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Prognostic effect of discontinuing renin–angiotensin–aldosterone-system-inhibitor (RAASi) for patients with heart failure (HF) after acute myocardial infarction (AMI) whose left ventricular (LV) systolic function was restored during follow-up is unknown. To investigate the outcome after discontinuing RAASi in post-AMI HF patients with restored LV ejection fraction (EF). Of 13,104 consecutive patients from the nationwide, multicenter, and prospective Korea Acute Myocardial Infarction-National Institutes of Health (KAMIR-NIH) registry, HF patients with baseline LVEF < 50% that was restored to ≥ 50% at 12-month follow-up were selected. Primary outcome was a composite of all-cause death, spontaneous MI, or rehospitalization for HF at 36-month after index procedure. Of 726 post-AMI HF patients with restored LVEF, 544 maintained RAASi (Maintain-RAASi) beyond 12-month, 108 stopped RAASi (Stop-RAASi), and 74 did not use RAASi (RAASi-Not-Used) at baseline and follow-up. Systemic hemodynamics and cardiac workloads were similar among groups at baseline and during follow-up. Stop-RAASi group showed elevated NT-proBNP than Maintain-RAASi group at 36-month. Stop-RAASi group showed significantly higher risk of primary outcome than Maintain-RAASi group (11.4% vs. 5.4%; adjusted hazard ratio [HRadjust] 2.20, 95% confidence interval [CI] 1.09–4.46, P = 0.028), mainly driven by increased risk of all-cause death. The rate of primary outcome was similar between Stop-RAASi and RAASi-Not-Used group (11.4% vs. 12.1%; HRadjust 1.18 [0.47–2.99], P = 0.725). In post-AMI HF patients with restored LV systolic function, RAASi discontinuation was associated with significantly increased risk of all-cause death, MI, or rehospitalization for HF. Maintaining RAASi will be necessary for post-AMI HF patients, even after LVEF is restored. [ABSTRACT FROM AUTHOR]

ILUMIEN IV was the first large-scale, multicenter, randomized trial comparing optical coherence tomography (OCT)-guided vs angiography-guided stent implantation in patients with high-risk clinical characteristics and/or complex angiographic lesions. The authors aimed to specifically examine outcomes in the complex angiographic lesions subgroup. From the original trial population (N = 2,487), high-risk patients without complex angiographic lesions were excluded (n = 514). Complex angiographic lesion characteristics included: 1) long or multiple lesions with intended total stent length ≥28 mm; 2) bifurcation lesion with intended 2-stent strategy; 3) severely calcified lesion; 4) chronic total occlusion; or 5) in-stent restenosis. The study endpoints were: 1) final minimal stent area (MSA); 2) 2-year composite of serious major adverse cardiovascular events (MACEs) (cardiac death, target-vessel myocardial infarction [MI], or stent thrombosis); and 3) 2-year effectiveness, defined as target-vessel failure (TVF), a composite of cardiac death, target-vessel MI, or ischemia-driven target-vessel revascularization. The postpercutaneous coronary intervention (PCI) MSA was larger in the OCT-guided (n = 992) vs angiography-guided (n = 981) group (5.56 ± 1.95 mm2 vs 5.26 ± 1.81 mm2; difference, 0.30; 95% CI: 0.14-0.47; P < 0.001). Compared with angiography-guided PCI, OCT-guided PCI resulted in a lower risk of serious MACE (3.1% vs 4.9%; HR: 0.63; 95% CI: 0.40-0.99; P = 0.04). TVF was not significantly different between groups (7.3% vs 8.8%; HR: 0.82; 95% CI: 0.59-1.12; P = 0.20). In complex angiographic lesions, OCT-guided PCI led to a larger MSA and reduced the serious MACE, the composite of cardiac death, target-vessel MI, or stent thrombosis, compared with angiography-guided PCI at 2 years, but did not significantly improve TVF. (Optical Coherence Tomography Guided Coronary Stent Implantation Compared to Angiography: A Multicenter Randomized Trial in PCI; NCT03507777) [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction: It remains controversial whether complete revascularization during index hospitalization can provide superior outcomes after acute ST-segment elevation myocardial infarction (STEMI) in patients with multivessel coronary artery disease compared to culprit vessel-only revascularization. As new randomized controlled trials (RCTs) have become available, we conducted an updated meta-analysis. Hypothesis: We hypothesized that complete revascularization with percutaneous coronary intervention (PCI) during index hospitalization (either during index procedure or as a staged procedure) is superior to culprit vessel-only treatment in STEMI patients with muti-vessel coronary artery disease. Methods: We identified RCTs meeting the inclusion criteria by searching three electronic databases (PubMed, EMBASE, and the Cochrane Library) from their inception to April 30, 2018. