Optical Flow Ratio (OFR) simulates fractional flow reserve (FFR) by analyzing coronary geometries from optical coherence tomography (OCT); however, its ability to assess pathophysiological coronary artery disease (CAD) patterns remains unclear. This study aimed to validate the accuracy of OFR-derived pullback pressure gradient (OFR-PPG) in characterizing CAD patterns using invasive pullback pressure gradient (PPG) as a reference. This is a pooled analysis of two multicenter prospective studies that included patients with hemodynamically significant CAD (FFR ≤ 0.80). Patients who underwent PPG assessment and OCT were included. The PPG algorithm was applied to the OFR pullback curves to derive OFR-PPG. The median value of invasive PPG was used as the threshold for defining focal and diffuse. A total of 110 patients (112 vessels) were analyzed. The median PPG was 0.60 (interquartile range [IQR], 0.49–0.73), while the median OFR-PPG was 0.55 (0.43–0.66). OFR-PPG showed a moderate correlation with PPG (r = 0.64; p < 0.001). The mean difference between OFR-PPG and invasive PPG was 0.06, with the limits of agreement − 0.19 to 0.31. Agreement in CAD pattern classification was moderate (Cohen’s κ = 0.52), with approximately one-quarter of vessels misclassified. Pathophysiological CAD patterns derived from OCT-derived FFR showed moderate agreement with invasively measured PPG.

BACKGROUND AND AIMS:Peripheral arterial disease (PAD) and coronary artery disease (CAD) are both clinical manifestations of atherosclerosis, sharing pathobiological features with aortic stenosis (AS). Pre-transcatheter aortic valve replacement (TAVR) planning routinely includes CT assessment of aorto-iliac and common femoral arterial disease. The aim was to assess the feasibility and accuracy of a novel PAD scoring system (Hostile score) to exclude obstructive CAD pre-TAVR. METHODS:Peripheral CTs of patients pre-TAVR, between 2019 and 2023, were retrospectively analysed and Hostile score calculated (low score ≤ 8.5, high score > 8.5). Obstructive CAD was defined as diameter stenosis ≥50% on invasive angiography. Feasibility and reproducibility of Hostile score was assessed. ROC analysis was performed to assess the accuracy of Hostile score to exclude obstructive CAD. RESULTS:350 patients included (age 82 ± 7.2 yrs); 78% hypertension; 29% diabetes, 59% CKD and obstructive CAD present in 32.6%. Median Hostile score was 5 (IQR 2-8.9) with a median analysis time of 2.14 min (IQR 1.68-4.40). There was excellent intra-observer correlation (r = 0.91, 95%CI 0.84, 0.96) and a good interobserver correlation (r = 0.84, 95% CI 0.72, 0.91). Sensitivity, specificity, positive and negative predictive value of Hostile score to exclude obstructive CAD was 91.1%, 58.8%, 82.1% and 76.1%, respectively, with a diagnostic accuracy of 80.6% (AUC 0.82). Patients with high Hostile score had increased risk of all-cause mortality (OR 2.13, 95%CI 1.13, 4.02, p = 0.02). CONCLUSION:Hostile score has a high sensitivity and accuracy for excluding obstructive CAD in patients with severe AS and was associated with a higher all-cause mortality. Incorporating Hostile score as a screening tool on TAVR-CT may potentially reduce the requirement for invasive angiography.

BACKGROUND:The pullback pressure gradient (PPG) is a novel physiological metric that quantifies coronary artery disease patterns as focal or diffuse on a scale from 0 to 1. This study assessed the relationship between PPG and residual angina at 1 year. METHODS:PPG Global is a prospective, investigator-initiated, single-arm, multicenter study that enrolled patients with at least 1 lesion with a fractional flow reserve ≤0.80 intended to be treated with percutaneous coronary intervention. After the PPG calculation, physicians could revise treatment assignment to medical therapy or coronary artery bypass graft surgery instead of percutaneous coronary intervention. Focal and diffuse disease were defined based on the median PPG value of 0.62. Patient-reported outcomes were assessed using the Seattle Angina Questionnaire at baseline and 1-year follow-up. RESULTS:The study included 947 patients with PPG and the Seattle Angina Questionnaire at 1 year. The mean age was 67.6±10.2 years, 24% were female, and 29% had diabetes. At 1 year, patients with focal coronary artery disease reported less angina than those with diffuse disease (Seattle Angina Questionnaire angina frequency score, 95.3±9.9 versus 92.5±15.0; P=0.006). PPG was independently associated with improvement in angina (P=0.017). CONCLUSIONS:In patients with flow-limiting coronary artery disease, a focal disease pattern defined by high PPG was associated with greater symptomatic relief at 1 year compared with diffuse disease (low PPG). By capturing the underlying pathophysiologic distribution of epicardial disease and its relation to post-treatment symptom relief, PPG may support a more tailored revascularization decision-making and percutaneous coronary intervention strategy.

