Background: Patient-reported outcomes are integral to chronic coronary syndrome (CCS) care. The Seattle Angina Questionnaire (SAQ) is validated and prognostic, yet its clinical integration in Bulgaria is undefined. Aim: The aim of this study was to provide a structured, clinically oriented framework for integrating the SAQ into the full CCS care pathway—from screening and phenotyping (obstructive vs. ANOCA/INOCA endotypes) to diagnostics, mechanism-tailored therapy, and follow-up—while outlining a pragmatic roadmap for Bulgarian implementation. Methods: We conducted a semi-structured narrative review (1995–2024) of SAQ’s validation, prognostic utility, and implementation in the literature, augmented with guideline-based frameworks for CCS/ANOCA care. Results: The SAQ (and SAQ-7) shows strong reliability and responsiveness and independently predicts health status and clinical outcomes. Embedding the SAQ at baseline, at 4–12 weeks after therapy changes, and after 6–12 months enables symptom-guided decision-making. A phenotype-guided pathway is proposed that couples the SAQ with CAD burden assessment and—where indicated—ANOCA diagnostics (CFR/IMR, vasoreactivity testing). Mechanism-tailored therapy maps to endotypes (e.g., VSA → CCB ± nitrates; MVA → beta-blocker/ACEi/statin ± ranolazine; obstructive CADGDMT ± PCI/CABG). A minimum dataset, metrics, and registry fields are specified for Bulgarian deployment. Conclusions: A clinically structured framework clarifies how the SAQ adds value beyond description—by informing triage, treatment selection, and follow-up across CCS phenotypes. This approach provides educational guidance and a practical blueprint for pilot implementation in Bulgaria.

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains among the most complex procedures in interventional cardiology, with variable technical success and heterogeneous long-term outcomes. Conventional angiographic scores such as J-CTO and PROGRESS-CTO provide only modest predictive accuracy and neglect critical patient and operator-related factors. Artificial intelligence (AI) and machine learning (ML) have emerged as transformative tools, capable of integrating multimodal data and offering enhanced diagnostic, procedural, and prognostic insights. Methods: We performed a structured narrative review of the literature between January 2010 and September 2025 using PubMed, Scopus, and Web of Science. Eligible studies were peer-reviewed original research, reviews, or meta-analyses addressing AI/ML applications in CTO PCI across imaging, procedural planning, and prognostic modeling. A total of 330 records were screened, and 33 studies met the inclusion criteria for qualitative synthesis. Results: AI applications in diagnostic imaging achieved high accuracy, with deep learning on coronary CT angiography yielding AUCs up to 0.87 for CTO detection, and IVUS/OCT segmentation demonstrating reproducibility > 95% compared with expert analysis. In procedural prediction, ML algorithms (XGBoost, LightGBM, CatBoost) outperformed traditional scores, achieving AUCs of 0.73–0.82 versus 0.62–0.70 for J-CTO/PROGRESS-CTO. Prognostic models, particularly CatBoost and neural networks, achieved AUCs of 0.83–0.84 for 5-year mortality in large registries (n ≈ 3200), surpassing regression-based methods. Importantly, comorbidities and functional status emerged as stronger predictors than procedural strategy. Future Directions: AI integration holds promise for real-time guidance in the catheterization laboratory, robotics-assisted PCI, federated learning to overcome data privacy barriers, and multimodality fusion incorporating imaging, clinical, and patient-reported outcomes. However, clinical adoption requires prospective multicenter validation, harmonization of endpoints, bias mitigation, and regulatory oversight. Conclusions: AI represents a paradigm shift in CTO PCI, providing superior accuracy over conventional risk models and enabling patient-centered risk prediction. With continued advances in federated learning, multimodality integration, and explainable AI, translation from research to routine practice appears within reach.

Factor VII defi ciency is a rare inherited coagulation disorder characterized by decreased activity of factor VII, leading to variable bleeding tendencies that may not correlate with measured FVII levels. While many patients remain asymptomatic, others can experience severe spontaneous hemorrhages. The condition poses signifi cant challenges during surgical or invasive procedures due to the potential for uncontrollable bleeding. Data regarding percutaneous coronary intervention (PCI) in such patients are extremely limited, mostly confi ned to isolated case reports. PCI requires anticoagulation during the procedure and dual antiplatelet therapy afterward, both of which elevate bleeding risk. Conversely, administering FVII concentrate may increase the chance of thromboembolic events. Therefore, individualized planning and a multidisciplinary approach are crucial to balance these opposing risks. We present the case of a 75-year-old Bulgarian woman with congenital FVII defi ciency and severe three-vessel coronary artery disease who underwent successful transradial PCI without FVII replacement. Drug-eluting stents were implanted in the left anterior descending and circumfl ex arteries, enabling short-term dual antiplatelet therapy. No bleeding complications occurred peri-procedurally, and only one minor episode of epistaxis was observed during follow-up. This case illustrates that, with meticulous preparation and procedural care, PCI can be a safe and effective revascularization strategy in patients with congenital FVII defi ciency.

