Mattia Galli

Objective: Coronary artery fistulas (CAFs) are rare congenital or acquired anomalies characterised by abnormal coronary communications, with variable natural history and no consensus on optimal management. Methods: A comprehensive state-of-the-art review and pooled analysis of published literature was conducted, integrating clinical, anatomical, imaging, management and outcome data from 1966 patients with 1986 CAFs. Comparative descriptive analyses between complicated and uncomplicated cases were performed to identify recurring features associated with adverse clinical outcomes. Results: Specific anatomical and clinical patterns were more frequently observed in patients with complications, including fistulas originating from the right coronary artery or left main coronary artery, drainage into venous or left-sided structures, large-calibre fistulas and reduced ventricular function. Based on these recurring patterns, two pragmatic phenotypes of CAFs (higher-risk and lower-risk) were identified. Given the descriptive nature of the available evidence and the absence of formal multivariable modelling, these findings should be considered hypothesis-generating rather than indicative of independent predictors. Conclusions: CAFs are heterogeneous vascular anomalies with variable clinical presentation and substantial potential for complications. An integrated assessment of anatomical configuration, fistula size, drainage pattern and ventricular function may support structured clinical evaluation and individualised management. We propose a practical anatomy- and risk-informed framework to guide multidisciplinary decision-making and follow-up strategies.

Background and Aims: Emerging data suggest that, in patients with chronic coronary syndromes (CCS), clopidogrel provides superior antithrombotic protection compared with aspirin for secondary prevention, without an associated increase in bleeding risk. The consistency of the observed benefits across ethnicities remains uncertain. Methods: Randomized controlled trials (RCTs) comparing aspirin vs clopidogrel for secondary prevention in patients with CCS were screened. The primary endpoint was trial-defined major adverse cardiovascular events (MACE). Prespecified subgroup interaction by ethnicity (East Asian vs non-East Asian) was performed. Trial sequential analysis was used to assess the statistical power of the results. Results: Seven RCTs were included, encompassing 30 165 patients, of whom 75.1% were East Asians. Median follow-up was 36.0 months. Overall, clopidogrel was associated with significant reductions in MACE (incidence rate ratio [IRR] 0.83, 95% confidence interval [CI] 0.69–0.99) and net adverse clinical events (IRR 0.83, 95% CI 0.69–0.99), compared with aspirin. There were no differences between groups in major bleeding, myocardial infarction, or mortality. The results were consistent in the East Asian population, whereas a significant interaction by ethnicity was observed for MACE (East Asians: IRR 0.76, 95% CI 0.59–0.98; non-East Asians: IRR 1.00, 95% CI 0.74–1.36; Pint = 0.010) and mortality (Pint = 0.014), with no significant benefits observed in non-East Asian patients. The analyses were statistically powered for most outcomes in East Asian populations but for none in non-East Asian populations. Conclusions: In patients with CCS, the overall body of evidence suggests improved outcomes with clopidogrel compared with aspirin, without an apparent effect on mortality. However, a high level of confidence in these findings is currently limited to East Asian populations, and additional evidence is needed to clarify their applicability to non-East Asian patients. Study registration: PROSPERO (CRD420251145176).

Bleeding is a prevalent and frequently serious complication of anticoagulant therapy. The use of oral anticoagulants to prevent thrombotic events in common cardiovascular conditions, such as atrial fibrillation, exposes patients to an increased risk of bleeding which is associated with morbidity and mortality. The consequences of bleeding extend well beyond the acute event, affecting treatment adherence, long-term management decisions, and increasing the risk of ischaemic events when anticoagulation is discontinued. Optimizing the balance between thrombotic and bleeding risk requires expertise in risk stratification, preventive strategies, acute management, and the appropriate timing of anticoagulation resumption after haemostasis. This review summarizes the epidemiology and clinical impact of bleeding in patients receiving oral anticoagulant therapy and provides contemporary, patient-centred flowcharts for acute management and safe resumption of treatment. Future efforts should focus on refining risk prediction, individualizing anticoagulant regimens, and improving access to targeted reversal agents to further improve patient outcomes.