AIMS:Timely reperfusion is a key quality-of-care target in ST-segment elevation myocardial infarction (STEMI). When primary percutaneous coronary intervention (PPCI) cannot be delivered within 120 min from first medical contact (FMC), guidelines recommend fibrinolysis as early as possible within 12 h of symptom onset in eligible patients. We quantified missed opportunities for fibrinolysis in a nationwide STEMI network. METHODS AND RESULTS:We analysed consecutive STEMI patients enrolled ≤24 h from symptom onset in the France-PCI registry (2014-22). First medical contact was approximated by the first diagnostic electrocardiogram (ECG). Initial reperfusion was classified as timely PPCI (FMC-to-device ≤120 min), delayed PPCI (>120 min), or fibrinolysis. Among delayed PPCI, eligibility for fibrinolysis required no oral anticoagulant, no prior stroke, and no documented contraindication. We evaluated temporal trends, regional variation, and outcomes. Among 19 472 patients, 12 633 (64.9%) underwent timely PPCI, 5895 (30.3%) delayed PPCI, and 944 (4.8%) fibrinolysis. Timely PPCI increased over time, whereas fibrinolysis declined. Among delayed PPCI, 3279/5895 (55.6%) presented within the prespecified early-presenter window (symptom-to-ECG ≤3 h) and met our strict fibrinolysis-eligibility criteria, yet underwent delayed PPCI; this proportion remained stable across years, with marked regional heterogeneity. Fibrinolysis use was favoured by mobile intensive care units, helicopter transport, and longer distance to PPCI centres, whereas older age was associated with delayed PPCI without fibrinolysis. CONCLUSION:In this national STEMI network, more than half of delayed PPCI in eligible early presenters represented a persistent missed-fibrinolysis gap. Routine audit of delayed PCI and missed fibrinolysis as system-level quality metrics should guide time-based pre-hospital triage and align reperfusion with guideline-recommended targets.

BACKGROUND:The management of calcified coronary lesions remains challenging. Although several devices for advanced plaque modification are available, their relative efficacy is debated. AIMS:We aimed to compare intravascular lithotripsy (IVL)- and rotational atherectomy (RA)-based strategies for calcified plaque preparation during percutaneous coronary interventions (PCI). METHODS:This multicentre, prospective, randomised non-inferiority trial compared IVL with RA for plaque preparation in moderate-to-severe stable calcified coronary lesions. All interventions were guided by optical frequency domain imaging. A non-inferiority margin of 0.75 mm2 was prospectively defined based on prior intracoronary imaging studies, and the sample size calculation was based on a standard deviation of 1.9 mm2, a one-sided alpha risk of 5%, and a power of 80%, under the assumption of no true difference between groups. The primary endpoint was the minimal stent area (MSA) following stent implantation. The target lesion failure (TLF) rate was analysed after 12 months. RESULTS:A total of 169 patients (RA: n=86, IVL: n=83; 81.1% male; mean age 71.8±8.2 years) were included in the final analysis. The baseline characteristics of each group were balanced. Calcified nodules were identified in 48% of the patients. IVL was not inferior to RA for the primary endpoint (6.0±2.3 mm2 vs 5.9±2.2 mm2, respectively; p for non-inferiority<0.05). Adequate geometrical stent expansion was similar in both groups (RA: 65.1%, IVL: 65.1%; p=0.994), whereas major strut malapposition was more frequently observed in the RA group (RA: 80.2% vs IVL: 57.8%; p=0.002). There was no difference between groups in terms of periprocedural complications. The TLF rates between groups after 12 months were equivalent (RA: 1.2%, IVL: 2.4%; p=0.61). CONCLUSIONS:In this trial, the IVL strategy was non-inferior to the RA strategy regarding MSA for PCI in moderate-to-severe calcified coronary lesions, with a comparable safety profile and equivalent clinical outcomes.

