BACKGROUND:Drug-coated balloons (DCBs) are increasingly adopted in percutaneous coronary intervention. Bail-out drug-eluting stent (DES) implantation due to suboptimal immediate results after DCB angioplasty is not infrequent, and the clinical outcomes of percutaneous coronary intervention with DCB angioplasty followed by bail-out DES implantation remain unexplored. The aim of this study was to evaluate the safety of bail-out DES implantation following DCB angioplasty in percutaneous coronary intervention. METHODS:The BAILOUT registry included consecutive patients undergoing bail-out DES implantation after DCB angioplasty at 17 European centers between 2011 and 2024. The primary end point was target lesion failure (TLF) at 1 year, defined as the composite of target lesion revascularization, target vessel myocardial infarction, and cardiac death. The TLF rate was compared with a performance goal of 7.0% for an upfront DES-only strategy, derived from a meta-analysis of contemporary randomized controlled trials. RESULTS:A total of 733 patients were included, accounting for 5.5% of all DCB-based percutaneous coronary interventions. At 1 year, the cumulative TLF incidence in the overall population was 7.0% (95% CI, 5.2%-9.3%), which was comparable to the performance goal (P=0.916). This was mainly driven by target lesion revascularization (4.1%), while cardiac death and target vessel myocardial infarction occurred both in 1.9% of patients. The incidence of stent thrombosis was 0.6%. Independent predictors of 1-year TLF included lesion length (hazard ratio, 1.02 per mm increase [95% CI, 1.01-1.03]; P<0.001), moderate-to-severe calcification (hazard ratio, 2.82 [95% CI, 1.48-5.40]; P=0.002), and the use of paclitaxel- versus sirolimus-coated balloons (hazard ratio, 1.99 [95% CI, 1.01-4.05]; P=0.048). CONCLUSIONS:In cases of suboptimal angiographic results after DCB angioplasty, bail-out DES implantation is safe, with no increased risk of TLF at 1 year compared with the expected performance goal for an upfront DES-only strategy.

BACKGROUND:Coronary sinus reducer (CSR) implantation is the only guideline-recommended percutaneous treatment for patients with refractory angina. Data from its real-world large-scale adoption are scarce. METHODS:This was a national audit of CSR implanting centres in the UK between November 2014 and 2024. Centres provided data on all patients undergoing clinical CSR implantation through a structured collection template. Data collected included demographics, medical history, medications, angina status, ischaemia testing, procedural characteristics and periprocedural complications. Prespecified endpoints were appropriate patient selection, procedural success and safety, and efficacy of CSR implantation. RESULTS:19 centres were included capturing 491 patients. Most were male (79%) with high rates of previous myocardial infarction (75%), percutaneous coronary intervention (78%) and coronary artery bypass grafting (69%). Diabetes mellitus (53%), hypertension (76%) and hypercholesterolaemia (78%) were prevalent. 74% had a preserved left ventricular ejection fraction (LVEF≥50%). Patients were severely symptomatic with 84% suffering from Canadian Cardiovascular Society (CCS) class ≥3 angina despite multiple antianginal medications (≥2 drugs 94%; ≥3 drugs 74%). Baseline ischaemia testing was common (79%). Successful CSR implantation was achieved in 95% of cases. 46 periprocedural adverse events (AEs) in 41 patients occurred (9.2%) most commonly due to access complications. Rates of major adverse cardiovascular events and severe AEs were low (<1%). 98% of patients stayed ≤1 night postprocedurally. Significant reductions in CCS class were observed at 6-month follow-up: 75% experienced ≥1 CCS class and 36% ≥2 CCS class angina reduction. Improved angina status was also observed after stratification by age, sex and diabetes mellitus. CONCLUSIONS:This national audit of real-world UK practice confirms CSR implantation is being performed appropriately and safely leading to symptom improvement for patients with refractory angina. Contemporary practice aligns with the recommendations of current guidelines supporting the continued use of CSR in UK clinical practice. Prospective data collection within a national registry is warranted.