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random-effects meta-analysis based on DerSimonian and Laird model. Results: Seven RCTs with 3,176 patients were included in this study. Compared with culprit vessel-only PCI, complete revascularization during index hospitalization was associated with lower risks of major adverse cardiac event (RR, 0.55; 95% CI, 0.34-0.89), cardiac death (RR, 0.51; 95% CI, 0.30-0.86), myocardial infarction (RR, 0.55; 95% CI, 0.38-0.82), and repeat revascularization (RR, 0.32; 95% CI, 0.25-0.40). There was no difference in all-cause mortality (RR, 1.08; 95% CI, 0.93-1.25), major bleeding (RR, 1.07; 95% CI, 0.78-1.49), cerebrovascular accident (RR, 1.01; 95% CI, 0.51-2.00), and contrast-induced nephropathy (RR, 0.71; 95% CI, 0.31-1.59) between the two strategies. Conclusions: Compared with culprit vessel-only revascularization, complete revascularization during index hospitalization in patients with STEMI and multivessel disease was associated with superior clinical outcomes without increase in complication. These results support complete revascularization during index hospitalization as a reasonable treatment strategy for STEMI patients with multivessel disease. [ABSTRACT FROM AUTHOR]

Background: Photon-counting detector-computed tomography (PCD-CT) has emerged as a promising technology, offering improved spatial resolution., Objectives: This study aimed to evaluate the clinical impact and diagnostic performance of PCD-CT vs conventional energy-integrating detector computed tomography (EID-CT) for obstructive coronary artery disease (CAD)., Methods: From 2022 to 2023, we retrospectively identified 7,833 consecutive patients who underwent clinically indicated coronary computed tomography angiography (CCTA) at a single center, with either PCD-CT (n = 3,876; NAEOTOM Alpha [Siemens Healthineers]) or EID-CT (n = 3,957; Revolution Apex 256 [GE HealthCare] or Aquilion ONE ViSION 320 [Canon Medical Systems]) scanners. Subsequent invasive coronary angiography (ICA) and percutaneous or surgical revascularization were performed as part of routine clinical care. Among those referred for ICA after coronary CTA, the presence of obstructive CAD in each vessel was determined by coronary CTA (severe stenosis on visual assessment per the Coronary Artery Disease Reporting and Data System) and ICA (≥50% diameter stenosis on quantitative coronary angiography) in a blinded fashion. The diagnostic performance of EID-CT and PCD-CT was compared by using quantitative coronary angiography as the reference standard., Results: Patients who underwent PCD-CT were less frequently referred to subsequent ICA than those undergoing EID-CT (9.9% vs 13.1%; P < 0.001). Among those who underwent ICA, revascularization was more frequently performed in the PCD-CT group than in the EID-CT group (43.4% vs 35.5%; P = 0.02). In the vessel-level analysis (n = 1,686), specificity (98.0% vs 93.0%; P < 0.001), positive predictive value (83.3% vs 63.0%; P = 0.002), and diagnostic accuracy (97.2% vs 92.8%; P < 0.001) were improved by PCD-CT. Sensitivity (90.9% vs 90.7%; P = 0.95) and negative predictive value (98.9% vs 98.7%; P = 0.83) for obstructive CAD were similar between the PCD-CT and EID-CT groups, respectively., Conclusions: PCD-CT exhibited excellent diagnostic performance for detecting obstructive CAD. Compared with patients undergoing conventional EID-CT, fewer patients were referred to ICA after PCD-CT, but those referred were more likely to undergo revascularization., Competing Interests: Funding Supportand Author Disclosures Dr Parikh has been a consultant to HeartFlow and Siemens. Dr E. Shlofmitz has been a consultant to Abbott Vascular, ACIST Medical, Boston Scientific, Gentuity, OpSens