The Use of Thrombin Generation as a Predictor of Thrombosis in Peripheral Artery Disease.

Long-term safety and efficacy of rotational atherectomy for lesion preparation of calcified coronary lesions.

Emergent carotid artery stenting (eCAS) is frequently performed in acute ischemic stroke to restore cerebral perfusion in patients with high-grade carotid stenosis or dissection. In the absence of prior dual antiplatelet therapy (DAPT), these procedures carry aheightened risk of acute in-stent thrombosis. Tirofiban, an intravenous glycoprotein IIb/IIIa inhibitor with rapid onset of action, has been proposed as abridging antiplatelet strategy, although its efficacy and safety in the neurovascular setting remain uncertain. analysis to evaluate the efficacy and safety of prophylactic tirofiban administration in patients undergoing eCAS without prior DAPT. Asystematic review and meta-analysis were conducted according to PRISMA guidelines. Studies comparing intravenous tirofiban to control (no tirofiban or alternative agents) in patients undergoing eCAS were included. Risk ratios (RR) were calculated using arandom-effects model. Four studies comprising 649 patients were included. Tirofiban use was associated with alower incidence of acute in-stent thrombosis (RR 0.21; 95% CI 0.09-0.49; I2 = 0%). No significant differences were found between tirofiban and control groups regarding sICH (RR 0.45; 95% CI 0.13-1.52; I2 = 41.4%), aICH (RR 1.28; 95% CI 0.64-2.59; I2 = 13.4%), or all-cause mortality (RR 0.72; 95% CI 0.41-1.26; I2 = 34.7%). Tirofiban appears to reduce the risk of acute in-stent thrombosis after eCAS without increasing the incidence of hemorrhagic complications or mortality. Further randomized trials are needed to validate these findings and define optimal periprocedural antiplatelet strategies.

To assess the association between body mass index (BMI) and 10-year clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. This is a pooled analysis of 5 randomized trials with 10-year follow-up. All-cause death was the primary outcome. Secondary outcomes were cardiovascular death, myocardial infarction (MI), definite stent thrombosis (ST) and repeat revascularization. A total of 9,486 patients were analyzed divided into four BMI groups (underweight [n= 92], normal-weight [n= 2,785], overweight [n= 4,296] and obese [n= 2,313]). After 10 years, the risk of all-cause death was significantly higher in underweight patients than in those of normal weight (adjusted hazard ratio [HRadj], 1.58; 95% confidence interval [CI], 1.01-2.47). Compared with normal-weight patients, overweight patients had a significantly lower risk of all-cause death (HRadj, 0.84; 95% CI, 0.78-0.90) and cardiovascular death, while the difference was not significant for obese patients. Overweight and obese patients had a significantly higher risk of definite ST within 30 days, while obese patients had a significantly lower risk of TLR than normal-weight patients. There was a U-shaped, non-linear association between BMI, all-cause death and cardiovascular death. The baseline BMI of patients undergoing PCI with DES may have important implications for long-term secondary prevention strategies. Further dedicated studies are needed to overcome the limitations of the current analysis.

This study evaluated the incidence, determinants, and clinical impact of stent optimization after optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) for complex lesions. From the OCCUPI randomized trial investigating the impact of OCT guidance compared to angiography guidance in complex lesions, patients who underwent OCT-guided PCI with post-stenting OCT evaluations were enrolled and classified into two groups based on whether they met the OCCUPI-OCT criteria: OCT Optimization vs OCT Sub-Optimization. The primary endpoint was the cumulative incidence of cardiac death, myocardial infarction, stent thrombosis, or ischemia-driven target vessel revascularization during one year in the as-treated population. Among the 773 patients who underwent OCT-guided PCI, 549 (71.0%) met the optimization criteria (OCT Optimization), whereas 224 did not (OCT Sub-Optimization). On multivariable analysis, long lesions and small-vessel disease were significant independent predictors of OCT Sub-Optimization. The occurrence of the primary endpoint was significantly lower in the OCT Optimization (2.9%) than in the OCT Sub-Optimization [9.4%, hazard ratio (HR): 0.30, 95% confidence interval (CI): 0.16-0.58, P < .001] or angiography guidance [7.5%, HR: 0.38, 95% CI: 0.22-0.66, P < .001]. Each acceptable component of OCCUPI-OCT criteria assessing stent expansion (minimal stent area, ≥80% mean reference lumen or ≥100% distal reference lumen areas; > 4.5 mm2), apposition (malapposed distance, <400 μm), and absence of major edge dissection, was significantly associated with favourable outcomes (all P < .001). The current study identifies long lesions or small-vessel disease as the determinants of stent optimization following OCT guidance, with the achievement of stent optimization significantly associated with improved clinical outcomes. Stent expansion, apposition, and edge dissection, the three key components of the OCCUPI-OCT criteria, were highly predictive of favourable clinical outcomes.

