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A 35–year–old man presents to the attention of the cardiology department for anterior STEMI. On history he reports hypertension, atrial fibrillation with CHA2DS2–VASc 2 on Rivaroxaban therapy, a previous PCI in the anterior interventricular artery, and a known genetic resistance to Clopidogrel (CYP2C19*2 mutation in heterozygosity) that emerged during diagnostic investigations for marked hyperhomocysteinemia (MTHFR A1298C variant in heterozygosity). Coronary angiography showed endoluminal thrombosis at the ostium of the anterior descending artery and an intrastent thrombosis. IVUS analysis, moreover, shows underexpansion and a concomitant protrusion of the stent at the ostium of the coronary. Thus, angioplasty with positioning of a drug eluting stent was performed. Antithrombotic therapy in these patients is usually triple therapy with ASA, clopidogrel and an anticoagulant. In this case the management of therapy was guided by the patient‘s genetic. Therefore, considering the low hemorrhagic risk and the high thrombotic risk, it was decided to undertake combination therapy with Dabigatran 150mg and Ticagrelor 90 BID in accordance with the Re–Dual PCI treatment trial. Thromboembolic events affect high mortality and morbidity, especially in the 30 days following the angioplastiy procedure. There is a part of the population that may have a poor response to the drugs used and most frequently to Clopidogrel. Genetic polymorphisms present in the coding regions for cytochrome CYP2C19 are involved in the altered metabolism and activation of the drug. The "genetic guided DAPT" used in the POPular Genetics study, was not inferior to Ticagrelor/Prasugrel therapy with regard to thrombotic events but showed a significant reduction in minor bleeding. Since long–term mortality post PCI is predominantly related to the occurrence of hemorrhagic rather than thrombotic events, the reduction of bleeding is very valuable in clinical practice. This case emphasizes the importance for the possible interindividual genetic variability and the most personalized approach possible in treatment choices. The feasibility in terms of cost and events saved of introducing "genetic–guided" DAPT into everyday clinical practice remains to be defined.

Transcatheter aortic valve implantation complicated by infectious endocarditis (TAVI–IE) is an uncommon clinical event with a death rate of 24–46%. Despite several risk factors (young age, sex male, CKD, concurrent PM implantation, residual aortic insufficiency and valve–in–valve implantation) have been reported, the identification of this clinical scenario remains a diagnostic challange due to less sensivity and specificity of echocardiography ascribed to possible imaging artifacts or to a localization of the infectious process that cannot always be evalueted.