Medical, Philips, Shockwave Medical, and Terumo; and is a speaker for Amgen Pharmaceuticals, Janssen Pharmaceuticals, Lexicon Pharmaceuticals, and Novo Nordisk. Dr Jeremias has received institutional grants and consulting fees from Abbott Vascular and Philips/Volcano; and has received consultant fees from ACIST and Boston Scientific. Dr Khalique has been a consultant to Siemens, Philips, and HeartFlow. Dr Ali has received institutional grants from Abbott, Abiomed, ACIST Medical, Boston Scientific, Cardiovascular Systems Inc, Medtronic, OpSens Medical, Philips, and Shockwave Medical; has received personal fees from Amgen, AstraZeneca, and Boston Scientific; and has equity from Elucid, Lifelink, SpectraWAVE, Shockwave, and VitalConnect. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2025 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Recent trials have shown that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) improves clinical outcome, as compared to angiography-guided PCI, in complex coronary artery lesions. However, it is unclear whether this benefit is affected by overall lesion complexity in each patient., Aims: The present study sought to investigate the impact of overall lesion complexity on the benefit of IVI-guided PCI., Methods: A total of 4,611 patients with complex coronary artery lesions from the RENOVATE-COMPLEX-PCI trial (n=1,639) and the institutional registry of the Samsung Medical Center (n=2,972) were classified according to the number of complex lesion features found in each patient. The primary outcome was target vessel failure (TVF) at 3 years, a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation., Results: The cutoff value for the number of complex lesion features to predict TVF, determined using the maximally selected log-rank test, was 3. Patients with ≥3 complex lesion features had a higher risk of TVF than those with <3 complex lesion features (11.0% vs 7.2%, hazard ratio [HR] 1.59, 95% confidence interval [CI]: 1.28-1.96; p<0.001). IVI-guided PCI significantly reduced the risk of TVF compared with angiography-guided PCI in both groups (≥3 complex lesion features: 7.4% vs 14.4%, HR 0.49, 95% CI: 0.35-0.69; p<0.001; <3 complex lesion features: 5.7% vs 8.1%, HR 0.72, 95% CI: 0.53-0.98; p=0.039). The benefit of IVI-guided PCI tended to increase as the number of complex lesion features increased (absolute risk reduction for TVF: -0.012 vs -0.027 vs -0.055 vs -0.077, respectively, for 1 vs 2 vs 3 vs ≥4 complex lesion features; interaction p=0.048)., Conclusions: In patients with complex coronary artery lesions, IVI-guided PCI showed a lower risk of TVF across all degrees of lesion complexity. The prognostic benefit of IVI-guided PCI tended to increase as patients had more complex lesion features. (RENOVATE-COMPLEX-PCI [ClinicalTrials.gov: NCT03381872]; Institutional cardiovascular catheterisation database of the Samsung Medical Center [ClinicalTrials.gov: NCT03870815]).

Coronary artery disease (CAD) is the leading cause of mortality among patients with chronic kidney disease (CKD), presenting unique challenges in diagnosis and management. Advanced CKD patients often present with atypical symptoms, and conventional diagnostic and interventional approaches carry risks, including contrast-induced nephropathy and the potential need for renal replacement therapy. These risks have led to the phenomenon of "renalism," where necessary procedures may be deferred due to concerns over renal injury. Emerging techniques, such as ultra-low contrast angiography (ULCA) and zero-contrast percutaneous coronary intervention (PCI), offer promising solutions by minimizing or eliminating contrast exposure. This review discusses the clinical presentation of CAD in CKD patients, limitations of traditional diagnostic approaches, and the challenges in managing these high-risk patients. It also provides an overview of ULCA and zero-contrast PCI techniques, which have shown both safety and feasibility even in complex cases. As these techniques continue to evolve, zero-contrast PCI holds the potential to become an essential component of revascularization strategies for high-risk CKD patients, enhancing procedural safety while maintaining therapeutic efficacy., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Inc.)