BACKGROUND:In the assessment of coronary physiology, non-hyperemic pressure ratios (NHPRs) provide an alternative to fractional flow reserve (FFR) without the need for hyperemic agents, reducing procedural time, side effects, and costs. However, it remains unclear whether NHPRs have similar diagnostic performance in the different coronary arteries. This study evaluates the diagnostic performance of NHPRs compared with FFR, stratified by coronary artery, in stable patients with coronary artery disease. METHODS:We conducted a systematic review and individual patient-level data meta-analysis from prospective studies involving patients with intermediate to severe coronary stenosis who underwent physiological assessment with NHPRs and FFR. NHPRs included resting full-cycle ratio or instantaneous wave-free ratio (iFR). The diagnostic performance of NHPRs was calculated using a threshold of ≤0.89 for NHPRs with FFR ≤0.80 as the reference and by stratifying between the left anterior descending artery (LAD) and non-LAD vessels. RESULTS:A total of 2120 paired FFR and NHPRs (1257 resting full-cycle ratio, 863 iFR) measurements were analyzed. The LAD artery was the interrogated vessel in 67% of cases, the left circumflex artery in 15%, and the right coronary artery in 17%. The mean NHPR and FFR values were 0.80±0.17 and 0.71±0.14, respectively. The overall sensitivity, specificity, and accuracy of NHPRs were 82%, 86%, and 83%. In non-LAD vessels, NHPRs had significantly lower sensitivity and accuracy, but higher specificity compared with LAD (69% versus 87%, 76% versus 86%, and 91% versus 81%, respectively, P<0.001 for all). The optimal NHPRs cutoff for detecting significant lesions differed between LAD (≤0.88) and non-LAD (≤0.92). CONCLUSIONS:NHPRs demonstrated lower diagnostic performance in non-LAD vessels compared with the LAD. These results underscore the need for vessel-specific interpretation of NHPR measurements.

The coexistence of severe aortic stenosis (AS) and coronary artery disease (CAD) is common and presents important diagnostic and therapeutic challenges, particularly in patients being considered for transcatheter aortic valve replacement. Accurate assessment of coronary lesion significance in this setting is difficult because severe AS alters coronary haemodynamics, myocardial oxygen demand, microvascular function, and the balance between resting and hyperaemic flow. These changes may influence the interpretation of conventional physiological indices and complicate decisions regarding revascularisation. This narrative review summarises the pathophysiological interaction between severe AS and CAD and examines the contemporary evidence supporting invasive and non-invasive approaches to coronary assessment. We review the limitations and potential utility of fractional flow reserve, and non-hyperaemic pressure ratios, highlighting the frequent discordance observed between indices and the uncertainty regarding optimal thresholds in severe AS. Importantly, identification of physiologically significant lesions should be distinguished from evidence that revascularisation of these lesions improves clinical outcomes, as prospective outcome data remain limited. While recent trials support physiology-guided revascularisation in patients undergoing TAVR, outcome data remain linked primarily to conventional FFR thresholds rather than proposed AS-specific cutoffs. We also discuss emerging non-wire-based approaches, including quantitative flow ratio and computed tomography-derived fractional flow reserve, which may offer complementary value in selected patients. In addition, we examine the practical implications of coronary physiology for clinical decision-making before and after valve intervention, including the timing of percutaneous coronary intervention and the need to distinguish lesion-level diagnostic performance from evidence of clinical benefit. Current data suggest that no single modality is universally applicable and that assessment should be individualised according to lesion characteristics, clinical context, and procedural strategy. Proposed severe AS-specific thresholds for FFR and NHPR are derived from small predominantly observational studies, have not been prospectively validated against clinical outcomes and should be hypothesis-generating. A hybrid approach integrating angiographic, physiological, and computed tomography-based information may be most useful. Further prospective studies are needed to define optimal thresholds, validate management algorithms, and clarify whether physiology-guided strategies improve outcomes in severe AS.