Calcified coronary lesions remain a challenge in percutaneous coronary intervention (PCI) in both situations of acute myocardial infarction (MI) and stable coronary syndrome. It significantly increases the risk of procedural complications due to difficulty in equipment delivery, balloon expansion, and stent delivery. Furthermore, stent thrombosis, dissection, perforation, and future in-stent restenosis occur more frequently in calcified coronary lesions, impacting repeat target vessel revascularization and increasing the risk of future MI. With intracoronary imaging (intravascular ultrasound and optical coherence tomography), peri-procedural success for treating calcified lesions has increased significantly. Different modalities of calcium modification techniques have since been introduced. This review will discuss the pathophysiology and phenotypes of calcium deposition in the coronary vessels, including eccentric calcified plaques and calcified nodules. We will also focus on calcium modification techniques and their mechanisms: (1) Balloon escalation technique, (2) intravascular lithotripsy, (3) orbital atherectomy, and (4) rotational atherectomy. We will focus on the strengths and limitations of each technique, based on current recommendations and expert consensus from SCAI. We will also provide contemporary evidence of each modality for treating different phenotypes of calcified lesions. In summary, this article provides a comprehensive review of current guidelines for optimizing the treatment of calcified coronary lesions in PCI.

BackgroundAdherence to antiplatelet therapy is critical for preventing stent thrombosis and recurrent ischemic events following percutaneous coronary intervention (PCI). Despite its importance, non-adherence remains a global challenge, particularly in settings where sociocultural factors, health system limitations, and interprofessional practices intersect. Limited research has examined how nurses and other healthcare professionals perceive these challenges in the Saudi context.AimTo explore nurses’ and other healthcare professionals’ perspectives on barriers and enablers to antiplatelet medication adherence among post-PCI patients in Saudi Arabia.MethodsA qualitative descriptive study was conducted in two tertiary cardiac centres in Riyadh. Using purposive sampling, 24 healthcare professionals (13 nurses, 8 cardiologists, 3 pharmacists) participated in semi-structured interviews. Data—reflecting healthcare providers’ perspectives—were analyzed thematically following Braun and Clarke’s framework. Analytical transparency and trustworthiness were ensured through triangulation, member checking, and reflexive journaling.ResultsThree overarching themes emerged: (1) patient- and family-related barriers, including misconceptions, cultural influence, and psychological factors; (2) healthcare system and communication challenges, including language barriers, fragmented continuity of care, and affordability issues; and (3) interprofessional collaboration and professional roles, highlighting nurses as trust builders, physicians as clinical anchors, and pharmacists as regimen simplifiers.ConclusionFindings reflect healthcare professionals’ perceptions of multifactorial barriers and enablers influencing adherence. Strengthening family-inclusive education, multilingual communication strategies, structured follow-up, and equitable access to medicines—supported by interprofessional collaboration—may enhance post-PCI outcomes in Saudi Arabia.Clinical trialNot applicable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12912-025-04067-9.

Zalunfiban is a glycoprotein IIb/IIIa (integrin αIIbβ3) inhibitor designed for subcutaneous administration on first medical contact with patients with suspected ST-segment elevation myocardial infarction (STEMI). An international, double-blind, placebo-controlled trial randomly assigned patients with STEMI in a 1:1:1 ratio to receive a single subcutaneous injection of zalunfiban (0.11 mg/kg or 0.13 mg/kg) or placebo. The primary efficacy end point was a hierarchical proportional odds model ranking seven end points from worst to best: all-cause death, stroke, recurrent myocardial infarction, acute stent thrombosis, new-onset or rehospitalization for heart failure, larger infarct size, or no end point through 30 days. The primary safety end point was the occurrence of severe or life-threatening bleeding as per the global use of strategies to open occluded coronary arteries (GUSTO) criteria. The trial randomly assigned 2467 patients (853 to zalunfiban 0.11 mg/kg, 818 to zalunfiban 0.13 mg/kg, and 796 to placebo). The primary efficacy end point was significantly improved by zalunfiban (adjusted odds ratio 0.79; 95% confidence interval, 0.65 to 0.98; P=0.028). GUSTO severe bleeding was similar between those who received zalunfiban versus placebo (1.2% vs. 0.8%; P=0.40), but GUSTO mild to moderate bleeding was increased (6.4% vs. 2.5%; P<0.001). Angiography showed faster coronary blood flow with zalunfiban versus placebo (corrected frame count of the infarct-related artery 109 [interquartile range 35 to 176] vs. 176 [interquartile range 40 to 176]; P=0.012). In patients with STEMI, zalunfiban administered at first medical contact significantly improved preintervention infarct-related patency and reduced the likelihood of a worse 30-day multicomponent hierarchical clinical end point. Zalunfiban was not associated with increased severe or life-threatening bleeding but was associated with increased mild to moderate bleeding. (Funded by CeleCor Therapeutics; CELEBRATE ClinicalTrials.gov number, NCT04825743).

