Stable coronary artery disease (CAD) has recently been replaced by a new entity described as chronic coronary syndrome (CCS). This new entity has been developed based on a better understanding of the pathogenesis, the clinical characteristics, and the morbi-mortality associated to this condition as part of the dynamic spectrum of CAD. This has significant implications in the clinical management of CCS patients, that ranges from lifestyle adaptation, medical therapy targeting all the elements contributing to CAD progression (i.e., platelet aggregation, coagulation, dyslipidaemia, and systemic inflammation), to invasive strategies (i.e., revascularization). CCS is the most frequent presentation of coronary artery disease which is the first cardiovascular disease worldwide. Medical therapy is the first line therapy for these patients; however, revascularization and especially percutaneous coronary intervention remains beneficial for some of them. European and American guidelines on myocardial revascularization were released in 2018 and 2021, respectively. These guidelines provide different scenarios to help physicians choose the optimal therapy for CCS patients. Recently, several trials focusing on CCS patients have been published. We sought to synthetize the place of revascularization in CCS patients according to the latest guidelines, the lessons learnt from recent trials on revascularization and medical therapy, and future perspectives.

Cardiovascular disease, including ischemic heart disease, is the leading cause of death worldwide, and percutaneous coronary interventions (PCIs) have been demonstrated to improve the prognosis of these patients on top of optimal medical therapy. PCIs have evolved from plain old balloon angioplasty to coronary stent implantation at the end of the last century. There has been a constant technical and scientific improvement in stent technology from bare metal stents to the era of drug-eluting stents (DESs) to overcome clinical challenges such as target lesion failure related to in-stent restenosis or stent thrombosis. A better understanding of the underlying mechanisms of these adverse events has led DESs to evolve from first-generation DESs to thinner and ultrathin third-generation DESs with improved polymer biocompatibility that seems to have reached a peak in efficiency. This review aims to provide a brief historical overview of the evolution of coronary DES platforms and an update on clinical studies and major characteristics of the most currently used DESs.

Out-of-hospital cardiac arrest (OHCA) continues to be a major global cause of death, affecting approximately 67 to 170 per 100,000 inhabitants annually in Europe, with a persisting high rate of mortality of up to 90% in most countries. Acute coronary syndrome (ACS) represents one of the most significant cause of cardiac arrest, and therefore invasive coronary angiography (CAG) with subsequent percutaneous coronary intervention (PCI) has emerged as a fundamental component in the management of OHCA patients. Recent evidence from large randomized controlled trials (RCTs) challenges the routine use of early CAG in the larger subgroup of patients with non-ST segment elevation myocardial infarction (NSTEMI). Additionally, emerging data suggest that individuals resuscitated from OHCA related to ACS face an elevated risk of thrombotic and bleeding events. Thus, specific invasive coronary strategies and anti-thrombotic therapies tailored to this unique setting of OHCA need to be considered for optimal in-hospital management. We sought to provide an overview of the prevalence and complexity of coronary artery disease observed in this specific population, discuss the rationale and timing for CAG after return of spontaneous circulation (ROSC), summarize invasive coronary strategies, and examine recent findings on antithrombotic therapies in the setting of ACS complicated by OHCA. By synthesizing the existing knowledge, this review aims to contribute to the understanding and optimization of care for OHCA patients to improve outcomes in this challenging clinical scenario.

Patients with myocardial infarction (MI) complicated by out-of-hospital cardiac arrest (OHCA) represent a heterogeneous population with variable outcomes. Data-driven approaches may help uncover clinically meaningful subgroups to improve risk stratification and guide management. We applied an unsupervised machine learning analysis using k-means clustering to a prospective cohort of 478 patients admitted after OHCA related to MI. Candidate variables included demographics, cardiovascular risk factors, cardiac arrest characteristics, admission laboratory data, hemodynamic parameters, and coronary angiography findings. In-hospital outcomes included all-cause mortality, bleeding, and stent thrombosis. Ninety-day all-cause mortality was also assessed. Three clusters were identified. Cluster 1 (n = 260, 54%) included younger patients with few comorbidities, predominantly shockable rhythms, and favorable hemodynamics. Cluster 2 (n = 118, 25%) included older patients with hypertension, diabetes, and prior coronary artery disease. Cluster 3 (n = 100, 21%) was characterized by severe cardiogenic shock, high lactate, low factor V, reduced left-ventricular ejection fraction, and frequent use of extracorporeal membrane oxygenation. Adverse in-hospital events, including all-cause mortality, bleeding, and stent thrombosis, were most frequent in cluster 3. Ninety-day mortality differed across groups: 22.5% in cluster 1, 53.0% in cluster 2, and 77.2% in cluster 3 (p < 0.001). Compared with cluster 1, hazard ratios for mortality at 90 days were 2.97 (95% CI, 2.07-4.26) in cluster 2 and 6.75 (95% CI: 4.74-9.60) in cluster 3. Unsupervised machine learning identified three phenotypes among patients with MI-related OHCA associated with distinct outcomes. This phenotypic classification may facilitate personalized management and refined prognostic assessment in this high-risk population.