BackgroundCurrent classification of Acute Myocardial Infarction (AMI) into ST-elevation (STEMI) and non-ST-elevation (NSTEMI) myocardial infarction does not fully reflect the clinical heterogeneity of patients.ObjectivesTo identify clinically meaningful phenotypes of AMI patients using an unsupervised clustering approach and assess their associations with management strategies and long-term outcomes.MethodsHierarchical agglomerative clustering using Ward’s method was performed in 4,947 patients from the French FAST-MI 2015 nationwide registry. Clustering was based on baseline clinical, demographic, and laboratory features. Between-cluster differences in baseline characteristics, management, in-hospital complications, and 1-year mortality were analyzed.ResultsFour phenotypic clusters were identified. Cluster 1 (n = 1,488) gathered older patients, predominantly men, with typical coronary risk factors, intermediate risk profile, and balanced STEMI/NSTEMI presentations. Cluster 2 (n = 1,305) gathered older polymorbid patients, 45% were women, 60% with NSTEMI presentation, with limited use of invasive strategies (71%), and a high 1-year mortality. Cluster 3 (n = 815) gathered young (mean age 44 years), predominantly male patients, with a high prevalence of smoking (73%) and few comorbidities, 62% STEMI, high rates of revascularization, and excellent prognosis. Cluster 4 (n = 1,339) was close to Cluster 3 with a more metabolic profile with higher rates of obesity, diabetes, and dyslipidemia, also with favorable outcomes. In-hospital complications were more frequent in Clusters 1 and 2. One-year mortality was lowest in Clusters 3 and 4 (1.5 and 2.3%), intermediate in Cluster 1 (6.0%), and highest in Cluster 2 (15.7%).ConclusionUnsupervised clustering identified four clinically relevant AMI phenotypes with distinct characteristics, management patterns, and prognoses. This data-driven classification highlights the diversity of AMI presentations and may offer complementary insights for patient profiling and risk stratification.

BACKGROUND:The link to mortality and respective weight of ischemic events, hemorrhagic events or both after percutaneous coronary interventions (PCI) remain unclear, especially in regards of the time of occurrence. OBJECTIVES:To compare the association between ischemic and bleeding complications and mortality according to the timing of their occurrence after PCI. METHODS:All patients included in the FRANCE PCI registry between 2014 and 2020 were categorized, according to the occurrence of an ischemic complication (stent thrombosis, myocardial infarction, stroke or unplanned revascularization), a major bleeding (BARC type≥3), both or none of these complications. The analysis was also performed according to the timing of the complication (in-hospital or within one year of PCI). The primary outcome was all-cause mortality, analyzed 1/ during the index hospitalization for PCI by multivariable logistic regression, and 2/ over different periods of time after discharge from the index hospitalization, with a piecewise Cox multivariable model using ischemic and hemorrhagic complications as time-dependent variables. RESULTS:A total of 54,599 patients were included (75% male, median age 69 years), with an acute PCI in 52.9% of the cases. During hospitalization, ischemic complications (aOR 8.4, 95% CI 6.4-10.9), bleeding complications (aOR 10.3, 95% CI 8.1-13.2), and their combination (aOR 13.2, 95% CI 7.0-24.7) were all associated with increased mortality. After discharge, both ischemic and bleeding complications remained significantly associated with all-cause mortality although the strength of these associations decreased over time. Late (beyond 24 weeks) bleeding complications were more strongly associated with mortality (aHR 6.0 95%CI:5.0-7.3) than late ischemic complications (aHR 2.5 95%CI:2.0-3.1). CONCLUSIONS:After PCI there is an incremental risk of death with ischemic, bleeding and the combination of ischemic and bleeding complications occurring during hospitalization. Bleeding complications late after discharge seem to bear a higher risk of death than ischemic complications.