Despite guideline recommendations, evidence for the use of non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy in patients with atrial fibrillation after implantation of a drug-eluting stent remains limited. In this multicenter, randomized, open-label, noninferiority trial in South Korea, we assigned patients with atrial fibrillation who had undergone the implantation of a drug-eluting stent at least 1 year earlier in a 1:1 ratio to receive NOAC monotherapy or combination therapy (NOAC plus clopidogrel). The primary end point was net adverse clinical events, a composite of death from any cause, myocardial infarction, stent thrombosis, stroke, systemic embolism, or major bleeding or clinically relevant nonmajor bleeding at 12 months. The noninferiority margin was 3.0 percentage points. A total of 960 patients underwent randomization: 482 patients to receive monotherapy and 478 to receive combination therapy. The mean age of the patients was 71.1 years, and 21.4% were women. At 12 months, a primary end-point event had occurred in 46 patients (Kaplan-Meier estimate, 9.6%) in the monotherapy group and in 82 patients (Kaplan-Meier estimate, 17.2%) in the combination-therapy group, for an absolute difference of -7.6 percentage points (95.2% confidence interval [CI], -11.9 to -3.3; P<0.001 for noninferiority) and a hazard ratio of 0.54 (95.2% CI, 0.37 to 0.77; P<0.001 for superiority). Major bleeding or clinically relevant nonmajor bleeding occurred in 25 patients (5.2%) in the monotherapy group and in 63 patients (13.2%) in the combination-therapy group (hazard ratio, 0.38; 95% CI, 0.24 to 0.60). Among patients with atrial fibrillation who had undergone implantation of a drug-eluting stent at least 1 year earlier, NOAC monotherapy was noninferior to combination therapy for net adverse clinical events. (Funded by Cardiovascular Research Center and Samjin Pharmaceutical; ADAPT AF-DES ClinicalTrials.gov number, NCT04250116.).

Background: Data regarding clinical outcomes after optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) compared to angiography-guided PCI in patients with coronary artery lesions are limited. Methods: We systematically searched PubMed, Embase and Cochrane library for randomized controlled trials (RCTs) comparing the impact of OCT-guided PCI versus Angiography-guided PCI on clinical outcomes in patients with coronary artery lesions with primary outcome of interest being all-cause mortality. The secondary outcomes include major adverse cardiovascular events (MACE), stroke, stent thrombosis, bleeding, target vessel revascularization (TVR), target lesion revascularization (TLR), cardiovascular death and myocardial infarction (MI). We pooled risks ratio and their 95% confidence intervals. Heterogeneity was examined using the I 2 statistics and studies with high heterogeneity were examined using the random-effect model. Results: We included 10 RCTs consisting of 8729 patients of which 4256 (48.8%) patients had OCT-guided PCI treatment while 4473 (51.2%) patients had angiography-guided PCI treatment. The mean age of the included studies was 64 ± 10.2 years and 82.6% of the included studies were males. The pooled risks ratio showed no significant differences between groups for all-cause mortality (RR = 0.71; 95% CI [0.50, 1.01]; I 2 = 0%; p = 0.05), stroke (RR = 0.06; 95% CI [0.08, 4.51]; I 2 = 52%; p = 0.62), bleeding (RR = 0.70; 95% CI [0.21, 2.35]; I 2 = 0%; p = 0.56), TLR (RR = 0.75; 95% CI [0.45, 1.23]; I 2 = 49%; p = 0.26), TVR (RR = 0.78; 95% CI [0.59, 1.02]; I 2 = 0%; p = 0.07) and MI (RR = 0.82; 95% CI [0.67, 1.01]; I 2 = 0%; p = 0.06). However, OCT-guided PCI significantly reduced the incidence of MACE (RR = 0.70; 95% CI [0.56, 0.87]; I 2 = 0%; p = 0.002), stent thrombosis (RR = 0.61; 95% CI [0.39, 0.94]; I 2 = 0%; p = 0.02) and cardiovascular death (RR = 0.54; 95% CI [0.35, 0.83]; I 2 = 0%; p = 0.005) compared to angiography-guided PCI. Conclusions: Among patients with coronary artery lesions, OCT-guided PCI was associated with lower incidence of MACE, stent thrombosis and cardiovascular death. However, there was no significant difference between groups for all-cause mortality, bleeding, stroke, TVR, TLR and MI.

