularization (20.2% vs. 16.1% vs. 9.7%, p < 0.01) and the composite of death or myocardial infarction (17.2% vs. 14.1% vs. 9.1%, p = 0.01) were increased in patients with DES overlap compared with the other groups. CONCLUSIONS DES overlap occurs in >10% of patients undergoing percutaneous coronary intervention in routine clinical practice and is associated with impaired angiographic and long-term clinical outcome, including death or myocardial infarction. (Sirolimus-Eluting Versus Paclitaxel-Eluting Stents for Coronary Revascularization; NCT00297661).

… The purpose of this study was to compare outcomes (18-month mortality, 18-month mortality/… revascularized using stents in the era following the introduction of drug-eluting stents (DES). …

… We sought to determine the prognostic implication of the angiographic pattern of in-stent restenosis in drug-eluting stents. We analyzed data on 250 lesions (163 focal and 87 nonfocal). …

… improved clinical outcomes after drug-eluting stent (… drug-eluting stent (DES) use are particularly controversial given the improved outcomes with DES compared with bare metal stents. …

Objectives : The purpose of this study was to investigate the long-term safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation for …

… It is still controversial whether implantation of drug-eluting stents (DES) guided by IVUS could reduce adverse clinical outcomes. Zhang et al. (4) recently performed a meta-analysis on …

… This study sought to evaluate the long-term angiographic and clinical outcomes after the treatment of drug-eluting stent in-stent restenosis (DES-ISR) based on the angiographic pattern …

… were treated with drug-eluting stents. We preferentially reported the outcomes at the longest … of treatment allocation, blinded outcome assessment, and description of loss to follow-up. …

AIMS Late acquired incomplete stent apposition (ISA) is more common after drug-eluting stent (DES) than bare metal stent (BMS) implantation and has been associated with vascular hypersensitivity and stent thrombosis (ST). We investigated the impact of incidentally discovered ISA as assessed by intravascular ultrasound (IVUS) 8 months after DES implantation on the long-term clinical outcome. METHODS AND RESULTS A total of 194 patients with 221 lesions were prospectively followed through 5 years. At 8 months, IVUS showed evidence of ISA among 37 patients with 39 lesions (18%) (mean ISA(max) 4.7 ± 5.0 mm(2)), whereas no ISA was observed among 157 patients with 182 lesions. Incomplete stent apposition was more prevalent among segments treated with sirolimus-eluting (n = 103) than paclitaxel-eluting stents (n = 118) (27 vs. 9%, P = 0.001). Between IVUS investigation at the 8-month and 5-year follow-up, major adverse cardiac events occurred more frequently in patients with (18.9%, n = 7) than without ISA (7.0%, n = 11) (HR = 2.71, 95% CI: 1.05-6.96, P = 0.031). While there were no differences with respect to death, the rate of myocardial infarction was higher among patients with (13.5%, n = 5) than without ISA (1.9%, n = 3) (HR = 7.53, 95% CI: 1.79-31.6, P = 0.001). Very late ST was more common among patients with than without ISA [Academic Research Consortium-definite ST:13.5% (n = 5) vs. 0.6% (n = 1) HR = 23.2, 95% CI: 2.65-203, P < 0.001]. CONCLUSION In the present study, the presence of ISA as assessed by IVUS 8 months after DES implantation was associated with a higher rate of myocardial infarction and very late stent thrombosis during long-term follow-up. The prognostic impact of ISA on long-term clinical outcomes requires further investigation.

OBJECTIVES The aim of this study was to evaluate the long-term impact of coronary artery calcification (CAC) on outcomes after percutaneous coronary intervention and the respective performance of first- and second-generation drug-eluting stents (DES). BACKGROUND Whether contemporary DES have improved the long-term prognosis after percutaneous coronary intervention in lesions with severe CAC is unknown. METHODS Individual patient data were pooled from 18 randomized trials evaluating DES, categorized according to the presence of angiography core laboratory-confirmed moderate or severe CAC. Major endpoints were the patient-oriented composite endpoint (death, myocardial infarction [MI], or any revascularization) and the device-oriented composite endpoint of target lesion failure (cardiac death, target vessel MI, or ischemia-driven target lesion revascularization). Multivariate Cox proportional regression with study as a random effect was used to assess 5-year outcomes. RESULTS A total of 19,833 patients were included. Moderate or severe CAC was present in 1 or more target lesions in 6,211 patients (31.3%) and was associated with increased 5-year risk for the patient-oriented composite endpoint (adjusted hazard ratio [adjHR]: 1.12; 95% confidence interval [CI]: 1.05 to 1.20) and target lesion failure (adjHR: 1.21; 95% CI: 1.09 to 1.34), as well as death, MI, and ischemia-driven target lesion revascularization. In patients with CAC, use of second-generation DES compared with first-generation DES was associated with reductions in the 5-year risk for the patient-oriented composite endpoint (adjHR: 0.88; 95% CI: 0.78 to 1.00) and target lesion failure (adjHR: 0.73; 95% CI: 0.61 to 0.87), as well as death or MI, ischemia-driven target lesion revascularization, and stent thrombosis. The relative treatment effects of second-generation compared with first-generation DES were consistent in patients with and without moderate or severe CAC, although outcomes were consistently better with contemporary devices. CONCLUSIONS In this large-scale study, percutaneous coronary intervention of target lesion moderate or severe CAC was associated with adverse patient-oriented and device-oriented adverse outcomes at 5 years. These detrimental effects were mitigated with second-generation DES.

