Olivier Muller

Percutaneous coronary intervention (PCI) has undergone remarkable evolution over the past decades, leading to substantial improvements in procedural success, patient outcomes, and long-term prognosis, although significant challenges remain. Recent technological and therapeutic advances are reshaping contemporary PCI practice. In acute coronary syndromes, novel thrombectomy approaches and emerging reperfusion strategies aim to improve myocardial salvage. In chronic coronary syndromes, the increasing adoption of intracoronary imaging, advanced calcium modification technologies, drug-coated balloons, and next-generation bioresorbable scaffolds is driving the transition toward more individualized and less implant-dependent revascularization strategies. Parallel developments in antithrombotic therapy, including shortened dual antiplatelet therapy (DAPT) regimens, aspirin-free approaches, and personalized treatment algorithms, seek to improve the balance between ischemic protection and bleeding risk. Furthermore, growing recognition of coronary microvascular disease has expanded the focus of PCI beyond epicardial stenoses, highlighting the importance of functional assessment and targeted therapeutic strategies. Finally, artificial intelligence (AI) is emerging as a transformative tool with potential applications in procedural planning, imaging interpretation, physiological assessment, and clinical decision-making. This review summarizes the most relevant contemporary innovations in PCI and discusses future perspectives that are likely to redefine the management of coronary artery disease.

Background: Occlusion myocardial infarction (OMI) on the electrocardiogram (ECG) can present as ST-elevation myocardial infarction (STEMI), non-STEMI, ST depression, or other patterns (eg, de Winter T waves and hyperacute T waves), posing a diagnostic challenge. Even experienced physicians may overlook OMI on ECG, leading to delays in catheterization laboratory activation. Recently, smartphone apps using AI have been shown to exhibit promising accuracy in ECG interpretation in large datasets. Objective: The objective of our study was to retrospectively compare the diagnostic performance of an AI-based application (PMCardio) with that of interventional cardiologists in interpreting nonpathognomonic ECGs that generated debates about diagnosis. Methods: In total, 33 ECGs that were diagnostically challenging upon patient admission to the emergency department were included. A group of 3 interventional cardiologists, blinded to the final diagnosis, independently assessed whether the ECG suggested OMI requiring immediate invasive coronary angiography. The diagnostic performance of the cardiologists was compared to that of the AI application, using the results of coronary angiography as the gold standard and considering any lesion with ≥90% stenosis as positive. Results: Of the 33 patients, 29 (88%) had a final diagnosis of cardiac origin for their chest pain, including 23 acute coronary syndromes, of which 13 (57%) were OMI. The 3 cardiologists achieved sensitivities of 62%, 85%, and 62%; negative predictive values (NPVs) of 74%, 83%, and 69%; specificities of 70%, 50%, and 55%; and positive predictive values (PPVs) of 57%, 52%, and 47%. Their overall misclassification rates were 33%, 36%, and 42%. In contrast, AI analysis demonstrated a sensitivity and NPV of 100%, a specificity of 60%, a PPV of 62%, and an overall misclassification rate of 24%. Conclusions: In this retrospective study of challenging ECGs, an AI application demonstrated better diagnostic performance of OMI as compared to cardiologists. These findings highlight the potential of AI to enhance diagnostic accuracy and support clinical decision-making.

Aims: Current guidelines recommend targeting systolic blood pressure (SBP) below 130 mmHg in patients at high cardiovascular risk, including after acute coronary syndrome (ACS), although evidence specific to the post-ACS setting remains limited. We evaluated the prognostic value of SBP measured 1 year after ACS on subsequent cardiovascular outcomes. Methods and results: The ELIPS cohort prospectively enrolled ACS patients across four Swiss tertiary-care centres (2009–2017). Patients alive at 1 year with available SBP measurements were included. The association between SBP at 1 year and 3-point major adverse cardiovascular events (MACE; cardiovascular death, non-fatal stroke/transient ischaemic attack, or non-fatal myocardial infarction) was modelled using restricted cubic splines, adjusted for age, sex, renal function, cardiovascular risk factors, index-event type, coronary revascularization, cardiac rehabilitation, heart failure history, and antihypertensive medication classes. Among 2074 patients (age 63 ± 12 years; 82% male; 53% STEMI), 229 MACE events occurred over a median follow-up of 4.0 years (2.7 per 100 patient-years). The SBP–MACE relationship was non-linear and J-shaped (P-non-linearity = 0.007), with lowest risk between ∼130 and 140 mmHg (formally estimated nadir 138 mmHg [95% CI 116–152]). Above 140 mmHg, each 5-mmHg increase was associated with a borderline increase in MACE risk (adjusted HR 1.08; 95% CI 1.00–1.17). The pattern was broadly consistent across sex, age and hypertension status, with a possible interaction with diabetes that could not be excluded (P-interaction = 0.08). Conclusion: In this large, predominantly male, well-characterized post-ACS cohort, SBP measured 1 year after ACS showed a J-shaped association with cardiovascular risk, with lowest risk at 130–140 mmHg.

