This article examines the management of high bleeding risk (HBR) patients undergoing percutaneous coronary intervention (PCI), addressing a critical clinical challenge in interventional cardiology. The document establishes definitions and risk stratification frameworks, including the ARC-HBR criteria, PRECISE-DAPT score, and CRUSADE score, which enable clinicians to identify patients at elevated hemorrhage risk. For HBR patients without oral anticoagulation indications, the article reviews evidence-based strategies including ticagrelor monotherapy following three months of dual antiplatelet therapy (DAPT), abbreviated one-month DAPT with subsequent single antiplatelet therapy, and de-escalation approaches to minimize bleeding complications. The guidance specifically recommends against aspirin omission immediately after PCI in these high-risk populations. Additionally, the article addresses HBR patients requiring oral anticoagulation, discussing strategies for abbreviating triple antithrombotic treatment and utilizing direct oral anticoagulants. These recommendations integrate current clinical evidence to optimize the balance between preventing stent thrombosis and minimizing life-threatening bleeding events, ultimately improving outcomes for this vulnerable patient population undergoing coronary revascularization.

The TWILIGHT trial investigated optimal antiplatelet therapy for chronic coronary syndrome (CCS) patients undergoing percutaneous coronary intervention (PCI). This post hoc analysis by Gitto et al examined 2,503 CCS patients who completed three months of dual antiplatelet therapy (DAPT) without adverse events, then were randomized to continue aspirin or receive placebo while all received open-label ticagrelor monotherapy for twelve months. Patients were stratified by high ischaemic risk (HIR) status, defined per 2019 European Society of Cardiology guidelines as multivessel disease plus diabetes, prior myocardial infarction, peripheral artery disease, or chronic kidney disease. Major adverse cardiac and cerebrovascular events (MACCE) occurred more frequently in HIR patients (3.9% versus 2.3% at one year), yet ticagrelor monotherapy and ticagrelor-based DAPT showed comparable MACCE and bleeding risks across both groups. These findings suggest that selected CCS patients with high-risk features may safely transition to ticagrelor monotherapy after initial DAPT, potentially reducing bleeding complications while maintaining ischaemic protection.

Four late-breaking trials presented at ESC Congress 2026 examined post-acute coronary syndrome (ACS) antithrombotic strategies, with focus on LIBREXIA ACS, which evaluated milvexian, a factor XIa inhibitor, added to antiplatelet therapy. The randomized, placebo-controlled trial enrolled 14,194 ACS patients receiving either milvexian 25 mg twice daily or placebo alongside standard antiplatelet therapy. After an interim analysis of 556 adjudicated efficacy events, the trial was terminated for futility. At 12.2 months, the primary efficacy endpoint of cardiovascular death, myocardial infarction, or ischemic stroke occurred in 5.4% with milvexian versus 5.1% with placebo (hazard ratio 1.05; p=0.50). Serious bleeding rates (BARC type 3c or 5) were similar in both groups at 0.3%. The findings challenge the hypothesis that factor XIa inhibition provides additional ischemic protection beyond contemporary antiplatelet therapy and revascularization. Although milvexian demonstrated a favorable bleeding profile, it failed to reduce ischemic events, demonstrating that improved safety alone is insufficient without meaningful clinical efficacy. These results do not support routine addition of milvexian to post-ACS antithrombotic regimens.

Severe coronary artery calcification (CAC) poses persistent clinical risks following percutaneous coronary intervention (PCI), despite achieving optimal stent expansion, according to a single-center retrospective study of 709 patients. Researchers classified patients into three groups based on calcification severity and used intravascular ultrasound (IVUS) imaging to assess outcomes over an 18.6-month median follow-up. While post-PCI minimum stent area and expansion indices were comparable across all groups, severe CAC—defined as calcification arc exceeding 180 degrees and length greater than 5 millimeters—remained independently associated with doubled target vessel revascularization (TVR) risk and increased major adverse cardiovascular events (MACE). Notably, calcified nodules, present in 64.5% of severe CAC lesions, independently predicted TVR. These findings challenge the traditional understanding that links adverse outcomes in calcified lesions exclusively to inadequate stent expansion, suggesting additional mechanisms contribute to residual risk. The research highlights that severe CAC warrants intensified clinical vigilance and potentially modified treatment strategies beyond mechanical optimization.