BACKGROUND:Coronary microvascular dysfunction (CMD) has been proposed as a mechanism underlying residual angina after percutaneous coronary intervention (PCI). OBJECTIVES:The objective of the study was to investigate the impact of CMD on symptoms in patients undergoing PCI. METHODS:Patients with hemodynamically significant coronary artery disease (CAD) (fractional flow reserve ≤0.80) were included. CAD was classified as focal or diffuse using the pull back pressure gradient (PPG) (diffuse CAD defined as PPG <0.62). CMD was defined as microvascular resistance reserve <3.0. The Seattle Angina Questionnaire (SAQ) was administered at baseline and 1 year. RESULTS:Among 201 patients (mean age 68.5 ± 10.1 years; 71% male), CMD was present in 75 (37.3%), with no difference between focal and diffuse CAD (41% vs 34%; P = 0.35). At baseline, CMD was associated with more severe symptoms without reaching statistical significance (SAQ summary score 64.0 ± 25.3 vs 69.6 ± 21.0; P = 0.09). At 1 year, symptoms were similar between groups (SAQ summary score 87.6 ± 16.0 vs 89.4 ± 16.4; P = 0.47). A significant interaction between PPG and microvascular resistance reserve was observed for residual angina (P for interaction = 0.015); patients with focal CAD and concomitant CMD had the highest burden of residual symptoms. CONCLUSIONS:CMD is present in approximately one-third of patients undergoing PCI and occurs with similar frequency in focal and diffuse CAD. CMD alone was not associated with residual angina. However, its clinical relevance varied according to the epicardial disease pattern: in focal CAD, concomitant CMD was associated with less symptomatic improvement after PCI, whereas in diffuse CAD, residual symptoms appeared to be driven predominantly by persistent epicardial disease.

BACKGROUND:Although physiological assessment has been used in decision-making for revascularization, its role in predicting the future risk of acute coronary syndrome (ACS) remains underexplored. OBJECTIVES:This study aims to investigate the independent and combined prognostic significance of hemodynamic disease severity and distribution in identifying ACS culprit vessels, in conjunction with lumen and plaque characteristics. METHODS:The EMERALD-II study is an international, multicenter, internal case-control study enrolling 351 patients with ACS who underwent coronary computed tomography angiography (CTA) 1 month to 3 years before the event. Culprit and nonculprit vessels were identified by matching invasive coronary angiography with coronary CTA findings. High-risk plaque (HRP) characteristics, including minimum lumen area <4 mm2, plaque burden ≥70%, low-attenuation plaque, positive remodeling, spotty calcification, and napkin-ring sign, were assessed by a core laboratory, with HRP defined as ≥3 HRP characteristics. From coronary CTA, the authors derived both the hemodynamic severity of the disease (fractional flow reserve derived from computed tomography [FFRCT]) and its spatial distribution (diffuse vs focal), as assessed by the pullback pressure gradient derived from coronary CTA (PPGCT). Vessels were categorized into 4 hemodynamic disease patterns: nonischemic (FFRCT >0.80), hemodynamic diffuse (FFRCT ≤0.80 and PPGCT ≤0.50), mixed (FFRCT ≤0.80 and 0.50 < PPGCT ≤0.60), and focal disease (FFRCT ≤0.80 and PPGCT >0.60). RESULTS:Among 873 vessels, the mean FFRCT was 0.74 ± 0.17 and the mean PPGCT was 0.54 ± 0.14. Both lower FFRCT and higher PPGCT were independently associated with higher ACS risk (OR per 0.1 increase in FFRCT: 0.71 [95% CI: 0.65-0.77]; P < 0.001; OR per 0.1 increase in PPG: 1.22 [95% CI: 1.09-1.37]; P < 0.001). Among the 4 subgroups of hemodynamic disease pattern, hemodynamic focal disease showed the highest risk of ACS (relative risk [RR]: 2.02 [95% CI: 1.74-2.36]; P < 0.001), myocardial infarction (RR: 1.75 [95% CI: 1.43-2.14]; P < 0.001), and unstable angina (RR: 2.54 [95% CI: 2.00-3.22]; P < 0.001). It remained a predictor for ACS in nonobstructive lesions (OR: 3.56 [95% CI: 1.43-8.84]), obstructive lesions (OR: 3.16 [95% CI: 1.96-5.07]), non-HRP (OR: 6.69 [95% CI: 3.59-12.5]), and HRP (OR: 2.98 [95% CI: 1.83-4.87]). Although the maximal lesion-level ΔFFRCT (differences in FFRCT across the lesion) demonstrated superior model performance compared with models incorporating FFRCT and PPGCT, higher PPGCT was additionally associated with increased ACS risk, particularly among vessels with maximal ΔFFRCT ≥0.10. CONCLUSIONS:Hemodynamic disease distribution, as measured by PPGCT, complements FFRCT in predicting ACS risk. The integration of hemodynamic disease patterns provides additional prognostic value beyond lumen and plaque characteristics, with hemodynamic focal disease emerging as an independent predictor and a potential therapeutic target for ACS prevention. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II [EMERALD II]; NCT03591328).