… SF is associated with a high rate of clinical events after the implantation of drug-eluting stents (DES). However, the chronological rate of SF and the effect of SF on clinical outcomes from …

… , and stent thrombosis. … stent length on the long-term clinical outcomes between first- and newer-generation DESs. The effects of stent length (≥32 vs <32 mm) on the clinical outcomes …

Coronary artery disease (CAD) is a common disease and has an impact in all over the word. With the development of life level and life style, the incident of morbidity and mortality largely increased [1]. Atherogenesis and the formation of thrombi are the main risk events. The application of percutaneous coronary intervention (PCI) released coronary artery disease and improved patients’ quality of life. The mortality of acute coronary syndrome (ACS) was obviously reduced [2]. The stent style including baremetal stents (BMS) and drug-eluting stents (DES) benefited many patients in clinic [3]. Antiplatelet therapy is standard treatment after PCI. Meanwhile, international guidelines and clinical practice recommend dual antiplatelet therapy (DAPT aspirin combination with P2Y12 inhibitors) after PCI [4,5]. Previous clinical application indicated that DES reduced major advent cardiac such as death, non-fatal myocardial infarction target lesion revascularization [6]. But the risk of stent thrombosis was increased, especially late stent thrombosis [7]. Therefore, in order to prevent stent thrombosis, prolonged antiplatelet therapy was recommended by clinical guidelines. Then DAPT combination of aspirin with P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) used to reduce the risk of stent thrombosis and adverse cardiac outcomes. However, the optimal duration of DAPT after coronary drug-eluting stent implantation remains debated. It will elevate stent thrombosis if stopping DAPT too early. For the other side, delaying DAPT will increase patients’ burden and reduce patients’ compliance; what’s more, the complication of bleeding will increase and it affects some surgeries. It is a challenge for clinician to balance the advantages and disadvantages.

BACKGROUND Whether guided selection of antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) is effective in improving outcomes compared with standard antiplatelet therapy remains controversial. We assessed the safety and efficacy of guided versus standard selection of antiplatelet therapy in patients undergoing PCI. METHODS For this systematic review and meta-analysis, from Aug 20 to Oct 25, 2020, we searched MEDLINE (via PubMed), Cochrane, Embase, and Web of Science databases for randomised controlled trials and observational studies published in any language that compared guided antiplatelet therapy, by means of platelet function testing or genetic testing, versus standard antiplatelet therapy in patients undergoing PCI. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. Risk ratios (RRs) and 95% CIs were used with random-effects or fixed-effect models according to the estimated heterogeneity among studies assessed by the I2 index. Coprimary endpoints were trial-defined primary major adverse cardiovascular events and any bleeding. Key secondary endpoints were all-cause death, cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis, and major and minor bleeding. This study is registered with PROSPERO (CRD42021215901). FINDINGS 3656 potentially relevant articles were screened. Our analysis included 11 randomised controlled trials and three observational studies with data for 20 743 patients. Compared with standard therapy, guided selection of antiplatelet therapy was associated with a reduction in major adverse cardiovascular events (RR 0·78, 95% CI 0·63-0·95, p=0·015) and reduced bleeding, although not statistically significant (RR 0·88, 0·77-1·01, p=0·069). Cardiovascular death (RR 0·77, 95% CI 0·59-1·00, p=0·049), myocardial infarction (RR 0·76, 0·60-0·96, p=0·021), stent thrombosis (RR 0·64, 0·46-0·89, p=0·011), stroke (RR 0·66, 0·48-0·91, p=0·010), and minor bleeding (RR 0·78, 0·67-0·92, p=0·0030) were reduced with guided therapy compared with standard therapy. Risks of all-cause death and major bleeding did not differ between guided and standard approaches. Outcomes varied according to the strategy used, with an escalation approach associated with a significant reduction in ischaemic events without any trade-off in safety, and a de-escalation approach associated with a significant reduction in bleeding, without any trade-off in efficacy. INTERPRETATION Guided selection of antiplatelet therapy improved both composite and individual efficacy outcomes with a favourable safety profile, driven by a reduction in minor bleeding, supporting the use of platelet function or genetic testing to optimise the choice of agent in patients undergoing PCI. FUNDING None.