Background: Patients with cardiogenic shock or out-of-hospital cardiac arrest undergoing percutaneous coronary intervention face delayed absorption of oral P2Y12 inhibitors due to impaired gastrointestinal perfusion, increasing thrombotic risk. Cangrelor, an intravenous P2Y12 inhibitor with immediate onset, may offer clinical benefit in these critically ill populations. We performed a systematic review and meta-analysis to evaluate the safety and efficacy of cangrelor compared with oral P2Y12 inhibitors in this setting. Research Question: Does cangrelor improve clinical outcomes compared with oral P2Y12 inhibitors in patients undergoing PCI for cardiogenic shock or cardiac arrest? Methods: We searched PubMed and Embase through May 1, 2025, for observational studies comparing cangrelor and oral P2Y12 inhibitors in patients with cardiogenic shock or out-of-hospital cardiac arrest undergoing PCI. Outcomes included all-cause mortality, major bleeding, stent thrombosis, and stroke. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using a random-effects model. Heterogeneity was assessed using the Chi-squared test and I 2 statistic. Subgroup analysis was performed based on clinical presentation. Results: Four studies, including 2,722 patients (1,170 with cardiogenic shock; 1,552 with out-of-hospital cardiac arrest) were analyzed. In cardiogenic shock, cangrelor significantly reduced mortality (RR: 0.81; 95% CI: 0.71–0.93; p = 0.003) without increasing major bleeding (RR: 1.35; 95% CI: 0.91–2.02). In cardiac arrest, cangrelor did not significantly reduce mortality (RR: 0.78; 95% CI: 0.42–1.43) and was associated with increased bleeding risk (RR: 3.10; 95% CI: 1.60–5.98; p = 0.0008). No significant differences were observed for stroke or stent thrombosis. Conclusion: Cangrelor use during PCI in cardiogenic shock was associated with lower mortality and no excess bleeding, supporting its use in this high-risk group. However, in out-of-hospital cardiac arrest, the increased risk of bleeding warrants caution. These findings suggest a phenotype-specific approach to antiplatelet therapy in patients undergoing PCI under critical conditions.

Background: Recent randomized controlled trials (RCTs) of various strategies to guide percutaneous coronary intervention (PCI) have yielded mixed results. We aimed to compare the outcomes with various PCI guidance strategies, including coronary angiography (CA), optical coherence tomography (OCT), intravascular ultrasound (IVUS), fractional flow reserve (FFR), quantitative flow ratio (QFR), and instantaneous wave-free ratio (iFR). Method: We searched electronic databases until March 2025 to include RCTs that assessed the clinical outcomes with IVUS, FFR, QFR, iFR, and OCT compared to CA among patients undergoing PCI. The primary outcome was major adverse cardiac events (MACEs). Network meta-analysis was performed using a frequentist framework. The outcomes were reported as risk ratios (RR) with 95% confidence intervals (CIs) using a random-effect model. Results: Eighty studies, encompassing 45,146 patients, were included. Compared to CA, IVUS (RR 0.70, 95%CI 0.61-0.80), OCT (RR 0.74, 95%CI 0.58-0.93), and FFR (RR 0.82, 95%CI 0.70-0.95) were associated with a lower incidence of MACE. IVUS (RR 0.81, 95%CI 0.66-0.98), OCT (RR 0.75, 95%CI 0.56-0.99), and FFR (RR 0.75, 95%CI 0.59-0.94) were associated with a lower incidence of myocardial infarction. IVUS and OCT were also associated with a lower incidence of cardiovascular mortality (IVUS: RR 0.57, 95%CI 0.42-0.76; OCT: RR 0.51, 95%CI 0.29-0.88), stent thrombosis (IVUS: RR 0.60, 95% CI 0.41-0.88; OCT: RR 0.55, 95% CI 0.36-0.85) and ischemia-driven target lesion revascularization (IVUS: RR 0.62, 95% CI 0.42-0.90; OCT: RR 0.64, 95% CI 0.43-0.95) Conclusion: Intracoronary imaging and FFR guidance were associated with improved outcomes compared with CA. Intracoronary imaging was also associated with a lower incidence of cardiovascular mortality, stent thrombosis, and ischemia-driven TLR. These findings emphasize the importance of integrating intracoronary imaging and FFR to guide PCI decisions.