BACKGROUND:Intravascular imaging (IVI) during percutaneous coronary intervention (PCI) improves outcomes. Pullback pressure gradient (PPG) characterizes coronary artery disease patterns as focal or diffuse; however, the benefit of IVI across this spectrum remains incompletely understood. We aimed to evaluate clinical outcomes after PCI with or without IVI guidance in patients with focal and diffuse disease defined by PPG. METHODS:Prospective, multicenter, single-arm study of 811 patients (840 vessels) undergoing PCI. PPG was calculated from manual fractional flow reserve pullbacks to define focal (PPG ≥0.62) or diffuse coronary artery disease. IVI use was at the operator's discretion. The primary outcome was target vessel failure at 1-year follow-up. RESULTS:IVI-guided PCI was performed in 41% of patients. In the overall cohort, target vessel failure was lower with IVI guidance (adjusted hazard ratio, 0.60 [95% CI 0.36-0.99]; P=0.044), with a lower incidence of cardiac death (P=0.042). IVI significantly reduced target vessel failure in focal disease (unadjusted HR, 0.41 [95% CI, 0.18-0.91]; P=0.029), whereas no difference was observed in diffuse disease (unadjusted HR, 0.91 [95% CI, 0.48-1.73]; P=0.771). There was no interaction between PPG and IVI guidance for target vessel failure (P for interaction=0.128). CONCLUSIONS:In patients undergoing physiology-guided PCI, the use of IVI reduced clinical events at 1 year. These findings suggest that the benefit of IVI extends across the full spectrum of coronary artery disease.

BACKGROUND:Coronary artery disease (CAD) is common in patients with severe aortic stenosis (AS) and may impact transcatheter aortic valve replacement (TAVR) procedural and long-term outcomes. CT coronary angiography (CTA) and CT-derived fractional flow reserve (FFRCT) are tools used to assess CAD. However, adoption in the TAVR population is hindered by safety concerns with nitroglycerin and beta-blockers. The safety, accuracy, and utility of CTA and FFRCT optimised with these medications for TAVR have not been established. METHODS:This international, multi-center, prospective registry included severe AS patients referred for TAVR, assessed for CAD with CTA and FFRCT. Patients all received nitroglycerin and beta-blockers as needed to optimise image quality. Severe ventricular dysfunction, recent syncope/heart failure, critical hemodynamics, or prior revascularization were excluded. Significant CAD was defined as CTA stenosis ≥50 ​% and FFRCT≤0.75. Primary endpoint was per-patient sensitivity and negative predictive value (NPV) of CTA compared to invasive coronary angiography (ICA). Secondary endpoints included specificity and positive predictive value (PPV) of CTA and FFRCT, safety, feasibility (non-evaluable rate), and the modelled potential of CTA ​+ ​FFRCT to reduce pre-TAVR ICA. RESULTS:327 patients (75.9 ​± ​9.7 years, 53 ​% male) underwent CTA. CTA was safe and well tolerated in nearly all patients, with transient hypotension in 4 (1.2 ​%). CTA was evaluable in 326 patients (99.7 ​%), with 9 (2.8 ​%) having a non-evaluable vessel. FFRCT and ICA were performed in 110 (33.6 ​%) and 133 (40.7 ​%) patients, respectively. Per-patient sensitivity, specificity, NPV, and PPV of CTA were 100 ​%, 71.4 ​%, 100 ​%, and 75.9 ​% and per-vessel 82.7 ​%, 78.9 ​%, 92.3 ​%, and 59.9 ​%. FFRCT improved specificity and PPV to 88.9 ​% and 88.0 ​% for per-patient and 95.1 ​% and 81.8 ​% for per-vessel analysis. Using a simulated triage model deferring ICA in patients with CTA <50 ​% or ≥50 ​% stenosis with FFRCT >0.75, 267 patients (81.7 ​%) could potentially have avoided ICA. CONCLUSION:Coronary CTA performed with nitroglycerin and selective use of beta-blockers is safe and effective for assessing CAD in stable severe AS patients. Combining CTA and FFRCT enhances diagnostic accuracy, potentially reducing the need for invasive angiography and streamlining TAVR workup.

