Drug-coated balloon (DCB) PCI can avoid permanent metallic scaffolding in selected acute coronary syndrome (ACS) lesions, but interpretation depends on lesion preparation, procedural selection, and follow-up ascertainment. We analyzed a retrospective dual-center registry of 276 unique patients who underwent one index DCB-treated ACS procedure after operator-judged adequate lesion preparation. Presentations were NSTEMI in 174 patients (63.0%), STEMI in 90 (32.6%), and unstable angina in 12 (4.3%). Paclitaxel-coated DCBs were used in 262 patients (94.9%) and sirolimus/non-paclitaxel DCBs in 14 (5.1%). Thrombus aspiration and GP IIb/IIIa inhibitors were used selectively in 17 (6.2%) and 28 (10.1%) patients, respectively. Bail-out stenting was required in 13 patients (4.7%). Predominantly benign/non-flow-limiting angiographic dissection was recorded in 18 patients (6.5%). A follow-up of at least 365 days or death within 365 days was available for 274 patients (99.3%). Clinically driven TLR occurred in 18 patients (crude 18/274, 6.6%; Kaplan–Meier 365-day estimate, 6.8%; 95% CI, 4.3–10.5), all occurring between 3 and 9 months. All-cause death occurred in 12 patients (Kaplan–Meier estimate, 4.4%; 95% CI, 2.5–7.5). In selected ACS lesions that passed a preparation gate, DCB treatment was associated with feasible procedural results and acceptable 12-month clinically recorded outcomes. The findings do not estimate all-comer DCB eligibility and should not be interpreted in terms of the efficacy of DCBs compared with DESs.

Despite significant progress in revascularization techniques, the vascular approach itself can still be a challenge in complex polyvascular disease. In this case report, we describe the feasibility of a potentially underutilized alternative vascular approach in a patient with multiple arterial occlusions who presented to our hospital with acute multivessel thromboses and chronic occlusions of the distal aorta and subclavian arteries, which rendered noninvasive blood pressure measurements unreliable. The patient also exhibited signs of heart failure with a severely reduced ejection fraction, likely due to ongoing ischemia, as the ventricles had not yet remodeled. To overcome the anatomical limitations safely, we used superficial temporal artery access for coronary angiography - an approach first described, to the best of our knowledge, by Csavajda et al. In addition, this access enabled angiography of the aorta and its branches, visualization of collateral flow, and invasive intra-aortic blood pressure measurement. Together with the possibility to better titrate medical therapy, this additional diagnostic information allowed us to plan aortocoronary bypass surgery with appropriate graft selection and ultimately contributed to improved patient outcomes.Clinical Impact:In complex polyvascular patients with multiple arterial occlusions, when standard femoral and radial access sites are not feasible and peripheral blood pressure measurements are unreliable, an alternative vascular approach through the superficial temporal artery for coronary angiography, aortography, and invasive blood pressure measurement can be safely utilized to improve diagnostic accuracy, therapeutic planning, and clinical outcomes. This illustrative case highlights the usefulness and safety of this vascular approach and demonstrates additional technical possibilities that can be achieved through its use.

BackgroundPlatelet reactivity varies after ST-segment-elevation myocardial infarction (STEMI). We evaluated serial platelet function-guided P2Y12 modulation after a 1-month ticagrelor run-in.MethodsAt month 1, 114 patients were randomized to continued ticagrelor (n=59) or an adenosine diphosphate (ADP)-guided strategy (n=55). Month-1 ADP was the preintervention baseline; months 2, 3, 6, 9, and 12 were analyzed using baseline-adjusted generalized estimating equations. Exploratory net adverse clinical events (NACE) were assessed from randomization through month 12 after STEMI.ResultsIn the guided group, month-1 ADP was 52 U (range, 4-466); 37 patients received clopidogrel 75 mg and 18 received 150 mg, with 17 dose-threshold discordances. Adjusted postrandomization ADP was higher with the guided strategy (geometric mean ratio, 1.26; 95% confidence interval [CI], 1.05-1.51). NACE occurred in 14/59 versus 4/55 patients (risk ratio [RR], 0.31; 95% CI, 0.11-0.87; absolute risk difference, -16.5 percentage points; exact P=.020). Any investigator-classified BARC bleeding occurred in 13/59 versus 3/55 (RR, 0.25; 95% CI, 0.07-0.82; exact P=.014), and the post hoc ischemic-or-BARC ≥2 composite in 9/59 versus 2/55 (RR, 0.24; 95% CI, 0.05-1.06; exact P=.055). One ischemic event occurred in each group.ConclusionsSerial ADP-guided modulation produced pharmacodynamic separation and was associated with fewer investigator-recorded, bleeding-driven events. Dose-threshold deviations, unverified extreme ADP values, incomplete BARC 2 documentation, and only 2 ischemic events restrict interpretation to hypothesis generation; efficacy and safety cannot be established.