BACKGROUND:Heart rate (HR) is a key prognostic factor after myocardial infarction (MI), but its relevance in the modern reperfusion era is uncertain. We aim to evaluate the association between HR and β-blocker interruption on cardiovascular outcomes. METHODS:A prespecified secondary analysis of the ABYSS trial (Assessment of Beta-Blocker Interruption 1 Year After an Uncomplicted Myocardial Infarction), including 3698 stable post-MI patients (left ventricular ejection fraction ≥40%) randomized to continue or interrupt β-blockers, was conducted. Patients were grouped by prerandomization HR tertiles: <60 bpm (T1), 60 to <68 (T2), and ≥68 (T3). We examined associations between HR, treatment strategy, and the primary endpoint (death, MI, stroke, or cardiovascular rehospitalization), major secondary endpoints, and on-treatment HR. RESULTS:Median age in the study population was 63.5 years (55.9-71.1), and there were 621 women (17.1%). Baseline HR was not associated with the primary endpoint (22.4% versus 21.8% versus 21.6%; P=0.867). Higher HR was associated with increased risk of death, MI, or stroke (5.5% versus 6.4% versus 9.2%; P<0.001; T3 versus T1 adjusted hazard ratio, 1.55; 95% CI, 1.14-2.12) and death, MI, stroke, or heart failure (6.5% versus 7.1% versus 10.4%; P=0.007; T3 versus T1 adjusted hazard ratio, 1.47; 95% CI, 1.11-1.97). All-cause mortality rose across tertiles (2.9% versus 3.4% versus 5.9%; P=0.004; P trend=0.008). β-Blocker interruption produced a dose-dependent HR increase of ≈10-13 bpm during follow-up. The association between interruption and worse outcomes was consistent across HR tertiles (no significant interaction) and LVEF categories (40% to 49% and >50%). CONCLUSIONS:In stabilized post-MI patients with preserved ejection fraction, higher HR remains associated with adverse cardiovascular events and mortality in the reperfusion era. Interrupting β-blockers substantially increases HR and is consistently linked with worse outcomes irrespective of baseline HR, supporting continuation of β-blocker therapy.

Background:Spontaneous coronary artery dissection (SCAD) is a severe and under-diagnosed pathology that generates diagnostic and therapeutic difficulties. Case summary:This case is about a 45-year-old female with a history of coronary spasm in 2012 without ergonovine provocation confirmation. She was admitted in 2014 for an acute coronary syndrome (ACS) revealing an aspect of thrombus of the left anterior descending (LAD) coronary artery. GPIIb/IIIa antagonists, unfractionated heparin, and antiplatelet therapy were introduced. Angiographic control 10 days later showed that the lesion was not thrombotic but a SCAD which spread on the left main coronary artery and LAD proximal part. Angiographic control at 1 month showed a partial healing but persistent focal dissection of the mid-LAD treated by two bioresorbable vascular scaffolds. In 2018, she presented with a new case of SCAD treated at another hospital, where she had been misdiagnosed with myocarditis. A review of the angiograms revealed findings typical of distal SCAD of the circumflex artery. In June 2022, a new ACS was related to a right coronary artery SCAD. The distal part was occluded by an extensive haematoma. This was turned into a dissection by using a cutting balloon. No stent was implanted. Discussion:SCAD is a complex condition that presents diagnostic challenges, as this case illustrates. Such diagnostic errors can lead to the prescription of inappropriate medication, such as anticoagulant therapy, which may exacerbate the condition by increasing the size of the haematoma. It is also a condition that can recur, and clinicians must bear this in mind.

BACKGROUND:Dual antiplatelet therapy reduces ischaemic complications after percutaneous coronary intervention, but increases bleeding risk, especially in patients who are already at high bleeding risk. Current guidelines therefore recommend abbreviated dual antiplatelet therapy in this population. AIM:To evaluate the real-world use of abbreviated dual antiplatelet therapy (≤3 months) after percutaneous coronary intervention according to bleeding risk, using data from the nationwide FRANCE-PCI registry. METHODS:All consecutive patients undergoing percutaneous coronary intervention for either acute or chronic coronary syndrome between 2014 and 2023 across 56 hospitals, who were alive at 1 year, and in whom dual antiplatelet therapy duration was known, were included. High bleeding risk was defined as the presence of at least one of the following: age≥75 years; chronic oral anticoagulant therapy; previous stroke; or chronic kidney disease. RESULTS:Among 115,992 patients included, 41.4% met the criteria for high bleeding risk. Abbreviated dual antiplatelet therapy was prescribed in 23.1% of patients with a high bleeding risk versus 3.6% of patients without a high bleeding risk. Among patients with a high bleeding risk, factors independently associated with prolonged (>3 months) dual antiplatelet therapy use were: increasing age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.02-1.03); female sex (OR 1.18, 95% CI 1.11-1.25); diabetes mellitus (OR 1.15, 95% CI 1.08-1.22); previous stroke (OR 1.54, 95% CI 1.39-1.69); chronic kidney disease (OR 1.24, 95% CI 1.15-1.34); acute coronary syndrome (OR 1.52, 95% CI 1.44-1.61); and stent length≥60mm (OR 1.18, 95% CI 1.09-1.28). CONCLUSIONS:In real-word practice, less than one third of patients with a high bleeding risk received abbreviated dual antiplatelet therapy after percutaneous coronary intervention. The use of prolonged dual antiplatelet therapy remained driven by ischaemic risk markers, highlighting persistent uncertainty in bleeding risk/ischaemic risk trade-offs.