BACKGROUND Wire-based pressure pullback gradient (PPG) is the reference method for differentiating focal from diffuse coronary artery disease (CAD). However, it requires invasive instrumentation and hyperaemia. The quantitative flow ratio (QFR)-derived PPG [QFR virtual pullback (QVP) index] is a non-invasive alternative. AIM To evaluate the correlation between QVP index and PPG, and to explore the diagnostic performance of QVP index for identifying focal CAD. METHODS We retrospectively studied 74 patients (86 vessels) who underwent coronary angiography, fractional flow reserve (FFR), wire-based PPG, angio-based QFR and QVP index between December 2021 and October 2023. The primary analysis focused on FFR-significant lesions (FFR <= 0.75, n = 31), as these are clinically relevant for guiding percutaneous coronary intervention. QVP index was calculated from the maximal QFR drop over 20 mm and the length of the epicardial segment with the greatest reduction. Focal disease was defined by PPG > 0.73. RESULTS QFR was strongly correlated with FFR (r = 0.84, P < 0.001). In FFR significant vessels (FFR <= 0.75, n = 31), QVP index showed a moderate correlation with PPG (r = 0.45, P = 0.01). QVP index demonstrated excellent intra-observer and inter-observer variability with intraclass correlation coefficients of 0.918 (P < 0.001) and 0.932 (P < 0.001), respectively. QVP index predicted focal disease (defined as PPG > 0.73) with area under the curve of 0.73 (P = 0.02). A retrospectively derived threshold of QVP index > 0.53 yielded 90% sensitivity and 53% specificity (P = 0.04), though this cut-off was derived from the same dataset and should be regarded as hypothesis-generating. CONCLUSION QVP index correlates with PPG in FFR-significant lesions and may help to identify focal CAD patterns. However, these findings are hypothesis-generating and derived from a small, retrospective, single-centre cohort without external validation. Prospective multicentre studies are needed to validate cut-offs and determine whether QVP index provides incremental clinical value beyond existing physiological and imaging tools.

BACKGROUND:Risk assessment of coronary side branch (SB) lesions remains challenging because stenosis-based assessment alone often fails to identify clinically relevant lesions. OBJECTIVES:To characterize SB lesions associated with acute coronary syndrome (ACS), evaluate the performance of conventional main vessel (MV)-derived high-risk plaque criteria in SB lesions, and identify independent SB predictors of ACS. METHODS:We analyzed 2451 coronary lesions (2011 MV, 440 SB) from the EMERALD-II study, in which coronary CT angiography was performed 1-36 months before ACS using an AI-assisted quantitative analysis platform. Lesion characteristics included stenosis severity, plaque burden, adverse plaque characteristics (APCs), and the change in CT-derived fractional flow reserve across the lesion (ΔFFRCT). Diagnostic performance of conventional high-risk plaque criteria was compared between MV and SB lesions. RESULTS:Culprit lesions showed greater stenosis severity, plaque burden, APC count, and ΔFFRCT than non-culprit lesions in both vessels. However, these interrelationships were weaker in SB lesions. Among lesions meeting high-risk criteria, SB lesions were less often ACS culprits than MV lesions: ≥50% stenosis, 11.1% vs. 38.5%; plaque burden ≥70%, 8.6% vs. 23.8%; ≥2 APCs, 18.2% vs. 34.4%; and ΔFFRCT ≥0.10, 19.4% vs. 49.4%. Positive predictive values and F1-scores were consistently lower for SB lesions. APC count and ΔFFRCT were independent predictors of ACS in SB lesions. CONCLUSIONS:SB lesions had a substantially lower likelihood of subsequent ACS culprit status than equivalent MV lesions. These findings from AI-assisted CCTA analysis highlight the limitations of applying MV-derived thresholds to SB lesions and support the need for SB-specific risk assessment.