Introduction and Objectives: Recent randomized controlled trials support the use of intravascular imaging-guided percutaneous coronary intervention (PCI) to improve patient prognosis. However, the subsequent risk of clinical events in patients with coronary artery disease is not determined solely by lesion characteristics or how these lesions are treated. The current study investigated whether the effects of intravascular imaging in complex PCI vary according to atherothrombotic risks., Methods: This study was a post hoc analysis of the RENOVATE-COMPLEX-PCI trial, which compared intravascular imaging-guided PCI with angiography-guided PCI in patients with complex coronary artery lesions. The study population was stratified by atherothrombotic risk, assessed using the Thrombolysis in Myocardial Infarction risk score for secondary prevention (TRS-2P). TRS-2P is calculated based on the presence of the following factors: age ≥ 75 years, diabetes mellitus, hypertension, smoking, peripheral arterial disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction. Patients were categorized into low-risk (TRS-2P <3) or high-risk (TRS-2P ≥ 3) groups. The primary endpoint was target vessel failure, a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization., Results: Among the total study population, 1247 patients were categorized as low-risk, and 392 as high-risk. The risk of target vessel failure was significantly higher in the high-risk group than in the low-risk group (15.5% vs 7.2%; HR, 2.13; 95%CI, 1.51-3.00; P <.001). The benefits of intravascular imaging-guided PCI over angiography-guided PCI did not differ between the low-risk group (5.6% vs 10.4%; HR, 0.56; 95%CI, 0.36-0.86) and the high-risk group (14.1% vs 18.5%; HR, 0.71; 95%CI, 0.41-1.24), with no significant interaction (interaction P=.496)., Conclusions: In this hypothesis-generating post hoc analysis of the RENOVATE-COMPLEX-PCI trial, patients with high atherothrombotic risk had significantly worse clinical outcomes than those with low atherothrombotic risk. Nevertheless, the prognostic impact of intravascular imaging-guided PCI compared with angiography-guided PCI was similarly observed in both low- and high-risk groups. RENOVATE-COMPLEX-PCI clinical trial register number: NCT03381872., (Copyright © 2024 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Coronary intravascular lithotripsy (IVL) safely facilitates stent implantation in severely calcified lesions., Aims: This analysis sought to determine the relative impact of IVL on acute and long-term outcomes specifically in calcified nodules (CNs)., Methods: Individual patient-level data (N=155) were pooled from the Disrupt CAD optical coherence tomography (OCT) substudies. Severely calcified lesions with and without CNs were compared by OCT for acute procedural results and for target lesion failure (TLF) at 2 years - a composite of cardiac death, target vessel myocardial infarction, and ischaemia-driven target lesion revascularisation., Results: A CN was identified in 18.7% (29/155) of lesions. When comparing lesions with and without CNs, there were no significant differences in preprocedure minimal lumen area or diameter stenosis; however, the mean calcium angle and calcium volume were greater in CN lesions. Despite a higher calcium burden, the final minimal stent area (CN: 5.7 mm 2 [interquartile range [IQR] 4.4, 8.3] vs non-CN: 5.7 mm 2 [IQR 4.7, 7.2]; p=0.80) and stent expansion (CN: 79.3% [IQR 64.3, 87.0] vs 80.2% [IQR 68.9, 92.4]; p=0.30) were comparable between the two groups. In the CN group, the final stent area and expansion at CN sites were 7.6 mm 2 (IQR 5.5, 8.5) and 89.7% (IQR 79.8, 102.5), respectively. The cumulative incidence of TLF at 2 years was 13.9% and 8.0% in the CN and non-CN groups, respectively (p=0.32)., Conclusions: Despite a greater calcium volume in CNs, IVL use was associated with comparable stent expansion and luminal gain in both CN and non-CN lesions. Further studies powered for clinical outcomes comparing different plaque modification techniques in this lesion subset are warranted.