Background/Objectives: Chronic total coronary occlusion (CTO) is frequently associated with persistent angina, functional limitation, and impaired health-related quality of life. Although CTO percutaneous coronary intervention (CTO-PCI) has improved technically, its clinical value is best assessed through patient-reported outcomes (PROs) and patient-centered clinical endpoints. This study evaluated the association between CTO-PCI plus optimal medical therapy (OMT) and 12-month patient-reported and clinical outcomes compared with OMT alone. Methods: This single-center, non-randomized retrospective observational cohort analysis included 251 patients with chronic coronary syndrome and angiographically confirmed CTO. Patients were managed with either a CTO-PCI + OMT strategy (n = 153) or OMT alone (n = 98). The analysis used routinely collected clinical, angiographic, echocardiographic, procedural, and follow-up data, complemented by patient-reported Seattle Angina Questionnaire (SAQ) data obtained after written informed consent. The overall SAQ assessment was considered the primary patient-reported framework, and SAQ Angina Frequency was defined as the principal symptom-specific domain for adjusted comparative analysis. Propensity-score overlap weighting was used as a sensitivity analysis to address measured baseline imbalance and treatment-selection bias. Secondary outcomes included Canadian Cardiovascular Society angina class, left ventricular ejection fraction, cumulative 12-month cardiovascular rehospitalization, and survival. Results: The complete-case SAQ population included 217 patients: 136 in the CTO-PCI + OMT group and 81 in the OMT group. Thirty-four patients lacked complete 12-month SAQ data: 24 died before SAQ reassessment, and 10 were lost to SAQ follow-up. SAQ Angina Frequency improved in both groups, from 70.81 ± 17.97 to 92.35 ± 12.37 in the CTO-PCI + OMT group and from 63.09 ± 20.10 to 83.09 ± 15.14 in the OMT group. In the multivariable ANCOVA model, CTO-PCI + OMT was associated with higher 12-month SAQ Angina Frequency compared with OMT alone (β = 7.07 points; 95% CI, 3.36–10.79; p < 0.001). This finding remained consistent in the propensity-score overlap-weighted sensitivity analysis adjusted for baseline SAQ Angina Frequency (β = 6.55 points; 95% CI, 2.39–10.70; p = 0.002). Cardiovascular rehospitalization was observed in 11 of 153 patients (7.2%) in the CTO-PCI + OMT group and in 19 of 98 patients (19.4%) in the OMT group, corresponding to lower odds of cumulative 12-month rehospitalization (OR = 0.32; 95% CI, 0.15–0.71; p = 0.005). The rehospitalization endpoint was analyzed as a cumulative binary outcome rather than as a time-to-event outcome. Overall survival estimates were 92.0% and 87.4%, respectively, with 12 deaths in each group (log-rank p = 0.225). Because only 24 deaths were recorded, the study was underpowered to evaluate mortality differences. Conclusions: In selected patients with chronic coronary syndrome and CTO, CTO-PCI + OMT was associated with greater improvement in disease-specific health status, particularly SAQ Angina Frequency, compared with OMT alone. CTO-PCI + OMT was also associated with lower cumulative 12-month cardiovascular rehospitalization, although this secondary finding should be interpreted cautiously because of the non-randomized retrospective design, modest event numbers, lack of time-to-event rehospitalization data, and potential expectation- and care-related biases. Survival analyses were underpowered and should not be interpreted as evidence of either prognostic benefit or absence of benefit. These findings support consideration of CTO-PCI as a patient-centered therapeutic option in carefully selected symptomatic patients, while acknowledging residual confounding by indication and the open-label study design.

Background: Chronic coronary syndrome (CCS) is a leading cause of morbidity and mortality worldwide, substantially impairing patients’ quality of life. Patient-reported outcomes (PROs) complement traditional clinical endpoints, with the Seattle Angina Questionnaire (SAQ) recognized as the most validated disease-specific tool for assessing symptom burden and health-related quality of life. Methods: A narrative review of the literature was conducted through searches in PubMed, Scopus, and Web of Science, focusing on studies evaluating the SAQ’s development, validation, clinical applications, and prognostic value, as well as its potential use in Bulgaria. Results: Evidence from pivotal trials consistently demonstrated the sensitivity of the SAQ in detecting treatment-related benefits. In the COURAGE trial, percutaneous coronary intervention (PCI) in addition to optimal medical therapy improved angina frequency and quality of life without affecting mortality. The ISCHEMIA trial confirmed greater improvements in SAQ scores with an initial invasive strategy, particularly in patients with frequent baseline angina. The EuroCTO trial showed significant gains in angina relief and quality of life following successful revascularization of chronic total occlusions. Observational registries further established low baseline SAQ scores as predictors of hospitalization and mortality. Conclusions: The SAQ is an indispensable instrument for quantifying quality of life in patients with CCS. Its systematic implementation in Bulgaria would align national practice with international standards, enhance patient-centered decision-making, and strengthen research capacity. Keywords

Background: Coronary artery perforation is a highly feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and can lead to pericardial effusion, tamponade, and, rarely, emergent cardiac surgery. Perforation of coronary artery or epicardial collaterals during retrograde CTO-PCI may be particularly challenging to treat, as embolization from both sides of the perforation may be required to control the bleeding. However, only conservative measures in selected cases can be effective. We report a case of distal posterior descending (PD) branch of left circumfl ex (LCX) artery vessel perforation that was managed conservatively with anticoagulation reversal. Case Summary: An 85-year-old Caucasian male patient, with a history of lateral and inferior myocardial infarction and previous PCI, underwent a planned coronary arteriography due to progressive angina. Coronary angiography revealed normal function of implanted drug eluting stents (DES) in the mid-LAD and in the proximal right coronary artery (RCA) and CTO of dominant LCX. A septal branch in the midsegment of LAD was supplying the distal PD of LCX retrogradely. After failed attempt at antegrade PCI for the LCX’s CTO, the retrograde approach was tried. This intervention fi nally succeeded through the septal collateral but after removing the retrograde guidewire with the support of microcatheter, vessel perforation of distal PD of LCX was observed. This complication was successfully managed conservatively with anticoagulation reversal. Post-operatively, the patient had no complications and was stable at 6-month follow-up. Discussion: Coronary artery perforation can be managed conservatively only with anticoagulation reversal in selected cases.