Platelets play a central role in both the short- and long-term manifestations of atherothrombosis. In acute coronary syndrome (ACS), there is a steep rise in cardiovascular events early, followed by an incremental rise in cardiovascular events over the long term. This long-term event rate is related to persistent platelet activation and thrombin generation. There is therefore a need to optimize both short- and long-term oral antiplatelet and antithrombotic strategies. The benefits of aspirin therapy, when administered early and continued over the long term, were demonstrated in several early randomized trials. The Antithrombotic Trialists' Collaboration found a 46% reduction in vascular events with antiplatelet therapy (mostly aspirin). However, despite treatment with aspirin and proven therapies, recurrent events remain high. The adenosine diphosphate receptor antagonists, ticlopidine and clopidogrel, inhibit the early steps of platelet activation, degranulation, and release of prothrombotic and inflammatory mediators, while also preventing activation of the glycoprotein IIb/IIIa receptor. The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial demonstrated the benefits of aspirin plus clopidogrel in reducing major cardiovascular events (cardiovascular death, myocardial infarction [MI], and stroke reduced by 20%, p = 0.00009) in a broad range of patients with ACS when administered early and continued over the long term. The benefits emerge very rapidly after a 300 mg loading dose. For the large number of patients undergoing percutaneous coronary intervention in the CURE trial, there was a substantial risk reduction with clopidogrel pretreatment followed by long-term therapy (p < 0.002). This benefit was present, regardless of whether intervention was performed early or late. The significant benefits of aspirin and clopidogrel persist for the combined efficacy-safety end point of cardiovascular death, MI, stroke, or life-threatening bleeding when clopidogrel is started early, combined with aspirin and other standard therapies, and continued for up to one year.

… several prospective studies as a novel strategy of antiplatelet therapy after PCI. This review shows a current status and provides future perspectives for the antiplatelet therapy after PCI. …

Importance Acute coronary syndrome (ACS) is a major cause of morbidity and mortality in the United States with an annual incidence of approximately 1 million. Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces cardiovascular event rates after ACS. Observations In 2016, the updated guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommended aspirin plus a P2Y12 inhibitor for at least 12 months for patients with ACS. Since these recommendations were published, new randomized clinical trials have studied different regimens and durations of antiplatelet therapy. Recommendations vary according to the risk of bleeding. If bleeding risk is low, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established. If bleeding risk is high, shorter duration (ie, 3-6 months) of DAPT may be reasonable. A high risk of bleeding traditionally is defined as a 1-year risk of serious bleeding (either fatal or associated with a ≥3-g/dL drop in hemoglobin) of at least 4% or a risk of an intracranial hemorrhage of at least 1%. Patients at higher risk are 65 years old or older; have low body weight (BMI <18.5), diabetes, or prior bleeding; or take oral anticoagulants. The newest P2Y12 inhibitors, prasugrel and ticagrelor, are more potent, with high on-treatment residual platelet reactivity of about 3% vs 30% to 40% with clopidogrel and act within 30 minutes compared with 2 hours for clopidogrel. Clinicians should avoid prescribing prasugrel to patients with a history of stroke or transient ischemic attack because of an increased risk of cerebrovascular events (6.5% vs 1.2% with clopidogrel, P = .002) and should avoid prescribing it to patients older than 75 years or who weigh less than 60 kg. The ISAR-REACT-5 trial found that prasugrel reduced rates of death, myocardial infarction, or stroke at 1 year compared with ticagrelor among patients with ACS undergoing percutaneous coronary intervention (9.3% vs 6.9%, P = .006) with no significant difference in bleeding. Recent trials suggested that discontinuing aspirin rather than the P2Y12 inhibitor may be associated with better outcomes. Conclusions and Relevance Dual antiplatelet therapy reduces rates of cardiovascular events in patients with acute coronary syndrome. Specific combinations and duration of dual antiplatelet therapy should be based on patient characteristics-risk of bleeding myocardial ischemia.