This prospective, multicenter, randomized clinical trial, published in BMC Cardiovascular Disorders in March 2026, evaluates the efficacy and safety of paclitaxel drug-coated balloon angioplasty for treating coronary small vessel disease. The study addresses a significant clinical challenge, as small vessel coronary disease requires specialized interventional approaches to prevent restenosis and improve patient outcomes. Paclitaxel drug-coated balloons deliver the antiproliferative agent directly to vessel walls during angioplasty, potentially reducing neointimal hyperplasia without permanent stent placement. This open-access research provides comparative safety and efficacy data across multiple centers, establishing evidence for this therapeutic approach in a previously difficult-to-treat patient population. The findings contribute important clinical guidance for interventional cardiologists managing small vessel disease, potentially influencing treatment protocols and improving long-term cardiovascular outcomes by offering an alternative to traditional stenting strategies.

This systematic review and meta-analysis evaluated the long-term clinical performance of ridaforolimus-eluting stents (RES), a new-generation drug-eluting stent featuring thin struts and durable polymer technology designed to optimize the therapeutic-to-toxicity margin. Researchers systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials and prospective non-RCT studies, ultimately analyzing data from six studies encompassing 1,709 patients with coronary artery disease. The patient cohort had a mean age of 63 years, with 76% male predominance and 41% presenting with acute coronary syndrome. Analysis using generalized linear mixed models revealed favorable outcomes: target lesion failure occurred in 3.89% at one year and 11.73% at five years, while major adverse cardiac events were observed in 4.82% at one year and 16.22% at five years. Cardiovascular mortality remained notably low at 0.59% and 3.36% at respective timepoints. These findings demonstrate that RES achieves high procedural success with low adverse event rates, supporting its role as an effective treatment option for coronary artery disease across diverse patient populations.

This study examined whether ticagrelor provides superior ischemic outcomes compared with clopidogrel in Korean patients with acute coronary syndrome undergoing percutaneous coronary intervention. Researchers analyzed patient-level data from 1,199 participants across two prospective registries, using stabilized inverse probability of treatment weighting to balance baseline characteristics between 614 clopidogrel-treated and 585 ticagrelor-treated patients. The primary endpoint was major adverse cardiovascular events, comprising all-cause death, myocardial infarction, stroke, or any revascularization. After adjustment, weighted MACE incidence was 8.1% in the clopidogrel group versus 5.0% in the ticagrelor group, though this difference lacked statistical significance. Target vessel failure showed no significant differences between groups. While all-cause mortality was nominally lower with ticagrelor, this advantage was not accompanied by reductions in other ischemic endpoints. Subgroup analyses revealed no significant treatment interactions across various risk features. The findings indicate that ticagrelor did not demonstrate statistically significant ischemic event reduction compared with clopidogrel in this real-world Korean cohort, supporting individualized P2Y12 inhibitor selection based on patient-specific risk profiles.

Coronary angiography reveals anatomical stenosis severity, yet for intermediate lesions (40-70% narrowing), anatomical assessment alone often proves insufficient to determine whether stenosis functionally impairs blood flow. Modern interventional cardiology has evolved from conventional pressure wire technology to imaging-based and artificial intelligence-driven computational fluid dynamics approaches to answer the critical question: does this lesion cause physiologically significant flow obstruction? FFR remains the gold standard for invasive functional assessment, measuring pressure differential across lesions using pressure wire during adenosine-induced maximal hyperemia, with FFR ≤0.80 indicating functional significance warranting revascularization. QFR offers angiography-based physiological analysis without pressure wire insertion or adenosine administration, utilizing 3D vessel reconstruction and AI-powered contrast-flow analysis to calculate functional values with identical 0.80 threshold. VFR leverages high-resolution OCT imaging data for virtual FFR estimation through 3D anatomical modeling and AI-based computational fluid dynamics, simultaneously evaluating plaque and calcium structure with flow function. UFR integrates IVUS pullback data with AI-driven computational fluid dynamics for virtual FFR estimation, combining calcification and diameter assessment with flow analysis without pressure wire risks. Selection among these modalities reflects clinical context alignment rather than absolute superiority.

