Lampson Fan

Coronary in-stent restenosis (ISR) remains a major contributor to repeat revascularisation despite advances in drug-eluting stent (DES) technology. Its persistence reflects a complex and heterogeneous interplay among mechanical, biological, and procedural factors, and understanding the dominant mechanism in each case is fundamental to effective treatment selection. This narrative review provides a contemporary, mechanism-guided approach to the practical management of coronary ISR. We summarise the definition, incidence, and classification of ISR—including the Mehran, Waksman, and SCAI 2023 time-based frameworks—and outline patient-related, procedural, anatomical, and stent-related risk factors. The pathophysiology of neointimal hyperplasia and neoatherosclerosis is discussed with reference to its clinical implications. Intracoronary imaging with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) is central to ISR characterisation and treatment planning. Current international guidelines support imaging use in ISR management, though it is important to recognise that this recommendation is based largely on observational and surrogate-endpoint data rather than ISR-specific randomised trials demonstrating reductions in hard clinical outcomes, and practical barriers including cost, availability, and operator expertise must be acknowledged. Evidence-based treatment strategies—including drug-coated balloons (DCB), repeat DES implantation, lesion-modifying therapies, vascular brachytherapy, and coronary artery bypass grafting—are reviewed critically with reference to contemporary trial data and their specific clinical applicability. The choice between DCB and repeat DES is addressed with greater nuance, accounting for ISR type (BMS-ISR versus DES-ISR), lesion pattern, stent layering, and bleeding risk. Management considerations in complex subsets—chronic total occlusion ISR, left main ISR, saphenous vein graft ISR, and recurrent ISR—are also addressed. We propose a practical, substrate-driven management framework aligned with the 2024 ESC, 2021 ACC/AHA/SCAI, and 2018 JCS/JSCVS guidelines. Future research priorities include ISR-specific randomised trials with hard clinical endpoints, prospective validation of imaging-guided treatment algorithms, head-to-head comparisons of DCB platforms, and investigation of pharmacological strategies targeting neoatherosclerosis progression.

Background: ESC recommends ticagrelor over clopidogrel for the treatment of acute coronary syndrome (ACS) but the lack of evidence for elderly patients (≥75) and concerns over bleeding has led to significant variability in its use within the UK. Our aim is, therefore, to compare the safety of ticagrelor compared to clopidogrel in real-world elderly patients admitted with ACS and managed either medically or through percutaneous intervention. Methods: Unselected elderly patients (≥75) admitted to Royal Berkshire Hospital with ACS (2013–2015) were identified and followed for 1 year. The primary outcomes were bleeding events (TIMI criteria), all-cause mortality, cardiovascular mortality, ischemic stroke, angina, NSTEMI and STEMI. Results: A total of 288 patients with ACS were discharged with aspirin and either clopidogrel (137) or ticagrelor (151). In total, 152 of these patients underwent invasive angiography and revascularization. The baseline clinical characteristics and crusade bleeding score were similar between the groups receiving ticagrelor or clopidogrel. There were no significant differences in all-cause mortality (8.8% vs. 10.6%), cardiovascular mortality (2.9% vs. 2.0%), ischemic stroke (0.7% vs. 2.0%), angina (6.6% vs. 5.3%) or STEMI (2.2% vs. 1.3%). Patients on clopidogrel, however, had increased events of NSTEMI compared to ticagrelor (8.0% vs. 2.0%, OR 4.481, 95% CI 1.223–16.42) and overall MI (10.2% vs. 3.3%, p = 0.030). No difference was observed in either major (8.8 vs. 8.6%) or minor TIMI bleeding (18.2% vs. 20.5%) and after propensity score matching (minor bleeding p = 0.39, major bleeding p = 0.76). Conclusions: In this real-world analysis, ticagrelor did not increase major or fatal bleeding compared to clopidogrel in elderly patients. In view of the mortality benefit in the large trials, additional cardiovascular benefit of ticagrelor should not be withheld on the basis of age as a perceived risk factor for bleeding in ACS.

Smoking is one of the strongest modifiable risk factors for coronary artery disease. It is the cause of approximately 10–30% of deaths due to cardiovascular disease around the world. There is a 50% reduction in the risk of myocardial infarction by one year for people who successfully quit smoking. Considering the risk associated with smoking and the benefits of smoking cessation, it is important to identify and implement effective smoking cessation strategies. There are pharmacological as well as non-pharmacological interventions to assist in smoking cessation. Pharmacological therapies including nicotine replacement therapy; bupropion and varenicline have generally been studied more in patients with cardiovascular disease than the non-pharmacological interventions. Non-pharmacological strategies for smoking cessation include behavioural interventions such as counselling sessions and cognitive behavioural therapy. Studies and randomised controlled trials have demonstrated the safety of most of the pharmacological interventions. Nonetheless, the success rates are variable for the different pharmacological options. Data suggest that greater success can be achieved in smoking cessation with a combination of pharmacological and non-pharmacological treatment. However, more studies are needed to explore the best therapeutic options to improve the success of smoking cessation.

Ventricular free wall rupture is an infrequent but serious complication of myocardial infarction with high mortality despite surgical intervention. In recent years with the COVID-19 pandemic, observational studies have reported a rise in this complication most likely due to patient hesitation in seeking urgent medical assistance for fear of contracting COVID-19 in a hospital setting. This case report highlights the early recognition and diagnosis of ventricular wall rupture by the heart team with a good surgical outcome in a complex patient with ankylosing spondylitis. Ventricular rupture should be considered in deteriorating patients presenting with suspicion of late presentation myocardial infarction. Clinicians in the post-COVID-19 era should expect to see these complications more frequently.