AIM:To evaluate associations between polymorphisms in CYP3A4 (*1B, *22), CYP3A5 (*3), CYP2J2 (*7, rs11572325), ABCB1 (c.1236C>T, c.2677G>T/A, c.3435C>T, rs4148738) and ABCG2 (c.421C>A) and the occurrence of bleeding or occlusive events in patients receiving rivaroxaban in real-world clinical practice. METHODS:A nested case-control study, divided into two substudies (bleeding and thromboembolic events), was conducted within a prospective cohort of 385 adults receiving rivaroxaban at University Hospital Centre Zagreb (September 2021-September 2024). Bleeding events were classified per ISTH criteria, and genotyping was performed using TaqMan real-time PCR. Cases and controls were balanced using entropy balancing, and associations were estimated with Bayesian logistic regression under a skeptical prior N(0, 0.355); LASSO regression was used to identify clinical and genetic predictors of outcomes. RESULTS:In total, 71 patients (18.4%) experienced bleeding events, most frequently gastrointestinal (47.9%), while 314 patients served as controls. No pharmacogenomic variant showed a clear association with bleeding risk (raw and balanced odds ratios 0.80-1.35; 95% credible intervals crossing 1.0). LASSO regression identified age (OR 2.00 per decade), gastrointestinal comorbidity (OR 8.77), and eGFR as the dominant predictors of bleeding. Twenty-one patients experienced occlusive events (15 venous, 6 arterial); however, the low event count precluded meaningful pharmacogenomic analysis. CONCLUSIONS:Individual pharmacogenomic variants in CYP3A4, CYP3A5, CYP2J2, ABCB1, and ABCG2 together with pharmacogenetic-based phenotypes were not associated with clinically relevant bleeding in rivaroxaban-treated patients. Traditional clinical risk factors, particularly advanced age and gastrointestinal comorbidity, remain the dominant determinants of adverse outcomes. Routine pharmacogenomic testing to guide rivaroxaban dosing is not currently supported.

BACKGROUND:National income level influences the prevalence and outcomes of cardiovascular disease (CVD), with lower-income countries contributing disproportionately to the global CVD burden. Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) requires specialised equipment, increasing procedural costs. However, whether national income level contributes to disparities in managing patients with CTO remains unclear. OBJECTIVE:To compare the clinical profiles, procedural settings and outcomes of patients undergoing CTO-PCI in middle-income countries (MICs) and high-income countries (HICs). METHODS:This cross-sectional study included 15,329 patients who underwent CTO-PCI between 2021 and 2023. Data were obtained from the European Registry of Chronic Total Occlusions (ERCTO). Of the 24 enrolling countries, 7 were classified as MICs and 14 as HICs. RESULTS:Patients in HICs were older (67 ± 10 vs 61 ± 10 years; p < 0.001) and presented with greater CTO complexity (J-CTO score: 2.31 ± 1.25 vs 1.99 ± 1.17; p < 0.001). Conversely, patients in MICs were more likely to have diabetes (35% vs 29%; p < 0.001) and to be active smokers (59% vs 49%; p < 0.001). Patients in MICs had lower use of mechanical cardiac support (0.1% vs 0.8%; p < 0.001), advanced calcific plaque modification devices (1% vs 6.1%; p < 0.001), and intravascular ultrasound (14% vs 25%; p < 0.001). MICs achieved higher procedural success (89.5% vs 90.5%; p = 0.07) but higher mortality compared to HICs (0.6% vs 0.2%; p < 0.001). CONCLUSION:Among a selected population of patients undergoing CTO-PCI, notable clinical, anatomical, and procedural differences exist between MICs and HICs. These findings highlight the importance of tailoring public health strategies to optimise cardiovascular care across diverse economic settings.

Coronary artery disease (CAD) is one of the most common cardiovascular diseases, often requiring percutaneous coronary intervention (PCI). Depressive symptoms can significantly impair post-PCI recovery. Brain-derived neurotrophic factor (BDNF) has been implicated as a contributor to CAD and depression, however, its exact role remains unclear. Therefore, the aim of this study is to evaluate the association between serum BDNF levels and cardiac and depression outcomes following PCI with stent placement. This cohort study, with a 6-month follow-up, collected socio-economic, depression and cardiac data, along with serum samples for BDNF level evaluation. Depression was assessed using the Hamilton Rating Scale for Depression (HAMD) scale and Patient Health Questionnaire-15 (PHQ-15). Cardiac assessment included the Seattle Angina Questionnaire Short Form (SAQ-7) and Duke Activity Status Index (DASI). The final sample included 76 participants (mean age 61.4 years, 81.6 % male), of whom 41 presented with depression symptoms. Serum BDNF levels did not differ between groups but were positively correlated with DASI score at baseline and DASI, Physical Limitation SAQ-7 domain, and PHQ-15 scores in the follow-up. Hierarchical regression models showed that serum BDNF level was a significant positive predictor of DASI scores at follow-up (adjusted R2 = 0.298), but not of other variables. Our findings indicate that higher BDNF levels correlate with improved cardiac outcomes post-PCI with stent placement, independent of baseline cardiac status or depression. That suggests that serum BDNF levels may serve as a biomarker for post-PCI recovery, likely due to its role in cardiac myocyte function and vascular stability.