INTRODUCTION:The PRECISE study demonstrated that the Prospective multicentre imaging study for evaluation of chest pain (PROMISE) Minimal risk score (PMRS) can identify patients with recent onset stable chest pain who could safely be reassured and discharged without further testing. Despite this observation, the PMRS is not in widespread use. The aim of this analysis was therefore to retrospectively evaluate the performance of the PMRS had it been applied as a decision tool in a real-world population. METHODS:We performed a retrospective cohort analysis of all stable chest pain referrals from 03 April 2023 to 30 August 2024. All elements of the PMRS were measured, along with key patient outcomes including subsequent investigations and cardiovascular events (myocardial infarction (MI) and all-cause mortality). Statistical analyses were conducted in accordance with the data type and distribution. The cohort was split into the minimal risk cohort (PMRS >0.46) and the remainder of the cohort (PMRS ≤0.46). A Kaplan-Meier curve, with log rank analysis, was created to compare the incidence of death/MI between the minimal risk and the remainder of the cohort. RESULTS:This analysis included 3983 patients with a median age of 64 years (IQR 55-75 years) and 49.5% female. The median PMRS was 0.102 (IQR 0.041-0.257) with 10.9% (436) categorised as minimal risk (PMRS >0.46). In the minimal risk group, there were three CT coronary angiographies (0.7%) that demonstrated obstructive coronary disease. At a median follow-up of 306 days (IQR 177-428) there were no MI or deaths recorded in the minimal risk group. CONCLUSION:These data demonstrate that a PMRS >0.46 is associated with a very low frequency of significant coronary artery disease and MI or death. This proof of concept suggests that PMRS could be safely instituted into clinical practice to defer those patients at minimal risk from further investigations which would result in significant resource savings for healthcare services.

Intracoronary (IC) imaging-guided percutaneous coronary intervention (PCI) improves clinical outcomes in patients with high clinical and anatomical risk when compared to interventions guided by angiography alone. Recent Class I recommendations for the use of IC imaging guidance when performing PCI in left main stem or complex lesions may result in a significant uptake as the technology is embraced as standard of care. Routine application of IC imaging will provide interventional cardiologists with a wealth of high-fidelity intracoronary data on plaque composition and distribution. When paired with emerging data regarding the importance of plaque anatomical characteristics, developments in artificial intelligence and computational fluid dynamics, lesion stratification with IC imaging may herald the next paradigm shift in this field. In this review, we will explore this important emerging application of IC imaging to inform morphology-guided PCI, identify high-risk lesions for targeted therapies, and consider the prospects of harnessing automated image interpretation with artificial intelligence technologies to achieve an integrated physiological and morphological assessment. Lesion stratification with IC imaging has the potential to shape the future of interventional cardiology practice to guide therapies within and beyond the confines of the cardiac catheterisation laboratory.

Background Angina is a debilitating condition caused by coronary artery disease and microvascular dysfunction. Following coronary angiography angina and no obstructive coronary arteries is a common outcome, and women are disproportionately affected. The objectives are first, to assess causes of angina in patients undergoing invasive management; and second, to assess effects of coronary function test-guided management on clinical outcomes. Methods This is an international, multicenter, prospective, registry-based study and nested, randomized, controlled, triple-blind, and endpoint trial. Participants, community care providers, and outcomes assessors are masked. Consented participants enter the registry. Participants without obstructive coronary artery disease (luminal stenosis <50%, or fractional flow reserve >0.80) are eligible for randomization. Index of microcirculatory resistance (IMR; abnormal ≥25) and coronary flow reserve (CFR; abnormal <2.0; gray zone 2.0-2.5) are measured by bolus thermodilution, and results are disclosed (intervention) or not (control group) to the attending cardiologist. Results The primary outcome of the registry is the Seattle Angina Questionnaire summary score at baseline described by coronary artery disease status. Secondary outcomes include the prevalence of obstructive coronary artery disease, patient reported outcome measures and clinical outcomes. The primary outcome of the randomized trial is the within-individual change in Seattle Angina Questionnaire summary score at 12-months from baseline. Secondary outcomes include safety, diagnostic accuracy, patient reported outcome measures for quality of life, physical and psychological function, cardiovascular risk, clinical outcomes, health economics and mechanistic biomarkers. The first patient was screened on December 18, 2020 and the last patient was enrolled on June 30, 2026. Forty sites were included in the United Kingdom (n = 35), Republic of Ireland (n = 2), Holland (n = 2), and Poland (n = 1). In total, 1,483 participants were enrolled into the registry of whom 1,047 were randomized and 386 were not randomized (registry-only). Conclusion This international, registry-based clinical trial will provide novel evidence on the natural history of angina and stratified therapy for angina with no obstructive coronary arteries. Clinical trial registration https://clinicaltrials.gov/study/NCT04674449. Unique identifier NCT04674449