Aims: The Systematic Coronary Risk Evaluation 2 (SCORE2)/Systematic Coronary Risk Evaluation 2–Older Person (SCORE2-OP), recommended for estimating 10 year risk of first atherosclerotic cardiovascular disease (ASCVD), does not include lifestyle factors. We investigated whether adding self-reported physical activity and Mediterranean diet adherence improves prediction beyond SCORE2/SCORE2-OP. Methods and results: We included participants from the population-based CoLaus|PsyCoLaus cohort with data for the Physical Activity Frequency Questionnaire (PAFQ) and Mediterranean Diet Score (MedDietScore). We fitted Cox regression models including SCORE2 or SCORE2-OP as covariates, depending on the participants’ age, alone or in addition to PAFQ, MedDietScore, or both. We assessed discrimination (Harrell’s C), calibration slope, and net reclassification improvement (NRI) for all models. A total of 2587 participants (59% women) were followed for a median duration of 9.0 years (interquartile range: 8.13–11.6), during which 145 ASCVD events occurred. 2348 were younger than 70 years and evaluated using SCORE2, with 106 ASCVD events. The remaining 239 were aged 70 years or older and assessed with SCORE2-OP, with 39 ASCVD events. Adding physical activity or diet or both to SCORE2 did not improve discrimination (Harrell’s C: 0.74 for all models), calibration (slope: 1.06 for all), or reclassification (continuous total NRI: −8.8 to 2.5%). Adding both lifestyle factors to SCORE2-OP improved discrimination (Harrell’s C: 0.63–0.66), calibration (slope: 1.34 for SCORE2-OP to 1.16 for full model), and reclassification [continuous total NRI: 41% (95% CI 7%–74%) with event NRI of 28% and non-event NRI of 13%]. Conclusion: The addition of self-reported physical activity and Mediterranean diet may provide modest incremental value to improve ASCVD risk prediction in older adults beyond the traditional SCORE2-OP.

Background and Aims: Cardiogenic shock (CS) is the most dreadful complication of acute coronary syndromes (ACS). Endothelial dysfunction and vascular leakage are hallmarks of CS pathophysiology; however, biomarkers reflecting these early processes are lacking. The adrenomedullin (ADM) system—the inactive precursor glycine-extended ADM (ADM-Gly), the activating enzyme peptidylglycine α-amidating monooxygenase (PAM), and biologically active ADM (bio-ADM)—modulates vascular tone and permeability. This study investigated associations of ADM system components with CS and 1-year mortality risk after ACS. Methods: ADM-Gly, PAM, and bio-ADM were assessed in 4098 (Switzerland; SPUM-ACS) and 824 (France; FAST-MI) ACS patients without CS on admission. The primary endpoint was in-hospital CS; the secondary endpoint was 1-year mortality. Biomarker–outcome associations were analysed using multivariable-adjusted regression models, and the incremental predictive value beyond established risk scores was quantified. Results: Higher ADM-Gly and bio-ADM, but not PAM, were associated with systemic inflammation and haemodynamic compromise. ADM-Gly and bio-ADM independently predicted CS risk in Switzerland (adjusted odds ratio [aOR] per log2 increase, 1.44, 95% confidence interval [CI] 1.22–1.71, P < .001 and aOR 1.37, 95% CI 1.10–1.70, P = .004) and France (adjusted risk ratio [RR] per log2 increase, 1.82, 95% CI 1.34–2.48, P < .001 and aRR 1.55, 95% CI 1.15–2.10, P = .004), and were associated with 1-year mortality risk (adjusted hazard ratio [aHR] per log2 increase, 1.33, 95% CI 1.09–1.61, P = .005 and aHR 1.46, 95% CI 1.15–1.86, P = .002). Addition of ADM-Gly and bio-ADM to the ORBI risk score improved its discrimination (Δ area under the receiver operating characteristic curve 0.02), reclassification (net reclassification improvement 0.229), and model fit (Δ Akaike information criterion −26.9), with consistent results in external validation. Conclusions: ADM-Gly and bio-ADM, but not PAM, independently predict in-hospital CS and 1-year mortality risk in initially stable patients with ACS and improve early risk stratification.