Cordis has received FDA approval for the Selution sustained limus release (SLR) drug-eluting balloon to treat coronary in-stent restenosis, marking the first sirolimus-based drug-eluting balloon available for this indication. The device delivers sustained sirolimus release for up to 90 days without depositing additional metal during percutaneous coronary intervention procedures. The approval was supported by the SELUTION4ISR trial, a 418-patient study demonstrating noninferiority compared to standard care including drug-eluting stents and angioplasty, with target lesion failure rates of 15.2% versus 13.5% at one year respectively. Notably, Selution SLR was tested against modern drug-eluting stent comparators rather than plain balloon angioplasty alone, unlike Boston Scientific's earlier Agent paclitaxel-based balloon. The approval offers interventional cardiologists an effective treatment option that may reduce the need for repeat stenting while minimizing procedural burden on patients with coronary artery disease.

The FDA has approved the SELUTION SLR sirolimus drug-eluting balloon, marking a significant advancement in treating coronary in-stent restenosis. Developed by MedAlliance and commercialized by Cordis, this device offers a stentless alternative to traditional repeat stenting procedures. In-stent restenosis affects approximately ten percent of coronary interventions performed in the United States annually, occurring when arterial injury triggers excessive tissue growth and inflammation within previously placed stents. Conventional treatment involves deploying additional drug-eluting metal stents, which can increase long-term risks of stent thrombosis, recurrent restenosis, and compromise future surgical options. The SELUTION SLR addresses these limitations by delivering sirolimus directly to affected tissue without leaving permanent metallic hardware. Sirolimus provides a superior therapeutic index and broader cytostatic safety profile compared to paclitaxel, the active agent in previously approved drug-coated balloons. This approval provides interventional cardiologists with an innovative, biologically sound solution that treats the underlying cellular proliferation while preserving normal vessel compliance and maintaining surgical revascularization options.

Coronary intervention initiates thrombin generation through endothelial damage and plaque disruption. The subsequent thrombotic risk can persist for several weeks and dissipates, but not disappear, after stent endothelialisation. Adjunctive antithrombotic pharmacology, therefore, is a key determinant of acute and long-term outcomes with the range of available options improving outcomes but adding complexity to the decision making process. This review will focus on antithrombotic pharmacology before, during and after percutaneous coronary intervention (PCI) with stent deployment.

Between 40% and 44% of patients currently requiring percutaneous coronary intervention (PCI) are considered to be at high bleeding risk (HBR). Patients with HBR are known to be at increased risk of both bleeding and ischemic events, and since bleeding after PCI is a strong predictor of mortality, the prevention of bleeding complications is particularly important.

Quantitative flow ratio (QFR), an angiography-based method for estimating fractional flow reserve (FFR) without pressure wire, can be integrated into percutaneous coronary intervention (PCI) workflows to guide lesion treatment selection and stent optimization. The FAVOR III China trial demonstrated superior clinical outcomes with QFR vs visual angiographic guidance, while the FAVOR III Europe trial failed to demonstrate clinical non-inferiority of QFR-guided PCI to FFR-guided PCI, raising concerns with increased rate of spontaneous myocardial infarction (MI), potentially impacting the Class I(B) guideline endorsement. To address these safety concerns, the PIONEER IV steering committee, consultatively advised by the Data Safety Monitoring Board (DSMB), decided to report an interim analysis of the first 1270 patients (60%) in the trial to offer timely insights for the community.

Bifurcation lesions have a higher risk of adverse events after DCB angioplasty. The optimal antiplatelet strategy after DCB angioplasty remains uncertain. Stepwise DAPT de-escalation and standard DAPT showed similar risk-benefit profiles across subgroups. Stepwise DAPT de-escalation is safe and effective for ACS patients with these lesions.

The FDA convened a special two-day advisory panel on drug-eluting stents amid significant safety concerns and data gaps. While experts estimate between two to three million Americans carry these devices, precise tracking remains elusive. Drug-eluting stents, including Cypher (sirolimus-eluting) and Taxus (paclitaxel-eluting), have dominated coronary interventions since 2003 by dramatically reducing restenosis compared to bare-metal stents. However, concerns intensified following a March 2006 report from Swiss interventional cardiologists documenting elevated late stent thrombosis rates—often fatal complications. The debate escalated at September's European Society of Cardiology conference, where meta-analyses and registry data indicated increased late thrombosis risk. The FDA's Circulatory System Devices Panel addresses whether these devices represent life-savers or potential risks, highlighting the broader challenge in coronary stenting where new technologies adoption outpaces clinical evidence and extends beyond FDA trial parameters, necessitating comprehensive safety assessment.