BACKGROUND:Percutaneous coronary intervention for coronary chronic total occlusion (CTO PCI) is offered for symptom and quality of life improvement, despite the absence of blinded randomized evidence. OBJECTIVES:The aim of this study was to assess the efficacy of CTO PCI in the first randomized, placebo-controlled trial of CTO PCI. METHODS:ORBITA-CTO is a multicenter, randomized, blinded trial comparing CTO PCI with a placebo procedure. Patients had angina attributable to a single-vessel CTO, without bystander coronary disease. Angina symptoms were recorded daily using the ORBITA app. After dual-injection coronary angiography, patients were randomized to either CTO PCI or placebo. Blinding was maintained using auditory isolation and deep conscious sedation. Antianginal medications were stopped at randomization and reintroduced on a patient-initiated protocol. At the 6-month follow-up, assessments were repeated. The primary efficacy outcome was the angina symptom score, an ordinal scale combining the daily symptom burden assessed by the ORBITA app, antianginal use, and over-ride events. Secondary outcomes were symptom and quality of life questionnaires and blinding fidelity. RESULTS:Between October 19, 2021 and October 21, 2025, 50 patients were randomly assigned to CTO PCI (n = 25) or placebo (n = 25). One patient randomized to PCI was withdrawn during the procedure because of a complication. All 50 patients were included in the primary analysis. Compared with placebo, CTO PCI resulted in an immediate and sustained improvement in the angina symptom score (OR: 4.38; 95% credible interval [CrI]: 1.57-12.69; probability of benefit [Pr{Benefit}] = 0.996), arising from a clear reduction in the number of episodes of angina (OR: 4.38; 95% CrI: 1.55-11.78; Pr[Benefit] = 0.997). This resulted in an additional 30.6 days free of angina (95% CrI: 11.1-50.7; Pr[Benefit] >0.999). Improvements were also observed with the Seattle Angina Questionnaire in angina frequency (+10.7; 95% CrI: 1.4-20.2; Pr[Benefit] = 0.988), physical limitation, quality of life, and summary score and Canadian Cardiovascular Society class. Blinding of patients, staff, and researchers was maintained. CONCLUSIONS:In patients with symptomatic single-vessel CTO, CTO PCI improves angina beyond placebo. (A Placebo-controlled Trial of Chronic Total Occlusion Percutaneous Coronary Intervention for the Relief of Stable Angina [ORBITA-CTO]; NCT05142215).

BACKGROUND:Dedicated randomised studies on intravascular imaging guidance in unprotected left main coronary artery (LMCA) disease are lacking. AIMS:We aimed to investigate the clinical feasibility of optical coherence tomography (OCT) guidance in percutaneous coronary intervention (PCI) of true LMCA bifurcation lesions and to evaluate its prognostic impact compared with angiographic guidance. METHODS:Patients with true LMCA bifurcation lesions who were randomised to either OCT or angiographic guidance in the OCTOBER Trial were included. The feasibility of OCT guidance was assessed as the proportion of patients with successful and analysable OCT pullbacks before, during, and after stenting. Clinical outcomes between the two groups were compared based on the incidence of a composite of major adverse cardiac events (MACE), comprising cardiac death, any myocardial infarction, or target lesion revascularisation. RESULTS:In total, 227 patients were included (OCT: 111, angiography: 116). OCT guidance was successful, with 98% of cases having a pre-stenting pullback performed and 96% a final pullback, as per protocol. The proximal LMCA stent edge was analysable in 43% of patients, and in the remaining 57%, only 5% were limited by insufficient image quality. No statistically significant difference in MACE was observed between the two groups (OCT: 14.4% vs angiography: 18.4%, hazard ratio 0.78, 95% confidence interval: 0.39-1.51). CONCLUSIONS:OCT-guided PCI in true LMCA bifurcation lesions was clinically feasible, but visibility of the LMCA ostium was limited by short pullbacks, insufficient clearance, or guide catheter shadowing. OCT guidance was associated with a non-significant reduction in MACE, consistent with the effect estimate in the main trial.