Patients presenting to the emergency department (ED) with acute chest pain but without ischemic ST changes on ECG or elevated troponin levels pose a diagnostic challenge. Current guidelines recommend non-invasive evaluations, such as coronary computed tomography angiography (CCTA), to exclude coronary artery disease (CAD) or guide further management. However, CCTA remains underutilized, with many patients either discharged for outpatient follow-up or admitted for invasive coronary angiography (ICA), even when immediate invasive assessment may not be necessary. This study aimed to evaluate management strategies and healthcare costs for patients with acute chest pain, no ST-segment elevation, and normal troponin levels, focusing on comparing invasive and non-invasive CCTA approaches in both hospitalized and discharged patients. We conducted a retrospective analysis of patients presenting with acute chest pain, no ST-segment elevation, and normal troponin levels, who were either hospitalized or discharged from the ED between January and June 2024. Data collected included the initial diagnostic approach (ICA or non-invasive testing), findings, and subsequent management, whether medical or requiring revascularization. For revascularization cases, the type of intervention (percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)) was noted. Additionally, data on length of stay and healthcare costs were recorded for hospitalized patients. A total of 173 patients were analyzed, with 108 discharged and 65 hospitalized. In the discharged group, all patients underwent CCTA as recommended. Among these, 30 (30.6%) showed no evidence of CAD, 53 (49.1%) were diagnosed with non-obstructive CAD and managed medically, and 22 (20.4%) had suspected obstructive CAD, leading to invasive evaluation. Of those referred, 13 (12.0%) underwent PCI, and 1 (0.9%) received CABG. In the hospitalized group, 53 (81.5%) underwent ICA, with only 8 (12.3%) requiring PCI; no CABG was performed. Among the 12 (18.5%) who received non-invasive testing, CCTA was used in 5 (7.7%), identifying CAD in 1 patient who was managed medically. Average costs and lengths of stay were significantly lower for non-invasive testing, averaging €657 and 3.1 days, compared to €2876 and 4.0 days for ICA without PCI and €4259 for those with PCI. These findings indicate that among patients with acute chest pain, normal troponin levels, and no ST-segment elevation, only one in eight requires revascularization, regardless of inpatient or outpatient status. CCTA is as effective as invasive coronary angiography in identifying cases needing intervention but is significantly more cost-effective. These results support the use of CCTA in the ED to improve management and reduce costs.

Radiation-induced valvular heart disease mainly results in aortic stenosis (AS), with concurrent chemotheraphy adding to damage. The management of outcomes is complex because of simultaneous regurgitant and stenotic valvular lesions, as well as multiple valve involvement. The study aimed to identify variables associated with the development of valve disease, primarily severe aortic stenosis, in patients with or without a history of chest radiation and to determine multivalvular involvement apart from the aortic valve stenosis. We retrospectively analysed a database of 551 patients with severe aortic stenosis who were admitted from September 2020 to September 2024 at the Heart Valve Department. Patients had an average age of 78.432 years ± 8.423 (range: 30-95), with 54.4% being female, and an average BMI of 27.749 ± 5.038 (15.6-44.4). They were divided into two groups: group (I) included severe AS and a history of chest radiation (CR) and chemotherapy due to malignancy, and group (II) consisted of severe AS without mediastinal radiation/chemotherapy. For the groups of patients, we analysed risk factors: arterial hypertension (AH), diabetes mellitus (DM), dyslipidaemia (DIS), smoking, the presence of atrial fibrillation (AF), coronary artery disease (CAD), the intervention (TAVR or SAVR) and the presence of the coexisting multivalvular involvement (aortic, mitral, tricuspid valve regurgitation and mitral valve stenosis). Of the 551 analyzed patients with severe aortic stenosis, predominantly were females (75% vs. 53.0%, P=0.01) among the 36 oncology patients with a history of chest radiation/chemotherapy, mostly due to breast cancer history. When comparing the group of patients with severe AS and a history of chest radiation/chemotherapy (6.5%) to the group without chest radiation/chemotherapy and AS (93.5%), there was a statistically significant difference (P<0.001). There was no age difference between the groups (P=0.194). Despite overall higher presence of multivalve involvement in the group of patients with chest radiation/chemotherapy, it wasn't statistically significant compared to the group of patients with severe AS and no history of CR. DM was more common in patients with severe AS and no CR (group II) compared to a group I (severe AS and CR), with a statistically significant difference between groups (respectively 32.8% vs. 11.1%, P=0.007), whereas dyslipidaemia showed a tendency for positive significance (75.7% vs. 61.1%, P = 0.051). Our results suggest that there is an increased risk of developing severe symptomatic aortic stenosis after malignancy treatment and chest radiation, especially in women. The multivalve involvement was overall more common in the chest radiation group, but not statistically significant. Comparing risk factors, DM and DIS had more impact on development of degenerative AS group and chest radiation in patients with a malignancy history group.