Background: Angiography has been the standard for imaging guidance during the Percutaneous Coronary Intervention (PCI) in patients with Myocardial Infarction. Intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) are the emerging techniques for guiding the PCI for better patient outcomes. However, there is still limited data on the impact of OCT on clinical outcomes compared to IVUS or angiography-guided PCI. We conducted a systemic review and meta-analysis of all the available randomized control trials comparing OCT-guided vs Angiography-guided or IVUS-guided PCI. Methods: PubMed and Cochrane Library were searched from their inception till September 2023 for all the randomized control trials (RCTs) that compared the clinical outcomes between OCT-guided PCI and Angiography-guided or IVUS-guided PCI. The outcomes of interest extracted from the finalized trials were minimal stent area (MSA), all-cause mortality, cardiovascular mortality, major adverse cardiac events (MACE), target vessel revascularization (TVR), myocardial infarction (MI), target lesion revascularization (TLR) and Stent thrombosis (ST). The trial results were presented as odds ratios (ORs) with 95% confidence intervals (CIs) and were pooled using a random effects model. Results: A significant increase in MSA was observed in OCT-guided stent implantation as compared to angiographic-guided stent implantation [MD: 0.36 (0.22, 0.50); P&lt; 0.00001]. There was a significant reduction in stent thrombosis events by OCT-guided procedures when compared with Angiography-guided procedures [RR: 0.52 (0.32, 0.83); P= 0.006]. There was no significant difference observed in all-cause mortality [RR: 0.92 (0.47, 1.78); P= 0.80], cardiovascular mortality [RR: 0.73 (0.24, 2.21); P= 0.58], and MI [RR: 1.26 (0.52, 3.02); P= 0.61] between OCT guided and IVUS guided PCI. Conclusion: In this meta-analysis, OCT-guided procedures demonstrated superior outcomes in terms of achieving a larger minimal stent area (MSA) and reducing the risk of stent thrombosis compared to angiography-guided PCI. While no significant differences were found between OCT-guided and IVUS-guided PCI, OCT's ability to optimize stent implantation is a valuable addition to traditional angiographic guidance, and advocates further research to address procedural complexities and confirm its clinical benefits.

A 58-year-old male with history of Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia (Ph+ ALL) on ponatinib, and hypertension was admitted to the Oncology service with three days of fever and chills. On hospital day one, he developed crushing chest pain. Electrocardiogram showed 3 mm ST elevations in leads II, III, and aVF with reciprocal ST-depressions in the anterior leads, consistent with an acute inferior ST-elevation myocardial infarction. He was started on aspirin and heparin and taken emergently to the cardiac catheterization lab, where he received a loading dose of clopidogrel. Coronary angiography showed a 95% mid-right coronary artery stenosis due to an ulcerated plaque (Figure 2A). Three drug-eluting stents were placed, restoring TIMI grade III flow (Figure 2B). Forty minutes later, he developed sudden altered mental status and was found pulseless with ventricular fibrillation on telemetry. Return of spontaneous circulation followed resuscitation. Repeat angiography revealed acute in-stent thrombosis (Figure 2C). He underwent aspiration thrombectomy and repeat percutaneous coronary intervention, and was started on intravenous cangrelor. The next morning, clopidogrel was switched to ticagrelor for enhanced antiplatelet effect. The patient stabilized, and ponatinib was discontinued. Ponatinib, a third-generation BCR-ABL tyrosine kinase inhibitor, is effective in Ph+ ALL but carries a risk of arterial thrombotic events, prompting its brief market withdrawal in 2013. The underlying pathophysiology is believed to involve endothelial dysfunction and heightened platelet activation, mechanisms that likely contributed to the hyperacute in-stent thrombosis in this case. This case highlights the therapeutic challenge of treating acute coronary syndromes in cancer patients on pro-thrombotic therapies. In this instance, the decision to pursue a standard dual antiplatelet strategy was influenced by concerns about bleeding risk in a patient with active leukemia and anemia, which likely contributed to the adverse outcome. There is a lack of evidence-based guidelines for antiplatelet management in oncology patients undergoing percutaneous coronary intervention, especially those on thrombogenic agents. As survivorship rises, the use of targeted therapies expands. The cardiovascular sequalae of these agents pose clinical challenges. Investigation into the vascular toxicities of novel cancer therapies is urgently needed to guide future management.