BACKGROUND:In the REFORM trial, treatment of coronary in-stent restenosis with a Biolimus A9™ drug-coated balloon (BCB) was found to be inferior with respect to in-segment percentage stenosis at 6-months in comparison to treatment with a standard paclitaxel coated paclitaxel-coated balloon (PCB). AIMS:In this manuscript, the final prespecified 2-year clinical follow up follow-up of the REFORM trial is reported. METHODS:The Prospective, Randomized, Non-Inferiority Trial to Determine the Safety and Efficacy of the Biolimus A9™ Drug Coated Balloon for the Treatment of In-Stent Restenosis: First-in-Man Trial (REFORM) was a multicenter, single blind, non-inferiority, randomized controlled trial comparing the BCB and PCB in the treatment of coronary in-stent restenosis (ISR). The primary angiographic endpoint of the trial was in-segment % diameter stenosis (%DS) at 6 months, which has previously been reported. A total clinical follow-up duration of 2 years was planned. Prespecified clinical outcomes at 2 years were: target lesion failure (TLF), target vessel failure (TVF), and their individual components. RESULTS:At 24 months, complete follow-up data was available for 93% (n = 188) of the intention to treat (ITT) population. The mean age was 68.7 years, and patients were predominantly male (80.2%). Comorbidities were well balanced between the 2 groups, including diabetes mellitus, which was present in 31% of the BCB group and 29.2% of the PCB group. ISR lesions were predominantly DES-ISR in both groups (BCB 80.7% vs. PCB 85.1%). Through to 2 year follow up, target lesion failure (TLF) occurred in 36 of 135 patients (27.8%) of patients in the BCB group and in 15 of 67 patients (23.5%) in the PCB group (HR: 1.25; 95% CI: 0.69-2.29). Clinically driven target lesion revascularization (CD-TLR) occurred in 31 of 135 patients (24.2%) in the BCB group versus 13 of 67 patients (20.4%) in the PCB group (HR: 1.26; 95% CI: 0.66-2.40). Target vessel myocardial infarction and cardiac death were comparable in both groups. CONCLUSION:In patients with coronary ISR, the final 2-year results from the REFORM study show that TLF rates were 27.8% in the biolimus-coated balloon BCB group and 23.5% in the paclitaxel-coated balloon PCB group. However, given the limited sample size and wide confidence intervals, the present analysis does not permit reliable inference regarding comparative event rates between treatment strategies. The results should be interpreted against the background of demonstrated inferior angiographic performance of the biolimus DCB at 6 months. TRIAL REGISTRATION:The trial was registered prospectively at www. CLINICALTRIALS:gov (identifier: NCT04079192).

OBJECTIVES:There are limited data on the use of excimer laser coronary atherectomy (ELCA) in conjunction with other calcium modification devices (intravascular lithotripsy [IVL], rotational/orbital atherectomy [RA/OA]). The aim of this analysis was to compare the use of ELCA as a sole device for coronary intervention with ELCA in combination with additional calcium modification devices. METHODS:This was a retrospective analysis of all patients treated with ELCA (either as a sole modification device or in conjunction with another calcium modification device) at a single high-volume center. Data and comparisons between ELCA alone and each of the combination therapies (with IVL, with RA/OA, with both IVL and RA/OA) were presented and compared using statistical methods appropriate to the data type. RESULTS:This analysis included 98 interventions using ELCA (67 as a sole device, 22 with IVL, 6 with RA/OA, 3 with IVL and RA/OA). ELCA alone or in conjunction with IVL were most utilized for in stent restenosis/underexpansion compared with ELCA in conjunction with RA/OA +/-IVL, which were used more frequently for uncrossable/calcified lesions. The frequency of coronary artery perforation across the entire cohort was 4.1%. Target vessel revascularization frequency was 9.2%, and target vessel myocardial infarction was 3.1% at a median of 1051 days, with no statistically significant differences between the device groups. CONCLUSIONS:ELCA combination therapies have a potential role in certain complex cases and though these are associated with higher risk, they can be safely performed in selected centers using radial access with good medium-term outcomes.