BACKGROUND:The optimal timing for initiating P2Y12 inhibitor therapy in patients undergoing percutaneous coronary intervention (PCI) remains controversial. In this study we analyzed the impact of dual antiplatelet therapy (DAPT) pretreatment on premature stent thrombosis in patients with chronic coronary syndrome and non-ST-elevation myocardial infarction treated by PCI. METHODS:We analyzed data from 53,898 PCI procedures (44,412 patients) in the "France PCI" registry between 2014 and 2020. Patients were divided into P2Y12 inhibitor pretreatment (83.2%) and no-pretreatment (16.8%) groups. The primary endpoint was incidence of in-hospital definite stent thrombosis. RESULTS:Pretreatment was associated with a significantly lower incidence of in-hospital stent thrombosis (0.1% vs 0.4%; odds ratio [OR] 0.35, 95% confidence interval [CI] 0.22-0.57). At 1 year, the pretreatment group showed lower rates of major adverse cardiovascular events (6.6% vs 7.8%; OR 0.83, 95% CI 0.74-0.92) and all-cause mortality (4.6% vs 6.0%; OR 0.71, 95% CI 0.63-0.80). Notably, there was no significant increase in major bleeding events in the pretreatment group. CONCLUSIONS:In this large, real-world cohort, P2Y12 inhibitor pretreatment was associated with a significant reduction in in-hospital stent thrombosis and improved 1-year clinical outcomes without increased major bleeding risk. Our findings suggest that selective use of antiplatelet pretreatment may still play a crucial role in improving ischemic outcomes for patients undergoing PCI.

Spontaneous coronary artery dissection (SCAD) is a rare, non-atherosclerotic cause of acute coronary syndrome (ACS) that predominantly affects young women without traditional cardiovascular risk factors. There is no definitive evidence on the optimal management of SCAD, and the general approach is conservative. In contrast to the well-established evidence-based rehabilitation programmes for atherosclerotic ACS and heart failure, no standardized cardiovascular rehabilitation (CR) protocol currently exists for SCAD. The READAPT-DISCO study is a retrospective observational sub-study of the French DISCO trial, which included data from 373 patients with confirmed SCAD aged >18 years between 2016 and 2018. Detailed information on CR modalities and their potential benefits for patients with SCAD was collected, alongside an evaluation of safety outcomes. Key findings . Cardiac rehabilitation is feasible for patients with SCAD. . There are considerable disparities in referrals to CR programmes and in CR modalities in France.