… strategy in anticoagulated AF patients who undergo percutaneous coronary intervention (PCI) and hence need antiplatelet therapy. Current clinical guidelines on antithrombotic …

… The authors assessed the effect of 30 months versus 12 months of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) based on the presence or absence of …

Antiplatelet therapy is the mainstay of pharmacologic treatment to prevent thrombotic or ischemic events in patients with coronary artery disease treated with percutaneous coronary intervention and those treated medically for an acute coronary syndrome. The use of antiplatelet therapy comes at the expense of an increased risk of bleeding complications. Defining the optimal intensity of platelet inhibition according to the clinical presentation of atherosclerotic cardiovascular disease and individual patient factors is a clinical challenge. Modulation of antiplatelet therapy is a medical action that is frequently performed to balance the risk of thrombotic or ischemic events and the risk of bleeding. This aim may be achieved by reducing (ie, de-escalation) or increasing (ie, escalation) the intensity of platelet inhibition by changing the type, dose, or number of antiplatelet drugs. Because de-escalation or escalation can be achieved in different ways, with a number of emerging approaches, confusion arises with terminologies that are often used interchangeably. To address this issue, this Academic Research Consortium collaboration provides an overview and definitions of different strategies of antiplatelet therapy modulation for patients with coronary artery disease, including but not limited to those undergoing percutaneous coronary intervention, and consensus statements on standardized definitions.

… after percutaneous coronary intervention (PCI) (1–4). Dual antiplatelet therapy with aspirin and … documented in clinical trials with dual antiplatelet therapy, it has been demonstrated that …

… timing of noncardiac surgery after coronary stent placement, 12… are likely to discontinue dual-antiplatelet therapy (DAPT), … surgery treated with antiplatelet therapy. Understanding …

… antiplatelet therapies like aspirin. In line with these findings, Guthikonda et al 79 recently reported an association between a higher percentage of circulating reticulated platelets and a …

… Duration of dual antiplatelet therapy: a systematic review for the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease…

… In patients with stable coronary artery … antiplatelet therapy with aspirin plus clopidogrel is advised following presentation with an acute coronary syndrome (ACS) or following coronary …

… Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y …

Importance A platelet ADP P2Y12 receptor (P2Y12) inhibitor plus aspirin is standard therapy for patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Compared with clopidogrel, prasugrel and ticagrelor are associated with superior antiatherothrombotic effects but increased bleeding risk; with recent guideline updates, it is important to describe current treatment patterns and the role of bleeding risk in treatment choice. Objective To describe secular trends and determinants of initial P2Y12 inhibitor choice and switching, including deescalation (switch from prasugrel or ticagrelor to clopidogrel). Design, Setting, and Participants This retrospective cohort study used MarketScan Commercial Claims Data from 2010 to 2019 for patients aged 18 years or older who underwent PCI for ACS, had no P2Y12 inhibitor use in the past year, and filled a P2Y12 inhibitor prescription within 30 days after PCI hospitalization discharge. Data were analyzed from February to May 2022. Exposures Clopidogrel, prasugrel, and ticagrelor, with determinants including bleeding risk measured using Academic Research Consortium for High Bleeding Risk criteria, sociodemographic characteristics, P2Y12 inhibitor copays, and bleeding events during follow-up. Main Outcomes and Measures The prevalence of each P2Y12 inhibitor among patients who initiated the drugs and the prevalence of switching within 12 months after PCI were evaluated. The association between baseline bleeding risk and bleeding manifestations during follow-up and initial treatment and deescalation were calculated using multivariable logistic and Cox proportional hazards regression models. Results Between 2010 and 2019, 62 423 patients were identified who initiated P2Y12 inhibitors (females, 22.4%; males, 77.6%; mean [SD] age, 54.32 [7.13] years). The prevalence of clopidogrel as initial therapy decreased from 77.5% in 2010 to 29.6% in 2019, while initial use of prasugrel or ticagrelor increased from 22.5% to 60.4%. Within 1 year after PCI, 11.0% of patients switched therapy, mostly for deescalation. Deescalation prevalence increased from 1.8% in 2010 to 12.6% in 2018. Between 2016 and 2018, 8588 of 22 886 (37.5%) patients had major baseline bleeding risk, which decreased the selection of prasugrel or ticagrelor as initial therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.84). Among 11 285 patients who initiated prasugrel or ticagrelor, major bleeding risk at baseline (adjusted hazard ratio, 1.11; 95% CI, 1.00-1.23) and the occurrence of bleeding during follow-up (adjusted hazard ratio, 4.42; 95% CI, 3.62-5.93) were associated with deescalation. Conclusions and Relevance A strong shift in preference for prasugrel and ticagrelor as initial therapy following PCI for ACS was observed. Deescalation increased over the study period. Major bleeding risk at baseline was moderately associated with initial treatment choice but had a limited association with deescalation. The increasing use of more potent P2Y12 inhibitors emphasizes opportunities to enhance preemptive patient-centered treatment strategies to maintain optimal antiplatelet activity while reducing bleeding risk during the subacute period following PCI for ACS.

… study is to compare personalized antiplatelet therapy according to CYP2C19 phenotype with conventional antiplatelet therapy in patients after percutaneous coronary intervention (PCI). …

… coronary intervention (PCI) with stent implantation continues to increase and therefore, the need for treatment with dual antiplatelet therapy (… possibly more effective antiplatelet agents, …