BACKGROUND:Percutaneous coronary intervention (PCI) is increasingly used for revascularization of unprotected left main coronary artery disease. Whether intravascular ultrasonographic (IVUS) guidance during PCI results in better clinical outcomes than conventional angiographic guidance alone is uncertain. METHODS:In an international, multicenter, open-label trial, we randomly assigned patients with unprotected left main coronary artery disease in a 1:1 ratio to undergo either IVUS-guided PCI or angiography-guided PCI. The primary end point was a patient-oriented composite of any stroke, any myocardial infarction, any revascularization, or death from any cause at the longest follow-up. RESULTS:A total of 806 patients underwent randomization; 401 were assigned to undergo IVUS-guided PCI and 405 to undergo angiography-guided PCI. The mean (±SD) age of the patients was 71.4±10.7 years, 78.4% of the patients were men, and 34.7% had diabetes. At a median follow-up of 2.9 years, a primary end-point event had occurred in 135 patients (33.7%) in the IVUS-guided PCI group and in 125 patients (30.9%) in the angiography-guided PCI group (hazard ratio, 1.11; 95% confidence interval, 0.87 to 1.42; P = 0.40). The incidence of death, myocardial infarction, or revascularization appeared to be similar in the two groups. The percentages of patients with procedure-related and overall safety events also appeared to be similar in the two groups. CONCLUSIONS:Among patients with unprotected left main coronary artery disease, IVUS-guided PCI showed no additional benefit over angiography-guided PCI with respect to the incidence of stroke, myocardial infarction, any revascularization, or death from any cause at a median follow-up of 2.9 years. (Funded by Philips Image Guided Therapy Devices and Boston Scientific; OPTIMAL ClinicalTrials.gov number, NCT04111770.).

BACKGROUND:Implantation of drug eluting stents (DESs) is currently the default approach for percutaneous coronary interventions, but long-term adverse events still exist. An approach with minimal stenting deserves to be assessed in a randomized trial. We studied a novel sirolimus-eluting balloon (SEB) that elutes sirolimus over a 90-day period using a biodegradable polymer microreservoir technology. METHODS:In a multicenter, open-label, randomized trial, we compared an SEB-based strategy with provisional DES with one of systematic DES for de novo lesions in coronary arteries between 2 and 5 mm in diameter. Subjects were randomized 1:1 before percutaneous coronary intervention. The primary end point was target vessel failure, a composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target vessel revascularization. It was tested for noninferiority at 1 year with the use of an absolute margin equal to 50% of the combined event rate at a significance level of 0.025. The primary analysis population included all randomized subjects with completed or attempted percutaneous revascularization, analyzed according to the intention-to-treat principle. A sensitivity analysis was performed on the per-protocol population. RESULTS:Between August 27, 2021, and July 29, 2024, 3323 participants were randomized and treated in 62 sites. Among 1661 participants in the SEB strategy group, bailout stenting was performed in 343 (20.7%). Target vessel failure occurred over 365 days in 88 (5.3%) and 73 (4.4%) participants in the SEB and the systematic DES strategy groups, respectively (risk difference, 0.91% [95% CI -0.55% to 2.38%]; 1-sided P=0.02 for noninferiority with a 2.44% noninferiority margin). Clinically driven target vessel revascularization occurred more frequently in the SEB strategy group (3.3% versus 2.1%; risk difference, 1.22% [95% CI, 0.11%-2.33%). Safety events, including lesion thrombosis, were low and similar in both groups. Although the results of the per-protocol population (3194 participants, 96%) did not confirm noninferiority (upper boundary of the 95% CI, 2.63; P=0.04), they were similar to the intention-to-treat results in both magnitude and direction. CONCLUSIONS:At 1 year, in the primary intention-to-treat analysis population, a strategy of percutaneous coronary intervention with SEB and provisional DES was noninferior to the systematic use of DES for the primary end point of target vessel failure. The per-protocol population sensitivity analysis did not confirm noninferiority. Clinically driven target vessel revascularization occurred more frequently in the SEB strategy group. At 5 years, target vessel failure will be tested again for noninferiority and for superiority if noninferiority is achieved. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04859985.