BACKGROUND AND AIMS:Several randomized controlled trials (RCTs) have compared fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) with angiography-guided PCI in different clinical settings, yielding mixed results. This individual patient data meta-analysis focused on trials where FFR was used to assess intermediate coronary lesions in chronic coronary syndrome (CCS) or non-culprit vessels in non-ST-elevation acute coronary syndromes (NSTE-ACS). METHODS:Randomized controlled trials comparing FFR- vs angiography-guided PCI with a minimum follow-up of 1 year were searched. Studies lacking angiographic inclusion criteria or using FFR for culprit arteries in NSTE-ACS were excluded. Studies including patients with ST-elevation myocardial infarction (MI) or undergoing surgical revascularization could be included after censoring these two subgroups. The primary outcome was the 1-year rate of major adverse cardiac events (MACE), defined as a composite of all-cause death, MI, and repeat revascularization. The secondary outcomes were a composite of all-cause death and MI, the individual components of the primary outcome, cardiac death, spontaneous MI, and procedural MI. The present study is registered with PROSPERO (CRD42024553676). RESULTS:Five RCTs were selected, including 2493 patients: 1241 in the angiography arm and 1252 in the FFR arm. More vessels underwent PCI in the angiography group (45.1% vs 30.2%, P < .001), with more stents implanted per patient [2.0 (2.0-3.0) vs 1.5 (1.0-2.0), P < .001]. One-year MACE occurred in 14.7% of patients in the angiography group and 12.1% in the FFR group [hazard ratio (HR) .80, 95% confidence interval (CI) .64-.99; P = .046]. The risk of MI was significantly reduced in the FFR-guided group (HR .71, 95% CI .53-.96; P = .031). These outcomes were driven by a reduction in peri-procedural MI with FFR guidance, with no significant difference between groups in non-procedural MI, MACE between 30 days and 1 year, and secondary outcomes. CONCLUSIONS:Fractional flow reserve-guided PCI was associated with reduced major adverse events in patients with CCS and NSTE-ACS due mainly to fewer peri-procedural MIs, with no differences in mortality or MACE beyond 30 days.

Background: Angioplasty of coronary chronic total occlusions (CTOs) was a breakthrough, but there is a lack of data concerning stent healing after these complex procedures. Objectives: The main aim of the PERFECTO (Post-stEnting assessment of Reendothelialization with optical Frequency domain imaging aftEr CTO procedure) study is to assess, for the first time, stent strut apposition at the index CTO procedure and at 3-month follow-up using frequency-domain optical coherence tomography (FD-OCT). Methods: From March 2018 to January 2020, 114 consecutive patients who underwent successful CTO recanalization >20 mm in length were prospectively included in 7 centers. FD-OCT was performed for ad hoc guidance during the index procedure and at 3-month follow-up. All patients received the same last-generation drug-eluting stent. Results: Mean age was 63.2 years, and 87% were male. The rate of malapposed struts per patient was 7.84% at the end of the index procedure and 15.03% at 3-month follow-up (P < 0.0001), highlighting the phenomenon of acquired malapposition. Malapposed struts occurred more often with dissection and re-entry techniques and subintimal stenting compared to intimal techniques (12.8% vs 5.3%, P = 0.02). At 3-month follow-up, distal vessel minimal lumen area increased from 69% (index 2.19 mm2 vs 3.71 mm2 at 3 months, P < 0.0001). No complication occurred with FD-OCT. Conclusions: CTO-percutaneous coronary intervention could affect stent healing with a high incidence of immediate and late-acquired malapposition. These results support the interest of using FD-OCT during follow-up to better assess CTO recanalization results. (Post-stenting Assessment of Reendothelialization With OFDI After CTO Procedure [PERFECTO]; NCT03209843)