Introduction: Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 inhibitor, is standard care following percutaneous coronary intervention (PCI). However, DAPT increases the risk of gastrointestinal (GI) bleeding, prompting frequent co-prescription of proton pump inhibitors (PPIs). Despite their protective role, concerns exist that PPIs may diminish the efficacy of DAPT and worsen cardiovascular outcomes. This study evaluates the impact of PPI use on clinical outcomes in patients receiving DAPT post-PCI. Research Question: Does PPI use compromise the effectiveness of DAPT in post-PCI patients? Methods: A systematic search of online databases from inception to April 2025 identified eight studies (n = 12,586) assessing the impact of PPIs on aspirin and clopidogrel efficacy after PCI. Both randomized controlled trials and observational studies were included. Primary outcomes were all-cause mortality, recurrent myocardial infarction (MI), and major adverse cardiovascular events (MACE). Secondary outcomes included cardiac death, angina, arrhythmia, heart failure (HF), revascularization, stent thrombosis, and stroke. A random-effects model was used to pool data, with results expressed as risk ratios (RRs) and 95% confidence intervals (CIs). Results: Compared to non-PPI users, PPI use was significantly associated with an increased risk of stent thrombosis (RR 1.58; 95% CI 1.02–2.44; P = 0.04) and revascularization (RR 1.26; 95% CI 1.06–1.51; P = 0.01). No significant differences were observed in MACE (RR 1.30; 95% CI 0.91–1.86; P = 0.15), all-cause mortality (RR 1.24; 95% CI 0.91–1.69; P = 0.18), cardiac death (RR 1.13; 95% CI 0.60–2.14; P = 0.71), recurrent MI (RR 1.21; 95% CI 0.89–1.63; P = 0.22), stroke (RR 0.82; 95% CI 0.34–2.02; P = 0.67), heart failure (RR 1.07; 95% CI 0.65–1.77; P = 0.79), or angina (RR 0.94; 95% CI 0.62–1.41; P = 0.76). Conclusion: PPI use in patients on DAPT post-PCI does not significantly affect MACE, mortality, or recurrent MI risk. However, it is linked to higher risks of stent thrombosis and revascularization. These findings highlight important clinical considerations regarding PPI co-prescription in this population. While PPIs are vital for GI protection, clinicians must balance this benefit against potential cardiovascular risks. Individualized decisions should weigh GI bleeding risk, and further large-scale randomized trials are needed to guide optimal post-PCI management.

Background: While sirolimus-based drug-eluting stents have shown better outcomes than paclitaxel-based stents, it remains unclear whether the same advantage exists when these agents are delivered via drug-coated balloons (DCBs). This meta-analysis aims to compare the efficacy and safety of sirolimus-coated balloons (SCB) versus paclitaxel-coated balloons (PCB) in the treatment of coronary in-stent restenosis. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing SCB and PCB in the treatment of coronary in-sent restenosis (ISR). PubMed, Embase, and Cochrane Library databases were systematically searched. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model. Trial Sequential Analysis (TSA) was also performed to evaluate the robustness of the findings. Results: Four RCTs, including a total of 503 patients, were analyzed, of whom 252 underwent percutaneous coronary intervention (PCI) with SCB. There was no significant difference between SCB and PCB in the risk of target lesion revascularization (TLR) (RR 1.09; 95% CI 0.73 – 1.63, P=0.68), major adverse cardiac events (MACE) (RR 1.03; 95% CI 0.67 – 1.59, P=0.88), cardiovascular death (RR 0.63; 95% CI 0.12 – 3.22, P=0.58), stent thrombosis (RR 1.05; 95% CI 0.16 – 7.04, P=0.96), or myocardial infarction (RR 1.28; 95% CI 0.35 – 4.65, P=0.71), as shown in Figure 1A. TSA indicated that, although the required information size was not reached, the current evidence shows a stable trend, suggesting that future studies are unlikely to alter the finding of no significant difference between groups in TLR (Figure 1B). Conclusion: This meta-analysis of RCTs demonstrates no significant difference in clinical outcomes between SCB and PCB angioplasty for coronary ISR. Both DCB types appear to offer comparable efficacy and safety profiles.