BACKGROUND:Coronary computed tomography angiography (CTA) simulation of fractional flow reserve (FFR) is derived from allometric and morphometric scaling principles, allowing inference of physiological parameters from anatomical measures like left-ventricular (LV) mass and coronary luminal dimensions. Validity of these assumptions in humans remains uncertain, with supporting data derived from animal models. METHODS:Twenty-two patients with non-obstructive coronary artery disease underwent proximal-LAD intravascular ultrasound (IVUS) and Combowire assessment at rest and hyperemia. Coronary volumetric flow (Q, cm3/sec) was derived from average baseline peak-velocity (cm/sec) x IVUS cross-sectional-area (cm2). Baseline microvascular resistance (BMVR, mmHg/cm2) was calculated: distal coronary pressure (mmHg) - right atrial pressure (mmHg) divided by Q. Patients underwent same-day CTA to provide quantitative measures including LV mass (g), cumulative coronary luminal volume (mm3) and vessel length (mm). Relationships between quantitative CTA-derived metrics and invasive physiology were evaluated using Pearson's correlation. RESULTS:Mean FFR was 0.94 ​± ​0.06; median coronary flow reserve velocity was 2.54 [IQR 2.1-3.1]. Baseline Q and BMVR were 2.30 ​± ​1.0 ​cm3/s and 44.6 ​± ​21.6 ​mmHg/cm2, respectively. Average LV-mass was 148.6 ​± ​30.6g, coronary luminal volume 1038.6 ​± ​485.2 ​mm3 and vessel length 184.5 ​± ​66.8 ​mm. LV mass correlated strongest with coronary flow (r ​= ​0.87, p ​< ​0.001) followed by vessel length (r ​= ​0.75, p ​< ​0.0001) and coronary luminal volume (r ​= ​0.73, p ​< ​0.001). The scaling coefficient (1.87) significantly differed from experimental data. CT-derived metrics demonstrated strong negative correlation with BMVR (LV mass -0.70, coronary luminal volume -0.70, vessel length -0.76; P ​< ​0.0001 respectively). CONCLUSION:These findings support deriving coronary flow and microvascular resistance from CTA anatomical metrics. Revised scaling coefficients and hyperemic modelling could enhance CTA-derived FFR diagnostic performance.

Background Sex differences in coronary artery disease (CAD) have been increasingly recognized, as women present with distinct clinical characteristics and outcomes compared with men. This study investigated the impact of sex on pathophysiological CAD patterns (focal versus diffuse) in stable patients undergoing percutaneous coronary interventions (PCI). Methods We conducted a subanalysis of the PPG Global (Pullback Pressure Gradient Global Registry) study, a multicenter, prospective trial including 993 patients (236 [23.8%] women and 757 [76.2%] men) with hemodynamically significant CAD, defined as fractional flow reserve ≤0.80. The pullback pressure gradient metric categorized CAD patterns as focal or diffuse. Patient‐reported outcomes were collected using the 7‐item Seattle Angina Questionnaire. Optimal revascularization was defined as post‐PCI fractional flow reserve ≥0.88. Results Women were significantly older than men, with a mean age of 69.8±10.3 years compared with 67.0±10.1 years (P<0.001). Despite similar baseline fractional flow reserve (0.69±0.12 versus 0.67±0.11, P=0.093), women reported more severe symptoms compared with men, as reflected in the Seattle Angina Questionnaire‐7 angina frequency score (mean 76.7±22.9 versus 81.5±20.3, P=0.002). Women exhibited a more focal CAD pattern (pullback pressure gradient 0.65±0.16 versus 0.61±0.16, P=0.001) and achieved higher post‐PCI fractional flow reserve values (0.88±0.07 versus 0.87±0.07, P=0.02). Women undergoing PCI had a higher rate of optimal revascularization (54% versus 44%, P=0.01). Conclusions This study reveals clinically significant differences in CAD patterns between sexes, with women demonstrating a higher burden of angina, more focal disease distribution, and better physiological results after PCI.