Background: This national survey evaluated awareness of indications and perceived barriers to the application of intracoronary imaging (ICI) among physicians and cath lab allied health professionals (AHP) in the UK. Methods: A web-based questionnaire consisting of 35 questions, covering operator and institutional demographics, physician-based indications for ICI, physician confidence-competence and barriers to ICI use, was distributed to 974 physicians (consultant and trainee operators) and 713 AHPs via the British Cardiovascular Intervention Society. For statistical analyses, a two-sided p<0.05 was considered statistically significant. Results: In all, 327 physicians (including 30% of practising UK consultants) and 125 AHPs responded. The greatest response was observed in early career operators (uptake 38% versus 7% for those with ≤5 years versus >20 years’ experience, respectively). There was a preference for intravascular ultrasound (IVUS) over optical coherence tomography (OCT; 74% versus 26%, respectively). Strongest indications for ICI use by lesion aetiology were left main percutaneous coronary intervention (97.7%), stent failure (96.5%), procedural optimisation (92.6%) and calcific disease (89.8%). Operators reported OCT superiority in the identification of stent failure and plaque rupture, and IVUS superiority in ostial and left main disease, spontaneous coronary dissection and chronic total occlusion interventions. Core barriers to ICI application were procedural turnover (65.4%), lack of training and education (61.8%) and the absence of consultant-level proctorship (56.1%). A mismatch between operator-reported confidence in device use and competency in image interpretation across lesion aetiologies was identified, with 58.9% and 57.7% of operators expressing a desire to actively upskill and increase appropriate ICI usage, respectively. Conclusion: This first UK national survey on ICI highlights important barriers to the application of ICI in routine clinical practice. These data should stimulate a paradigm shift in collaborative widespread national training and education strategies for ICI in the UK.

Left main disease represents one of the most complex lesion subsets for percutaneous coronary intervention, associated with an increased risk of serious late complications. The recent endorsement of intracoronary imaging for the guidance of left main bifurcation percutaneous coronary intervention in both acute and chronic coronary syndrome, with respective recommendations in American and European guidelines, reflects the results of recent studies. Patient benefit can only be realized through the interventional community embracing the need for intracoronary imaging-guided planning, guidance and optimization of left main stenting. This clinical consensus statement summarizes the views of a global expert panel, coordinated by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the European Bifurcation Club (EBC). The document includes an appraisal of the most contemporary evidence and provides clinical guidance on how to maximize the benefit of intravascular ultrasound or optical coherence tomography in the treatment of left main bifurcation disease.