Background: Optical coherence tomography (OCT) offers superior imaging resolution compared to conventional angiography and has been linked to improved outcomes in percutaneous coronary intervention (PCI). Although prior studies support the overall benefits of OCT-guided PCI (OGP), its efficacy specifically in patients with complex coronary lesions—such as chronic total occlusions (CTO), severely calcified lesions, and bifurcations—remains unclear. These lesion types are clinically significant due to their association with increased procedural complications, suboptimal stent deployment, and higher rates of restenosis. To address this critical knowledge gap, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing OGP versus angiography-guided PCI (AGP) in this high-risk population. Methods: We performed a systematic search of MEDLINE, Cochrane Library, Google Scholar, ScienceDirect, and ClinicalTrials.gov through May 2025. Extracted outcomes included major adverse cardiovascular events (MACE), all-cause mortality, cardiac mortality, myocardial infarction, ischemia-driven target vessel revascularization, target lesion revascularization (TLR), stroke, and stent thrombosis. This study was registered with PROSPERO (CRD42024599058). Results: Five RCTs comprising 5,737 patients (OGP: 2,738; AGP: 2,999) with complex coronary lesions were included. Compared to AGP, OGP was associated with a significant reduction in MACE (RR: 0.71, p = 0.0001), all-cause mortality (RR: 0.58, p = 0.009), cardiovascular mortality (RR: 0.43, p = 0.003), TLR (RR: 0.53, p = 0.007), and stroke (RR: 0.17, p = 0.02). No significant differences were observed in periprocedural myocardial infarction or overall myocardial infarction between the two groups. However, procedural time was significantly longer in the OGP group (MD: 16.14 minutes, p = 0.0008). Conclusions: This meta-analysis demonstrates that OCT-guided PCI significantly improves important clinical outcomes in patients with complex coronary lesions. These findings support the incorporation of OCT into routine PCI practice for anatomically challenging lesions, where conventional angiography may be insufficient for optimal procedural planning and execution.

Background: After percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) is typically followed by long-term aspirin monotherapy, but emerging evidence suggests P2Y12 inhibitors may offer improved outcomes. The optimal choice of single antiplatelet therapy after DAPT remains uncertain. This study aims to compare the efficacy and safety of P2Y12 inhibitors versus aspirin monotherapy in post-PCI patients. Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. PubMed, Cochrane Library, and Google Scholar were searched from inception till April 2025. We conducted the statistical analysis using RevMan, version 5.4, using a random-effects model to pool odds ratios (ORs) along with 95% confidence intervals (CIs) for all outcomes. A p-value of less than 0.05 was considered statistically significant. Results: We pooled 7 studies (3 RCTs, 4 observational) including a total of 29,756 patients (P2Y12: 13,523; aspirin: 16,233). P2Y12 inhibitor monotherapy was associated with a significant reduction in major adverse cardiovascular events (MACE) compared to aspirin [OR: 0.73; 95% CI: 0.64–0.84; p &lt; 0.0001]. It also significantly reduced the risk of repeat revascularization [OR: 0.83; 95% CI: 0.73–0.94; p = 0.004] and stroke [OR: 0.63; 95% CI: 0.48–0.81; p = 0.0004]. No significant difference was observed in all-cause mortality [OR: 0.90; 95% CI: 0.77–1.05; p = 0.19], cardiac death [OR: 0.86; 95% CI: 0.68–1.09; p = 0.22], major bleeding [OR: 1.06; 95% CI: 0.67–1.68; p = 0.81], myocardial infarction [OR: 0.78; 95% CI: 0.56–1.08; p = 0.14], or stent thrombosis [OR: 0.71; 95% CI: 0.41–1.22; p = 0.21]. Conclusion: P2Y12 inhibitor monotherapy is associated with a significantly lower risk of MACE, repeat revascularization, and stroke compared to aspirin monotherapy, without increasing the risk of major bleeding or mortality. These findings support the potential role of P2Y12 inhibitors as a safer and more effective long-term antiplatelet therapy post-PCI. Further large-scale randomized trials are warranted to confirm these results and guide future clinical practice.