Introduction and Objectives: This study investigated the safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their fractional flow reserve (FFR)., Methods: A nationwide cohort study was conducted using the Korean National Health Insurance Service database. A total of 4657 patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR were identified from 2013 to 2020. FFR was indicated in patients with no prior evidence of myocardial ischemia and intermediate coronary artery stenosis (50%-70%) as determined by quantitative coronary angiography. Patients were classified according to whether antiplatelet therapy was initiated after the index procedure. The primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke, during a 5-year follow-up period. The primary safety outcome was any gastrointestinal bleeding., Results: After propensity score matching, there were 1634 patients in the antiplatelet therapy group and 1634 in the nonantiplatelet therapy group. The risk of MACCE was similar between the 2 groups (24.8% vs 24.7%; adjusted HR, 0.97; 95%CI, 0.84-1.13; P=0.745). The risk of gastrointestinal bleeding was higher in the antiplatelet therapy group than in the nonantiplatelet therapy group (2.2% vs 1.2%; aHR, 2.07; 95%CI, 1.08-4.00). These results were similar in subgroup analyses., Conclusions: In patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR, antiplatelet therapy may increase the risk of gastrointestinal bleeding without reducing the risk of future ischemic events., (Copyright © 2024 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Calcified nodules (CNs) are an increasingly important, high-risk lesion subset., Aims: We sought to identify the emergence of new CNs and the relation between underlying plaque characteristics and new CN development., Methods: Patients who had undergone two optical coherence tomography (OCT) studies that imaged the same untreated calcified lesion at baseline and follow-up were included. New CNs were an accumulation of small calcium fragments at follow-up that were not present at baseline. Cardiac death, myocardial infarction (MI), or clinically driven revascularisation related to OCT-imaged, but untreated, calcified lesions were then evaluated., Results: Among 372 untreated calcified lesions, with a median of 1.5 (first and third quartiles: 0.7-2.9) years between baseline and follow-up OCTs, new CNs were observed in 7.0% (26/372) of lesions at follow-up. Attenuated calcium representing residual lipid (odds ratio [OR] 3.38, 95% confidence interval [CI]: 1.15-9.98; p=0.03); log 10 calcium volume index (length×maximum arc×maximum thickness; OR 2.76, 95% CI: 1.10-6.95; p=0.03); angiographic Δangle between systole and diastole, per 10° (OR 2.30, 95% CI: 1.25-4.22; p=0.01); and time since baseline OCT, per year (OR 1.36, 95% CI: 1.05-1.75; p=0.02) were all associated with new CN development. Clinical events were revascularisation and/or MI and were more frequent in lesions with versus without a new CN (29.3% vs 15.3%; p=0.04)., Conclusions: New CNs developed in untreated, lipid-containing, severely calcified lesions with a larger angiographic hinge motion (between systole and diastole), compared with lesions without CNs, and were associated with worse clinical outcomes.