Coronary artery calcification represents a significant clinical challenge in interventional cardiology, affecting approximately 40% of patients undergoing coronary angiography and over 70% of lesions evaluated with intravascular imaging. These calcified lesions increase risks of stent underexpansion, dissection, stent thrombosis, and sudden cardiac death. While rotational atherectomy has long served as the definitive treatment for moderate to severe calcified plaques, it carries substantial procedural risks including vessel perforation and myocardial infarction. Recent evidence demonstrates that intravascular imaging guidance substantially improves outcomes compared to angiography alone. A comprehensive analysis of the multicenter ROCK registry showed that intravascular ultrasound guidance significantly reduced three-year cardiac death or myocardial infarction risk with a hazard ratio of 0.44. A network meta-analysis of randomized controlled trials further confirmed that both IVUS and optical coherence tomography reduced major adverse cardiovascular events in complex lesion subsets. These findings underscore the critical importance of intravascular imaging in guiding percutaneous coronary intervention for calcified lesions, providing superior clarity of disease morphology, plaque composition, and accurate stent sizing compared to two-dimensional angiography alone.

Eight major randomized trials have evaluated whether intracoronary imaging guidance improves percutaneous coronary intervention outcomes, revealing that imaging's value depends critically on translating visual findings into procedural changes rather than achieving technically successful image acquisition alone. In acute coronary syndrome, the IVUS-ACS trial demonstrated that IVUS-guided PCI reduced target vessel failure from 7.3% to 4.0% at one year by optimizing stent sizing and expansion while clarifying culprit lesion morphology beyond angiographic assessment. For long lesions requiring stents of at least 28 millimeters, IVUS-XPL showed sustained five-year clinical benefits through accurate vessel sizing and ensuring adequate diseased-segment coverage. In complex bifurcation lesions, the OCTOBER trial found that OCT-guided PCI significantly reduced two-year major adverse cardiac events by identifying stent deformation and incomplete expansion issues invisible on angiography. However, results in left main and heavily calcified lesions proved less consistently favorable; the 2026 OPTIMAL trial failed to demonstrate superiority of routine IVUS guidance over angiography in unprotected left main PCI. This reinforces that imaging utility depends not solely on lesion type but on whether findings trigger meaningful procedural optimization, with OCT offering superior calcium characterization while IVUS provides deeper tissue penetration for vessel assessment.

The AIR-STEMI trial, a randomized international study of 1,823 STEMI patients with multivessel coronary artery disease, demonstrates that functional coronary angiography-guided complete revascularization significantly improves outcomes compared with conventional angiography-guided approaches. Led by Simone Biscaglia at Azienda Ospedaliero Universitaria di Ferrara, Italy, and published in the New England Journal of Medicine, the study addressed critical uncertainty about identifying nonculprit lesions requiring treatment after successful culprit artery intervention. Over a median follow-up of 17.9 months, physiology-guided revascularization reduced major cardiovascular events to 8.9% versus 13.7% with conventional assessment, representing a 38% relative risk reduction. The physiology-guided strategy also demonstrated superior safety, with adverse events occurring in 4.6% versus 7.1% of patients. These findings suggest that functional assessment techniques enable more precise identification of hemodynamically significant lesions, optimizing revascularization decisions and reducing unnecessary interventions while improving clinical outcomes in this high-risk population.

Despite notable advancements in the acute and long-term management, coronary artery disease and myocardial infarction (MI) remain the leading cause of mortality worldwide. Atherothrombosis overlying coronary plaque rupture or erosion is the main pathophysiological mechanism of MI. Plaque disruption leads to the exposure of tissue factors and subintimal components to the luminal blood, triggering activation of the coagulation cascade and platelet aggregation, which ultimately result in luminal thrombosis. Protocolization of timely and effective revascularization in patients with acute MI is a milestone in the history of cardiovascular medicine. In the last decades, the widespread implementation of systems of care aimed at prioritizing immediate reperfusion by primary percutaneous coronary intervention or fibrinolysis (if primary percutaneous coronary intervention cannot be performed within 120 minutes), advancements in the acute phase management and secondary prevention measures has led to a substantial reduction of morbidity and mortality of MI.

In this network meta-analysis of predominantly ACS patients undergoing PCI, ticagrelor monotherapy reduced major bleeding compared with 12 months of aspirin plus prasugrel, whereas it did not meet noninferiority for MACCE. Direct randomized comparisons are warranted.