BACKGROUND:Elective left ventricular (LV) unloading during high-risk percutaneous coronary intervention (PCI) is hypothesized to mitigate hemodynamic instability and myocardial stunning, but has not been evaluated in a randomized trial. OBJECTIVES:This prespecified substudy of the CHIP-BCIS3 (Controlled Trial of High-risk Coronary Intervention With Percutaneous Left Ventricular Unloading) trial evaluated whether elective LV unloading with a microaxial flow pump (mAFP) reduces hemodynamic instability and postprocedural stunning. METHODS:Patients with severe LV systolic dysfunction undergoing complex PCI were randomized to elective LV unloading with an mAFP or standard care. Invasive hemodynamics were assessed using pulmonary artery catheterization at baseline and post-PCI. The coprimary outcomes were systolic blood pressure reduction, loss of pulse pressure (LOPP), and requirement for inotropes. Secondary outcomes included changes in cardiac index, LV filling pressure, and frequency of peri-procedural myocardial injury. RESULTS:Of 125 eligible patients, 97 were enrolled (50 mAFP; 47 standard care). Baseline cardiac index was 2.10 ± 0.55 L/min/m2. The incidence of systolic blood pressure reduction was similar between groups (relative risk [RR]: 0.86; 95% CI: 0.58-1.29), whereas inotrope use was lower with mAFP (RR: 0.57; 95% CI: 0.34-0.97). LOPP was more frequent with mAFP (RR: 7.83; 95% CI: 2.53-24.24) and was associated with peri-procedural myocardial injury (OR: 3.00; 95% CI: 1.00-9.03). Changes in cardiac index (-0.25 vs -0.24 L/min/m2; P = 0.20) and pulmonary capillary wedge pressure (2 vs 3 mm Hg; P = 0.79) were similar between groups. CONCLUSIONS:In patients undergoing complex PCI, elective LV unloading with mAFP reduced inotrope requirements but increased LOPP and did not prevent myocardial stunning. (Controlled Trial of High-risk Coronary Intervention With Percutaneous Left Ventricular Unloading [CHIP-BCIS3]; NCT05003817).

Coronary bifurcation disease remains one of the more challenging lesion subsets to treat with percutaneous coronary intervention due to bifurcation geometry and increased risk of target lesion failure. Whilst a provisional approach is preferred in most bifurcations, two-stent techniques may be required where there is a high risk of side branch compromise or a bailout; however, this further increases procedure complexity. Drug-coated balloons (DCBs) are emerging as a promising alternative that allow vessel healing without leaving behind a permanent metallic implant by delivering antiproliferative medication directly to the vessel wall and simplifying procedures. This state-of-the-art review summarises the current evidence and the evolving role of DCBs in the management of coronary bifurcation lesions with a focus on patient- and lesion-specific factors that might influence the treatment strategy choice.

Following the recently upgraded recommendations for intravascular imaging use from the European Society of Cardiology and the American Heart Association, we present a UK consensus statement on the use of intravascular ultrasound (IVUS) in percutaneous coronary intervention. Developed by 26 senior interventional cardiologists across a range of UK centres, this statement reflects growing evidence and changing expectations for IVUS use. We discuss the indications for IVUS, the current patterns of use in the UK, anticipated future standards and the need for broader adoption. We propose a standardised workflow and recommend routine documentation of a core IVUS dataset to support quality and as a mechanism for improvement. Persistent barriers, such as perceived cost, training variability and procedural integration, are addressed with practical solutions, including the introduction of national training curricula incorporating intravascular imaging accreditation for operators and targeted education for allied health professionals. Our goal is to support clinicians, catheter lab teams and service leads in embedding IVUS more consistently into practice to optimise patient outcomes.

Non-ST elevation acute coronary syndrome (NSTE-ACS) accounts for a substantial proportion of myocardial infarctions, with increasing incidence over the past two decades; this is partly attributed to the widespread use of high-sensitivity cardiac troponin assays, enabling earlier and more accurate detection of myocardial injury. NSTE-ACS predominantly affects older individuals, with a higher prevalence in those with co-morbid conditions such as hypertension, diabetes mellitus, dyslipidaemia and chronic kidney disease. While the short-term mortality is lower than in ST elevation ACS, individuals with NSTE-ACS exhibit more extensive coronary artery disease and co-morbidities, contributing to higher long-term mortality and recurrent ischaemic events. Diagnosis is primarily based on clinical presentation, electrocardiographic findings and elevated cardiac biomarkers, particularly high-sensitivity troponin, which confirms myocardial necrosis. Initial management involves stabilization with antiplatelet therapy, anticoagulation and prompt risk stratification, followed by invasive strategies such as percutaneous coronary intervention in high-risk patients. Secondary prevention focuses on pharmacological therapies including dual antiplatelet therapy, statins and β-adrenoceptor blockers, alongside lifestyle modifications. Despite favourable short-term outcomes with early intervention, the long-term prognosis remains dependent on effective management of the underlying risk factors and adherence to secondary prevention strategies, as recurrent cardiovascular events remain common.