Introduction: Dual antiplatelet therapy (DAPT) for 12 months is recommended as the standard strategy following percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). Short DAPT (1-3 months) followed by ticagrelor monotherapy is recommended for patients with high bleeding risk. Objective: We performed a frequentist pairwise and network meta-analysis comparing the durations of DAPT using potent P2Y12 inhibitors (P2Y12i) (ticagrelor, prasugrel) in patients undergoing PCI for ACS. Methods: PubMed, Scopus, and Cochrane CENTRAL databases were searched from inception through 5/2025 for randomized controlled trials (RCTs) comparing different potent P2Y12i-based DAPT durations. Outcomes of interest were major adverse cardiovascular events (MACE), net adverse clinical events (NACE; MACE + bleeding events), major bleeding, any bleeding, all-cause death, cardiac death, myocardial infarction, stroke, stent thrombosis, and target vessel revascularization. Frequentist random-effects pairwise and network meta-analysis was performed to calculate risk ratios (RRs) with 95% confidence intervals (CIs). DAPT strategies were ranked using P-scores. Results: Seven RCTs with 23,054 patients comparing 3 strategies (1-month DAPT: 31.2%; 3-month DAPT: 18.6%; 12-month DAPT: 50.2%) were included. Short DAPT reduced the risk of NACE (RR 0.70; 95%CI 0.59-0.84; p&lt;0.001; I 2 =51.2%), major bleeding (RR 0.42; 95%CI 0.33-0.54; p&lt;0.001; I 2 =4%), and any bleeding (RR 0.51; 95%CI 0.43-0.61; p&lt;0.001; I 2 =33.9%) compared with 12-month DAPT (Image 1). In the network comparison, 1-month and 3-month DAPT followed by potent P2Y12i monotherapy exhibited comparable P-scores and were identified as best to reduce NACE. 1-month DAPT was ranked to be the best strategy in reducing major and any bleeding. Conclusion: In patients with ACS undergoing PCI, potent P2Y12i monotherapy after short DAPT for ≤3 months reduced NACE, major bleeding, and any bleeding without increasing other adverse outcomes. A 1-month DAPT duration followed by P2Y12i monotherapy showed the most favorable bleeding profile, while both 1-month and 3-month DAPT durations were effective in reducing NACE. Short-term DAPT is a recommended approach for patients at high bleeding risk.

Introduction: Cytochrome P450 2C19 ( CYP2C19 ) loss-of-function (LOF) genotypes reduce clopidogrel, but not prasugrel or ticagrelor, effectiveness following percutaneous coronary intervention (PCI). Accumulating evidence has demonstrated the clinical benefit of using CYP2C19 genotype to guide selection of P2Y12 inhibitor therapy after PCI. However, these studies have primarily included patients of European and East Asian ancestry. Therefore, there is a paucity of data on the impact of CYP2C19 -guided antiplatelet therapy on clinical outcomes in Black patients. Aim: We aimed to assess the impact of CYP2C19 -guided P2Y12 inhibitor selection on risk for major atherothrombotic events (MAE) among self-reported Black patients within one-year post-PCI. Methods: Black adults across five institutions who underwent PCI and clinical CYP2C19 genotyping for LOF alleles and were prescribed clopidogrel or an alternative P2Y12 inhibitor (prasugrel, ticagrelor) were included. The ultimate prescribing decision was at the prescriber’s discretion. Atherothrombotic events were manually abstracted from the electronic health record and adjudicated. The primary outcome, MAE (composite of all-cause mortality, myocardial infarction, ischemic stroke, stent thrombosis, or unstable angina requiring revascularization), was compared between patients treated with alternative P2Y12 inhibitors (irrespective of CYP2C19 status) versus LOF allele carriers treated with clopidogrel, and separately versus non-LOF carriers treated with clopidogrel, using multivariable Cox regression. Results: The study population consisted of 1,244 Black patients (mean age 61±12 years; 44% women; 70% with acute coronary syndrome), with 734 patients prescribed clopidogrel (170 LOF-carriers, 564 non-LOF-carriers) and 510 prescribed an alternative inhibitor. MAE rates were higher in the LOF-clopidogrel vs alternative inhibitor group (29.1 vs . 13.9 events per 100 PY; unadjusted HR: 0.49 [95%CI: 0.31-0.77], p=&lt;0.01; adjusted HR: 0.54 [95%CI: 0.32-0.91], p=0.02). MAE rates did not differ between the non-LOF-clopidogrel and alternative inhibitor groups (15.4 vs. 13.9 events per 100PY; unadjusted HR: 0.99 [95% CI:0.61-1.32], p=0.57; adjusted HR: 0.99 [95% CI:0.65-1.50], p=0.97). Conclusion: These data suggest that clopidogrel is as effective as alternative P2Y12 inhibitors in post-PCI Black patients without a CYP2C19 LOF allele, while alternative therapy improves outcomes in LOF allele carriers.