Background and hypothesis: Evidence supporting renin–angiotensin system (RAS) inhibition in dialysis-dependent patients with heart failure with reduced ejection fraction (HFrEF) remains limited. We performed a systematic review and meta-analysis to assess the efficacy and safety of angiotensin receptor–neprilysin inhibitors (ARNIs) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEis/ARBs) in this population (PROSPERO ID: CRD420251274393). Methods: Outcomes of interest included all-cause mortality and cardiovascular mortality. Eligible studies included adult patients with chronic HFrEF on maintenance hemodialysis or peritoneal dialysis, comparing ARNI versus non-ARNI regimens and ACEi/ARB versus control regimens. Literature searches were conducted through December 2025 in PubMed, Embase, Google Scholar, and Web of Science. Hazard ratios (HRs) and their respective 95% confidence intervals (CIs) were pooled and meta-analyzed across studies. Results: Overall, six studies evaluated ARNIs (3818 treated; 4344 controls), and three studies evaluated ACEis/ARBs (3293 treated; 1982 controls). ARNI use versus non-ARNI regimens was associated with significantly lower all-cause mortality (pooled HR 0.78, 95% CI 0.71–0.87), as was ACEi/ARB use versus placebo or no RAS blockade (pooled HR 0.76, 95% CI 0.68–0.84). ACEi/ARB therapy was also associated with lower cardiovascular mortality (pooled HR 0.62, 95% CI 0.54–0.71), whereas no significant association was observed with ARNIs (pooled HR 0.91, 95% CI 0.79–1.04). Safety data were sparse and heterogeneous, precluding pooled analysis; among ARNI studies, no consistent excess hypotension was observed, and some studies suggested a lower risk of hyperkalemia versus ACEi/ARB therapy. Conclusions: In dialysis-dependent patients with HFrEF, ARNI use versus non-ARNI regimens, and ACEi/ARB use versus placebo or no RAS blockade, were each associated with lower all-cause mortality, while lower cardiovascular mortality was observed only with ACEi/ARB therapy. These findings suggest a potential overall benefit of RAS inhibition in this population; however, they are derived predominantly from observational studies, remain susceptible to residual confounding, and should not be interpreted as demonstrating causal treatment effects.

Aims: Overweight and obesity are common among patients with acute coronary syndromes (ACS), yet the long-term cardiovascular consequences of post-ACS weight change remain uncertain. We investigated the association between 1-year weight change after ACS and 5-year clinical outcomes in overweight and obese patients. Methods and results: We analysed 1473 overweight and obese ACS participants from the Swiss ELIPS cohort with available weight measurements. Hazard ratios (HRs) were estimated per 1% and 5% weight change for the 5-year risk of major adverse cardiovascular events (MACE), defined as cardiovascular death, non-fatal myocardial infarction, coronary revascularization, stroke, or transient ischaemic attack. Models were adjusted for age, sex, body mass index (BMI), smoking, total cholesterol, hypertension, diabetes, and estimated glomerular filtration rate. Predefined subgroups included BMI ≥ 27 kg/m2 vs. 25–27 kg/m2. Among the participants (15.1% women, mean age 61.5 years), the median BMI was 28.1 kg/m2 (67% BMI ≥ 27 kg/m2). Median 1-year weight change was 0%; 47.5% lost weight and 18.7% achieved >5% weight loss. Patient characteristics associated with weight loss were older age, higher BMI, non-smoking status, and participation in cardiac rehabilitation. During follow-up, 278 MACE events occurred. Weight loss was associated with a lower risk of MACE [multivariate-adjusted HR per 5%: 0.90, 95% confidence interval (CI): 0.82–1.00, P = 0.04]. The association was stronger in patients with BMI ≥ 27 kg/m2 (adj HR per 5% 0.87, 95% CI: 0.77–0.97) compared to those with BMI 25–27 kg/m2 (adj HR per 5% 1.01, 95% CI: 0.85–1.20, interaction P = 0.16). Conclusion: Overweight and obese ACS patients who lose weight may have a lower risk of cardiovascular events.