Introduction and Objectives: The current study aimed to evaluate the causal association between hemodynamically significant stenosis and the occurrence of ischemic myocardium using an experimental animal model of coronary artery stenosis., Methods: In Yorkshire swine (n=10), coronary stenosis in the left anterior descending artery was induced using a customized vascular occluder to create varying degrees of occlusion severity (40%-99%). Serial changes in coronary pressure and flow velocity were measured in the left anterior descending artery before and after the implantation of the vascular occluder. At 1 month, 13 N-ammonia positron emission tomography (PET) was performed, followed by the collection of isolated hearts for 2,3,5-Triphenyltetrazolium chloride (TTC) staining to quantify the percent area of necrotic myocardium. Three animals in the control group were evaluated using the same protocols, but without the implantation of a vascular occluder., Results: The median diameter stenosis after vascular occluder implantation was 61.3% (Q1-Q3: 55.9%-72.3%). Significant differences were observed in hyperemic stenosis resistance, fractional flow reserve (FFR), stress perfusion defect and reversibility in PET, as well as in necrotic myocardium in TTC staining based on stenosis severity (control group: <50%, 50%-70%, 70%-90%, and >90%) (all P<.010). Animals with FFR <0.75 at 1 month exhibited a significantly higher area of stress perfusion defect (30.7±3.1% vs 6.0±4.2%, P<.001), reversibility in PET (11.0±4.0% vs 0.0±0.0%, P=.006), and necrotic myocardium in TTC staining (15.8±6.4% vs 0.0±0.0%, P<.001) than those with FFR ≥ 0.75., Conclusions: In a porcine model, the induction of hemodynamically significant stenosis with FFR <0.75 was associated with the development of stress perfusion defects and reversibility in PET, as well as necrotic myocardium identified by pathology., (Copyright © 2024. Published by Elsevier España, S.L.U.)

Background: Coronary computed tomography angiography-derived fractional flow reserve (FFR CT ) is a per-vessel index reflecting cumulative hemodynamic burden while coronary events occur in focal lesions., Objectives: The authors sought to evaluate the additive prognostic value of the local gradient of FFR CT (FFR CT gradient) in addition to FFR CT to predict future coronary events., Methods: The current study included 245 patients (634 vessels) who underwent coronary computed tomography angiography within 6 to 36 months before the index angiography, of which 209 vessels had future coronary events and 425 vessels did not. Future coronary events were defined as a composite of vessel-specific myocardial infarction or urgent revascularization during a mean interval of 1.5 years. Pre-existing disease patterns were classified according to FFR CT of ≤0.80 and FFR CT gradient of ≥0.025/mm., Results: Both FFR CT (per 0.01 decrease; adjusted HR: 1.040; 95% CI: 1.029-1.051; P  < 0.001) and FFR CT gradient (per 0.01 increase; adjusted HR: 1.144; 95% CI: 1.101-1.190; P  < 0.001) were significantly associated with the risk of future coronary events. Lesions with FFR CT gradient of ≥0.025/mm showed significantly higher risk of future coronary events than those with FFR CT gradient of <0.025/mm in both the FFR CT >0.80 (49.2% vs 30.1%; HR: 2.069; 95% CI: 1.265-3.385; P  = 0.004) and FFR CT  ≤0.80 groups (60.9% vs 38.3%; HR: 1.988; 95% CI: 1.317-2.999; P =0 .001). Adding FFR CT gradient into the model with FFR CT alone showed significantly increased predictability of future coronary events (global chi-square: 45.8 vs 39.9; P  = 0.015)., Conclusions: Patients with high FFR CT gradient showed increased risk of future coronary events irrespective of FFR CT . Integrating both FFR CT and FFR CT gradient showed incremental predictability of future coronary events compared with FFR CT alone. (Prediction and Validation of Clinical Course of Coronary Artery Disease With CT-Derived Non-Invasive Hemodynamic Phenotyping and Plaque Characterization [DESTINY Study]; NCT04794868)., Competing Interests: The current study was supported by the internal research funds provided from the Heart Vascular Stroke Institute, Samsung Medical Center (OTX0004011). Other than providing financial support, the sponsors were not involved with design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Dr Hahn has received institutional research grants from the National Evidence-Based Healthcare Collaborating Agency, Ministry of Health and Welfare, Korea; Abbott Vascular; Biosensors; Boston Scientific; Daiichi-Sankyo; Donga-ST; Hanmi Pharmaceutical; and Medtronic Inc. Dr Gwon has received institutional research grants from Boston Scientific, Genoss, and Medtronic Inc. Dr J.-M. Lee has received institutional research grants from Abbott Vascular, Boston Scientific, Philips Volcano, Terumo Corporation, Zoll Medical, and Donga-ST. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)