This perspective comprehensively analyzes the invasive pullback pressure gradient (PPG), a novel physiological index that characterizes the longitudinal distribution of coronary artery disease and guides revascularization strategy modified in 14% of patients in the PPG Global Registry based on PPG assessment. We trace the historical development from subjective pullback curve analysis to a standardized, quantitative metric and describe the procedural aspects of both motorized and manual PPG acquisition. We synthesize evidence supporting PPG’s clinical utility in predicting post-percutaneous coronary intervention outcomes, guiding revascularization decisions, and improving patient-centered outcomes. A central focus is PPG’s mechanistic role in explaining the physiological basis of discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), linking focal disease to FFR-positive/iFR-negative patterns and diffuse disease to FFR-negative/iFR-positive patterns. We conclude that PPG represents a fundamental advancement in coronary physiology, shifting clinical focus from individual stenoses to overall disease patterns. This paradigm shift provides deeper understanding of coronary artery disease pathophysiology and offers a powerful predictive tool to guide personalized revascularization strategies. Prospective randomized trials will be essential to solidify its role as a cornerstone of modern interventional cardiology practice.

The impact of diabetes mellitus (DM) on outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) was confirmed by several studies. However, it is unclear whether this effect is still present in large groups of unselected patients undergoing up-to-date treatment. Thus, we sought to assess the impact of DM on periprocedural outcomes of primary PCI in STEMI using data from the Polish National Registry of PCI. Data on 150,782 STEMI patients undergoing primary PCI were collected. Of them, 26,360 (17.5%) patients had DM. Patients with DM were higher-risk individuals who experienced longer reperfusion delays and were less likely to have closed infarct-related artery at baseline (TIMI 0 + 1 flow: 73.2% vs. 72.0%; p < 0.0001) and achieve optimal reperfusion after PCI (TIMI 3 flow: 91.8% vs. 88.5%; p < 0.0001). The periprocedural mortality (1.1% vs. 1.9%; p < 0.0001) was higher in patients with DM and DM was identified as an independent predictor of periprocedural death. In conclusion, despite continuous progress in STEMI treatment, DM remains a strong predictor of periprocedural mortality. However, this detrimental effect of DM may be partially explained by the overall higher risk profile of diabetic patients.

Guidelines recommend using hyperemic (FFR) and non-hyperemic (iFR/RFR) methods of evaluating coronary artery stenoses in patients with coronary artery disease. However, in some cases, achieved results indicating significant ischemia may differ between those methods. Thus, we sought to identify predictors of such a discrepancy. Data were collected on all consecutive patients with chronic coronary syndrome hospitalized between 2020 and 2021. For 279 patients (417 vessels), results for both FFR and iFR/RFR were available. Values of ≤0.80 for FFR and ≤0.89 for iFR/RFR were considered positive for ischemia. Discordant measurements of FFR and iFR/RFR were observed in 80 (19.2%) patients. Atrial fibrillation was the only predictor of the overall FFR and iFR/RFR discordance - OR (95%CI) 1.90 (1.02–3.51); p = 0.040. The chance of positive FFR and negative iFR/RFR decreased independently with age - OR (95%CI) 0.96 (0.93–0.99); p = 0.024. On the contrary, insulin-treated diabetes mellitus was the predictor of negative FFR and positive iFR/RFR discrepancy - OR (95%CI) 4.61 (1.38–15.40); p = 0.013. In everyday clinical practice, iFR/FFR correlates well with FFR. However, discordance between these methods is quite common. Physicians should be aware of the risk of such discordance in patients with atrial fibrillation, advanced age, and insulin-treated diabetes mellitus.

ST-segment elevation myocardial infarction (STEMI) represents a time-critical medical emergency where complete coronary artery occlusion initiates progressive myocardial necrosis. The fundamental principle of modern STEMI care—“Time is Muscle”—establishes that ischemic duration directly determines infarct size and clinical outcomes. Each minute of delay correlates with increased mortality, larger infarcts, and a higher risk of heart failure development. Total ischemic time encompasses both patient-mediated delays (often the largest component) and system-related delays, each influenced by distinct factors requiring targeted interventions. This comprehensive review analyzes the components of total ischemic time, quantifies the clinical consequences of delay, and evaluates evidence-based mitigation strategies. We examine the evolution from fibrinolysis to primary percutaneous coronary intervention and the resulting logistical challenges. System-level interventions—including public awareness campaigns, regionalized STEMI networks, pre-hospital ECG acquisition, and standardized hospital protocols—have dramatically reduced treatment times. However, persistent disparities based on geography, presentation timing, sex, race, and age remain problematic. Emerging technologies, particularly artificial intelligence for ECG interpretation, offer promise for further time reduction.

Background and Objectives: Coronary angiography is the gold standard for diagnosing coronary artery disease (CAD). In the case of borderline changes, patients require further diagnosis through ischemia assessment via one of the recommended methods of invasive evaluation. This study aimed to assess whether clinical factors influence the risk of a positive result in invasive myocardial ischemia assessment and if these potential factors change with the patient’s age and the consistency of ischemia assessment. Materials and Methods: Data were collected retrospectively on all consecutive patients hospitalized in the University Hospital in Krakow between 2020 and 2021, on whom physiological assessments of coronary circulation were performed. Patients were divided into two groups: patients aged 60 or younger and patients older than 60. Results: Despite the older patients having more risk factors for CAD, their physiological assessment results of borderline lesions were similar to those of the younger patients. Positive fractional flow reserve (FFR) assessments were obtained from almost 50% of vessels. In the younger patients, cigarette use and type 2 diabetes mellitus increased the risk of a positive FFR result by 3.5 and 2.5 times, respectively. In the older patients, male gender and peripheral vascular disease significantly increased the risk of a positive FFR by 2.5 and 2 times, respectively. Conclusions: Clinical characteristics of patients undergoing physiological assessment of borderline coronary stenosis varied significantly by age. Refining the definition of borderline lesions to include age, gender, and other factors may improve the identification of patients who would benefit from physiological assessment and coronary revascularization.