Background and Aims: Patients with acute coronary syndromes (ACS) are at high ischaemic risk to which cholesterol, inflammation, and yet-to-be-identified pathways jointly contribute. The junctional protein associated with coronary artery disease (JCAD) drives incident cardiovascular events by acting on coagulation and fibrinolysis. This study aimed to assess whether JCAD serves as a novel marker of or target to address residual risk. Methods: In the discovery cohort (SPUM-ACS; n = 4787), ACS patients at residual lipid risk [RLR; on-statin LDL cholesterol (LDL-c) ≥70 mg/dL or ≥1.8 mmol/L], residual inflammatory risk [RIR; on-statin high-sensitivity C-reactive protein (hs-CRP) ≥2.0 mg/L], or both (RILR; on-statin LDL-c ≥70 mg/dL and hs-CRP ≥2.0 mg/L) were identified and compared with propensity-score matched controls. Contributions of hs-CRP, LDL-c and JCAD to recurrent major adverse cardiovascular events (MACE) were analysed. In an independent cohort (RISK-PPCI study; n = 496), effects of JCAD on endogenous coagulation and fibrinolysis were gauged, and JCAD–MACE associations were externally validated. Results: At 1 year, patients at RLR, RIR, or RILR were at higher MACE risk as compared to controls [hazard ratio (HR), 1.55, 95% confidence interval (CI) 1.08–2.23; HR 1.80, 95% CI 1.24–2.61; and HR 1.75, 95% CI 1.12–2.75, respectively]. In those at RLR, MACE risk rose with increasing hs-CRP and JCAD, respectively, in uni- (HR per log2 increase, 1.17, 95% CI 1.06–1.30; HR 1.29, 95% CI 1.03–1.62) and multivariable-adjusted models [adjusted (a)HR 1.16, 95% CI 1.03–1.30; aHR 1.27, 95% CI 1.01–1.60]. In those at RIR, MACE risk increased 1.28-fold per log2 increase in JCAD (HR 1.28, 95% CI 1.03–1.59), which prevailed in multivariable-adjusted models (aHR 1.31, 95% CI 1.04–1.65). Similarly, in patients at RILR, MACE risk increased almost linearly with increasing JCAD (HR 1.45, 95% CI 1.09–1.92), independently of potential confounders (aHR 1.47, 95% CI 1.11–1.97). Plasma levels of JCAD correlated positively with proxies of impaired endogenous fibrinolysis, with the JCAD–MACE association being similarly observed in the external validation cohort. Conclusions: Acute coronary syndrome patients at RLR, RIR, or both are at high ischaemic risk. By modulating coagulation and endogenous fibrinolysis, JCAD represents a promising candidate to address the high residual risk that persists in ACS patients receiving guideline-recommended care. ClinicalTrials.gov Identifiers: NCT01000701, NCT02562690

Background: Fasting before elective or nonurgent coronary angiography is commonly recommended to reduce the risk of adverse events, such as aspiration pneumonia. This systematic review and meta‐analysis aimed to evaluate the impact of fasting versus nonfasting protocols on patient outcomes and satisfaction. Methods: We systematically searched PubMed, Embase, and Cochrane Library databases for randomized clinical trials comparing fasting and nonfasting states before cardiac catheterization. The primary outcome was a composite of adverse events including pneumonia, hypoglycemia, and nausea/vomiting. Secondary outcomes included individual adverse events and patient satisfaction. For each binary outcome we estimated crude event probabilities for each treatment arm. Next, we pooled study‐specific results in meta‐analyses using odds ratio (OR) and risk difference as effect measures for binary outcomes and standardized mean difference for satisfaction. Results: We identified 8 randomized clinical trials, including a total of 3147 patients. Our meta‐analysis showed no evidence of a difference in the incidence of composite adverse events between fasting and nonfasting groups in ORs (OR, 1.08, [95% CI, 0.78–1.51], where OR<1 favors fasting). The crude event probabilities were 4.9% and 4.4% for fasting and nonfasting groups respectively, with an estimated risk difference =0.4% (−1.1% to 1.8%), where risk difference <0 favors fasting. Patient satisfaction was found higher in nonfasting protocols, standardized mean difference 0.62 (0.11–1.13). Conclusion: Our meta‐analysis found no evidence that fasting before elective coronary angiography reduces adverse events. However, we found evidence that fasting reduces patient satisfaction. These findings question the necessity of fasting protocols in this context. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024595465 ; Unique identifier: CRD42024595465.