Background and Objectives: Older patients with ACS are less frequently treated with an invasive strategy, which may negatively impact their survival. This study aimed to investigate treatment approaches in elderly ACS patients and compare outcomes between invasively and conservatively treated groups. Materials and Methods: This retrospective study included consecutive patients aged 80 or older who presented with ACS at two tertiary institutions from November 2018 to October 2023. The invasive group consisted of patients who underwent percutaneous or surgical revascularization. The conservative strategy was defined as guideline-directed medical therapy only. The primary outcome was all-cause mortality during the six-month follow-up. Secondary outcomes were recurrent MI and CVI. Results: Among 670 ACS patients with a median age of 83 years (81–86) and 50.6% women, 429 (64%) were treated with an invasive strategy, and 241 (36%) were treated with a conservative strategy. A total of 176 (26%) patients died during the six-month follow-up period, with significantly higher mortality observed in the conservatively treated group compared to the invasively treated group (ACS: 37.8% vs. 19.3%, p < 0.001; STEMI: 49.4% vs. 26.8%, p < 0.001; NSTE-ACS: 32.1% vs. 10.9%, p < 0.001). Recurrent MI was documented in 2.5% of patients, while CVI occurred in 1.2%, with no difference between the treatment groups. Multivariable regression analysis identified invasive strategy (HR = 0.48; 95% CI: 0.33–0.71; p < 0.001) as a positive predictor of six-month survival in ACS patients. Conclusions: The invasive treatment strategy was associated with lower mortality in older ACS patients, regardless of the type of ACS. The incidence of recurrent MI and CVI did not differ between groups treated with different therapeutic approaches.

BACKGROUND:Significant calcifications within a coronary chronic total occlusion (CTO) increase procedural complexity and the risk for complications. Expert consensus documents recommend the use of advanced calcific plaque modification devices (ACPMDs) for calcified CTO percutaneous coronary intervention (PCI), whereas data on their procedural impact are limited. OBJECTIVES:The aim of this study was to describe trends, settings, and outcomes of PCI of severely calcified CTO performed with and without ACPMDs. METHODS:Data from 15,329 CTO PCIs enrolled in the ERCTO (European Registry of Chronic Total Occlusion) between 2021 and 2023 were analyzed. On the basis of the presence of severe calcifications within the CTO, the study population was divided into 2 groups: nonsevere (n = 12,289) and severe (n = 3,040) calcium. Then, the severe group was divided into non-ACPMD (n = 2,253) and ACPMD (n = 787), according to the use of ACPMDs. RESULTS:Compared with the non-ACPMD group, the ACPMD group had higher rates of antegrade wiring (77.9% vs 49.2%; P < 0.001) and technical success (97.6% vs 79.1%; P = 0.001) and lower rates of periprocedural and in-hospital major adverse cardiac and cerebrovascular events (MACCE) (1.8% vs 3.5%; P = 0.001). A severe amount of calcium was independently associated with technical failure (OR: 3.13; 95% CI: 2.43-4.09; P < 0.001) but not with MACCE (OR: 0.88; 95% CI: 0.58-1.35; P = 0.15). Furthermore, extraplaque crossing was independently associated with MACCE (antegrade dissection and re-entry without retrograde contribution: OR: 3.12; 95% CI: 1.79-4.20; P < 0.001; antegrade dissection and re-entry with retrograde contribution: OR: 3.12; 95% CI: 1.67-4.11; P = 0.049; retrograde dissection and re-entry: OR: 1.90; 95% CI: 1.25-2.86; P = 0.002). CONCLUSIONS:Applying ACPMDs in severely calcified CTO to PCI was associated with higher technical success and lower MACCE rates. The presence of severe coronary calcification on coronary angiography was a marker of clinical and procedural complexity and was associated with technical failure but not with MACCE.