Background An appropriate duration of dual antiplatelet therapy after percutaneous coronary intervention for acute myocardial infarction that has been treated with guideline-recommended complete revascularization and a contemporary drug-eluting stent remains unclear.Methods We conducted a multicenter, open-label, randomized trial at 40 European sites. Adults with acute myocardial infarction who had undergone successful complete revascularization within 7 days after the infarction and had subsequently completed 1 month of dual antiplatelet therapy with no ischemic or major bleeding events were randomly assigned to transition to a P2Y12 inhibitor as monotherapy or to continue dual antiplatelet therapy for an additional 11 months. The primary outcome was a composite of death from any cause, myocardial infarction, stent thrombosis, stroke, or major bleeding (defined by the Bleeding Academic Research Consortium [BARC] as a bleeding event of type 3 or 5) at 11 months after randomization (tested for noninferiority with a margin of 1.25 percentage points). The main secondary outcome was BARC type 2, 3, or 5 bleeding (clinically relevant bleeding) at 11 months after randomization (tested for superiority).Results Among the 2246 enrolled patients, 1942 underwent randomization: 961 to receive P2Y12-inhibitor monotherapy and 981 to continue dual antiplatelet therapy. A primary-outcome event occurred in 20 patients (2.1%) in the P2Y12-inhibitor monotherapy group and in 21 patients (2.2%) in the dual antiplatelet therapy group (difference, -0.09 percentage points; 95% confidence interval [CI], -1.39 to 1.20; P=0.02 for noninferiority). BARC type 2, 3, or 5 bleeding occurred in 2.6% of the patients in the P2Y12-inhibitor monotherapy group and in 5.6% of those in the dual antiplatelet therapy group (hazard ratio, 0.46; 95% CI, 0.29 to 0.75; P=0.002 for superiority). Stent thrombosis was infrequent, and the incidence was similar in the two groups. The incidence of serious adverse events appeared to be similar in the two groups.Conclusions Among low-risk patients with acute myocardial infarction who had undergone early complete revascularization and had completed 1 month of dual antiplatelet therapy without complications, P2Y12-inhibitor monotherapy was noninferior to continued dual antiplatelet therapy with respect to the occurrence of adverse cardiovascular and cerebrovascular events and resulted in a lower incidence of bleeding events. (Funded by MicroPort [France]; TARGET-FIRST ClinicalTrials.gov number, NCT04753749.) In low-risk patients with MI and early complete revascularization, stopping aspirin after 1 month and continuing P2Y12 monotherapy was noninferior to dual antiplatelet therapy for ischemic outcomes and led to reduced bleeding at 1 year.

Background The percentage of women <50 years of age hospitalized with myocardial infarction is increasing. We describe the clinical, morphological, and biological characteristics, as well as the clinical outcomes of this population. Methods and Results This prospective, observational study included consecutive women <50 years of age admitted for myocardial infarction at 30 centers in France (May 2017–June 2019). The primary outcome was the composite of net adverse clinical events: all‐cause death, cardiovascular death, recurrent myocardial infarction, stent thrombosis, any stroke, or major bleeding occurring during hospitalization with a 12‐month follow up. Three hundred fourteen women were included. The mean age was 43.0 (±5.7) years, 60.8% presented with ST‐segment–elevation myocardial infarction, 75.5% were current smokers, 31.2% had a history of complicated pregnancy, and 55.1% reported recent emotional stress. Most (91.6%) women presented with typical chest pain. Of patients on an estrogen‐containing contraceptive, 86.0% had at least 1 contraindication. Of patients with ST‐segment–elevation myocardial infarction, 17.8% had myocardial infarction with nonobstructive coronary arteries and 14.6% had spontaneous coronary artery dissection, whereas 29.3% presented with multivessel vessel disease. During hospitalization, 11 net adverse clinical events occurred in 9 (2.8%) women, but no deaths or stent thromboses occurred. By 12 months, 14 net adverse clinical events occurred in 10 (3.2%) women; 2 (0.6%) died (from progressive cancer) and 25 (7.9%) had an ischemia‐driven repeat percutaneous coronary intervention. Conclusions Most young women with myocardial infarction reported typical chest pain and had modifiable cardiovascular risk factors. History of adverse pregnancy outcomes and prescription of combined oral contraceptive despite a contraindication were prevalent, emphasizing the need for comprehensive cardiological and gynecological evaluation and follow‐up. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03073447.

Les dissections coronaires iatrogènes sont rares mais potentiellement gravissimes. Leur prise en charge est complexe en particulier si la dissection survient sans guide d'angioplastie dans la lumière artérielle. Dans ce contexte, l'angiographie seule s'avère insuffisante et le recours à l'imagerie endocoronaire est indispensable (par cohérence optique ou par IVUS) pour guider la prise en charge par angioplastie lorsqu'elle est nécessaire (guide en vraie lumière, couverture de la porte d'entrée). Nous rapportons ici le cas d'une dissection iatrogène de la coronaire droite traitée sous guidage OFDI.