Lipid lowering, with the use of statins after an acute coronary syndrome (ACS), is a cornerstone, well-established strategy for the secondary prevention of ischemic events in this high-risk cohort. In addition to the positive effect on lipid levels, statins have also been linked to improved atherosclerotic plaque characteristics, such as plaque regression and inflammation reduction, associated with the extent of reduction in LDL-C. The recent emergence of PCSK9 inhibitors for the management of dyslipidemia and the more extensive lipid lowering provided by these agents may provide better prevention for ACS patients when initiated after the ACS event. Several trials have evaluated the immediate post-ACS initiation of PCSK9 inhibitors, which has shown, to date, beneficial results. Furthermore, PCSK9 inhibitors have been linked with positive plaque remodeling and associated mortality benefits, which makes their use in the initial management strategy of such patients appealing. Therefore, in this review, we will analyze the rationale behind immediate lipid lowering after an ACS, report the evidence of PCSK9 inhibition immediately after the ACS event and the available data on plaque stabilization, and discuss treatment algorithms and clinical perspectives for the use of these agents in this clinical setting.

Purpose: Atrial fibrillation (AF) requires treatment that focuses on two main goals: symptom control and prevention of thromboembolic events. Catheter ablation and left atrial appendage occlusion (LAAO) constitute two well-established treatment methods in selected patients that accomplish these two goals correspondingly. Recently, there is increasing interest in performing the two procedures concomitantly in a so-called “combined” or “one-stop” procedure. This review aims to summarize the current data on the combined procedure, from the rationale and the techniques to its clinical efficacy, indications and future directions. Methods: An extensive search has been conducted using the MEDLINE/PubMed database to identify the relevant studies. Results: The reported success rates of the combined procedure are very high and frequently reach 100% when performed by experienced operators. The periprocedural and follow-up complications are low, the procedure is cost-effective, while there is significant stroke, bleeding and arrhythmia incidence reduction that does not seem to be undermined by interference between the two interventions. There are also a few indications that the one-stop procedure has a positive effect on left atrial mechanical function as it has been correlated with left atrial reverse remodeling. On the other hand, some studies suggest possible increase in peri-device leaks (PDLs), compared with LAAO alone, which could in turn negatively affect the clinical outcomes. Most available studies are small and observational, with a lack of randomized controlled trials. Conclusion: Catheter ablation and left atrial appendage occlusion can be safely and effectively combined in a cost-effective single procedure in carefully selected patients. Graphical AF = Atrial Fibrillation, CA = Catheter Ablation, DAPT = Dual Antiplatelet Therapy, LA = Left Atrium, LAAO = Left Atrial Appendage Occlusion, OAC = Oral Anticoagulation, PDL = Peri-device Leakage, RF = Radiofrequency

Coronary microvascular dysfunction (CMD) is a major mechanism of myocardial ischemia and adverse cardiovascular outcomes in patients with angina or dyspnea, both in the absence and in the presence of obstructive coronary artery disease. Because the coronary microcirculation cannot be visualized directly with routine angiography, diagnosis depends on physiological assessment. Non-invasive imaging has moved beyond relative perfusion analysis toward quantification of resting and hyperemic myocardial blood flow and flow reserve. Positron emission tomography (PET) remains the most extensively validated non-invasive method and provides robust absolute flow measurements with strong prognostic evidence. Quantitative stress cardiovascular magnetic resonance (CMR) is rapidly maturing, combining high-resolution perfusion mapping with ventricular and tissue characterization without ionizing radiation. Transthoracic Doppler echocardiography offers an accessible, radiation-free estimate of coronary flow velocity reserve, whereas myocardial contrast echocardiography can assess myocardial blood volume and replenishment kinetics. Dynamic cadmium-zinc-telluride single-photon emission computed tomography and stress computed tomography perfusion extend flow quantification to more widely available platforms, although standardization and outcome validation remain less developed. Across modalities, interpretation requires attention to the adequacy of vasodilator stress, resting hemodynamics, diffuse epicardial atherosclerosis, scar, and technical factors. A reduced flow reserve is not synonymous with isolated microvascular disease and cannot identify acetylcholine-provoked vasospasm. This review provides a clinically oriented framework for selecting, performing, interpreting, and reporting non-invasive CMD testing; examines the evidence, strengths, and limitations of each modality; and defines situations in which invasive coronary function testing remains necessary. Future progress will depend on cross-platform standardization, automated quality control, disease- and sex-specific reference ranges, and prospective trials linking imaging-defined endotypes to effective treatment strategies.

Mitral transcatheter edge-to-edge repair (M-TEER) has emerged as a cornerstone in the management of severe mitral regurgitation, serving as a robust, low-risk alternative to conventional mitral valve surgery. Although thromboembolic risk remains a critical clinical challenge, that varies significantly across the clinical continuum, from pre-procedural substrates to post-procedural management. This review highlights the role of atrial cardiomyopathy in creating a prothrombotic milieu even prior to intervention, while during the procedure, device time emerges as a potentially dominant independent predictor of embolic burden, marking the periprocedural window as the period of peak hazard. Furthermore, this article addresses the notable disparity between the near-universal presence of subclinical ischemic lesions on magnetic resonance imaging and the infrequent incidence of overt neurological deficits. As the post-procedural phase is considered, we discuss the shift from standardized antithrombotic protocols to individualized strategies and the potential role of concomitant left atrial appendage occlusion. Ultimately, integrating these stage-specific clinical and procedural determinants with emerging technologies—like digital twins and artificial intelligence—represents a promising frontier for mitigating embolic risks, optimizing procedural planning and patient safety in the evolving landscape of mitral valve interventions.