Coronary physiological measurements have transformed the treatment of coronary artery disease (CAD), with increasing evidence supporting the use of pressure wire guided revascularisation. Advances in microvascular assessment have enabled clinicians to discern angina aetiology even in patients without obstructive epicardial coronary artery disease, paving the way for more effective tailored therapy. In this article, the authors will examine pressure wire indices, their role in influencing clinical outcomes and future directions.

Acute coronary syndrome (ACS) is one of the leading causes of morbidity and mortality with a major impact on healthcare resources and expenditure. Dual antiplatelet therapy (DAPT) is recommended for the treatment of ACS. DAPT is associated with an increased risk of gastrointestinal (GI) bleeding, which is seen in 1.2%–2.4% of patients on DAPT and associated with fivefold increase in mortality at 30 days and fourfold increase at 1 year. European Society of Cardiology guidelines recommend that patients on DAPT should also be prescribed a proton pump inhibitor (PPI) to reduce the risk of GI bleeding. We assessed compliance with this recommendation on the cardiology ward of our tertiary cardiac unit. At baseline, only 56% of patients on DAPT were coprescribed a PPI. We subsequently devised and delivered a service improvement project (three completed audit cycles) to improve concomitant prescription of PPI, with the aim of achieving 100% compliance with the guidelines. We introduced low-cost interventions that included educational sessions for junior doctors, cardiac nursing staff and pharmacists, as well as posters which served as visual prompts for discharging doctors. We also initiated a protocol that the pharmacy team clarify with the discharging doctor whether a patient on DAPT should also be on PPI, before the discharge summary is finalised. Consequently, 100% of patients on DAPT were coprescribed PPI within fourteen weeks of the onset of our intervention. This improvement was sustained across a subsequent cohort of junior doctors. Our interventions should help to reduce the risk of GI bleeding in this population.

The p47^phox is a key regulatory subunit of Nox2-containing NADPH oxidase (Nox2) that by generating reactive oxygen species (ROS) plays an important role in Angiotensin II (AngII)-induced cardiac hypertrophy and heart failure. However, the signalling pathways of p47^phox in the heart remains unclear. In this study, we used wild-type (WT) and p47^phox knockout (KO) mice (C57BL/6, male, 7-month-old, n = 9) to investigate p47^phox-dependent oxidant-signalling in AngII infusion (0.8 mg/kg/day, 14 days)-induced cardiac hypertrophy and cardiomyocyte apoptosis. AngII infusion resulted in remarkable high blood pressure and cardiac hypertrophy in WT mice. However, these AngII-induced pathological changes were significantly reduced in p47^phox KO mice. In WT hearts, AngII infusion increased significantly the levels of superoxide production, the expressions of Nox subunits, the expression of PKCα and C-Src and the activation of ASK1 (apoptosis signal-regulating kinase 1), MKK3/6, ERK1/2, p38 MAPK and JNK signalling pathways together with an elevated expression of apoptotic markers, i.e., γH2AX and p53 in the cardiomyocytes. However, in the absence of p47^phox, although PKCα expression was increased in the hearts after AngII infusion, there was no significant activation of ASK1, MKK3/6 and MAPKs signalling pathways and no increase in apoptosis biomarker expression in cardiomyocytes. In conclusion, p47^phox-dependent redox-signalling through ASK1, MKK3/6 and MAPKs plays a crucial role in AngII-induced cardiac hypertrophy and cardiomyocyte apoptosis.

Background and Aims: Coronary calcification remains a significant challenge for the contemporary interventional cardiologist. We aim to describe the use of intravascular lithotripsy (IVL) in a range of real‐world settings.Methods: A retrospective two‐center analysis of patients treated with IVL between June 2018 and November 2019. Technical and procedural success, as well as procedural complications and 30‐day outcomes (death, myocardial infarction, or repeat target vessel revascularization), was recorded.Results: Sixty‐five patients underwent IVL: 80% were male and the mean age was 70.1 ± 12.0 years. 54% of patients presented with acute coronary syndrome (ACS) and 68% of patients had intracoronary imaging. Twelve patients required IVL within pre‐existing stents, and 12 underwent IVL in the left main stem. All balloons were successfully delivered with 98.5% procedural success. There was a significant gain in MLA post PCI of 261.9 ± 100% following IVL. There were two procedural complications. At 30‐day follow‐up, there was one death, and one patient required a repeat procedure due to stent underexpansion.Conclusions: In this largest real‐world series of imaging‐guided IVL for calcified lesions to date, we demonstrate that IVL is deliverable, safe, and effective at calcium modification especially when intracoronary imaging is used.

Percutaneous coronary intervention (PCI) of severely calcified lesions is known to result in lower procedural success rates, higher complication rates, and worse long‐term clinical outcomes compared to noncalcified lesions. Adequate lesion preparation through calcium modification is crucial in ensuring procedural success and reducing adverse cardiovascular outcomes. There are numerous calcium modification devices currently available whose usefulness depends on the nature of the calcific disease and its anatomical distribution. It can be challenging for the interventionists to decide which device is best suited for their patient. There is also emerging evidence for intravascular imaging in guiding selection of calcium modification devices using parameters such as calcium distribution and depth that directly impact on procedural success and clinical outcomes. In this review we aim to discuss the pathophysiology of coronary calcification, evaluate strategies and technologies of calcium modification and propose an A‐M‐A‐S‐A algorithm in managing calcified coronary lesions.