Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for managing patients with acute coronary syndromes (ACS) is the first major update since the 2013-2015 ST-elevation myocardial infarction (STEMI) and non-ST elevated myocardial infarction (NSTEMI) guidelines. It brings both conditions together into a single framework. This review covers the most important new and revised recommendations and points out where evidence is still lacking. RECENT FINDINGS/RESULTS:New findings show that several significant updates are based on recent large-scale trials. The use of bivalirudin with high-dose infusion after percutaneous coronary intervention (PCI) is now given a Class I recommendation for primary PCI in the case of STEMI, as a result of the BRIGHT-4 trial. Complete revascularization is also now recommended as Class I for stable STEMI patients who have multivessel disease, according to the COMPLETE trial. For a selected group of patients with refractory cardiogenic shock resulting from a myocardial infarction, the percutaneous microaxial flow pump has received a new Class IIa recommendation from the DanGer Shock trial, while the intra-aortic balloon pump and extracorporeal membrane oxygenation are classified as Class III for routine use. Intracoronary imaging (intravascular ultrasound and optical coherence tomography) is now given a Class I recommendation for complex PCI, based on the data of the RENOVATE-COMPLEX-PCI, OCTOBER, and OCTIVUS trials. The guidelines also suggest specific low-density lipoprotein cholesterol (LDL-C) targets, and non-statin drugs should be added if the LDL-C level remains above 70 mg/dL even when maximum statin therapy is used. Regarding antiplatelet therapy, ticagrelor or prasugrel is now preferred to clopidogrel in the case of ACS-PCI, and it is formally recommended to switch to P2Y12 monotherapy at one month in patients at high risk for bleeding as an alternative to standard DAPT. The updates indicate a shift towards more potent antiplatelet therapy at hospital presentation, use of radial access when feasible, more use of imaging-guided PCI, stricter lipid targets, and more refined antiplatelet approaches at the time of discharge. That said, significant gaps in the evidence still exist. It has not yet become clear whether physiology-guided revascularization of non-culprit arteries in patients with STEMI or NSTEMI is better than angiography-guided PCI-a question that is currently being investigated in the randomized COMPLETE-2 trial. The optimal time to provide mechanical circulatory supper in cases of cardiogenic shock remains uncertain. The recent neutral findings from intracoronary imaging studies such as OPTIMAL and IVUS-CHIP might alter the existing Class I recommendation. Lastly, new data from the HOST-EXAM, and SMART CHOICE 3, studies suggest that P2Y12 monotherapy may be better than aspirin for the long-term prevention of major adverse cardiovascular events, and this could influence future guideline recommendations for long term antiplatelet therapies in the chronic phase.

Infrarenal aortic pathology can complicate the approach to renal denervation using currently approved transfemoral systems. We describe a case of infrarenal aortic tortuosity precluding stable engagement of the right renal artery. Based on the patient's height and the treatment catheter's length, we successfully converted to a left transradial approach to complete the procedure without complication.

Cardiogenic shock (CS) is a cardiovascular emergency with short-term mortality ranging from 30% to 40% despite an expanding therapeutic armamentarium. Structured systems of care have transformed outcomes in ST-segment-elevation myocardial infarction, stroke, and out-of-hospital cardiac arrest through tiered hospital designations, standardized protocols, and regionalized networks, yet no analogous framework exists for CS. CS differs from these conditions in ways that complicate direct application of existing models: the appropriate intervention varies by cause, hemodynamic phenotype, and shock severity; the therapeutic trajectory is iterative and uncertain rather than binary and time-fixed; prehospital identification is rarely feasible; and the exit strategy, encompassing myocardial recovery, durable mechanical support, transplantation, or palliation, has no parallel in other cardiovascular emergencies. Observational data suggest an association between structured multidisciplinary care, regionalized networks, and more consistent care delivery though causal relationships remain unestablished, and no standardized national framework for CS center designation yet exists. We propose that CS systems of care should be organized around a node-based model in which each hospital tier has a defined role, transfer is guided by physiological trajectory and exit strategy candidacy rather than geography, and system performance is evaluated by metrics of timing, outcomes, and equity. The American Heart Association Cardiogenic Shock Registry, designed to enroll consecutive patients across all etiologies and severity levels, represents the natural infrastructure around which this framework can be constructed. Realizing this vision will require dedicated registries, implementation research, and a definition of success that extends beyond in-hospital survival to encompass recovery, function, and equitable access to care.

BACKGROUND:Recent societal guidelines provide a Class I recommendation for intracoronary imaging (ICI)-guided percutaneous coronary intervention (PCI) for complex or left main coronary artery disease; however, recent trials have failed to show a benefit. OBJECTIVES/OBJECTIVE:The study aim was to re-evaluate the efficacy of ICI-guided PCI and to explore heterogeneity of results across trials. METHODS:PubMed, Embase, Cochrane Central, and ClinicalTrials.gov databases were searched through June 3, 2026, for randomized controlled trials (RCTs) comparing outcomes with ICI-guided PCI vs angiography-guided PCI in the drug-eluting stent era. Direct comparison meta-analyses, mixed treatment comparison meta-analyses, trial sequential analyses, fragility analysis, and Bayesian meta-analyses were performed. Meta-regression analysis was performed to evaluate heterogeneity using the following variables: stent length (surrogate for lesion length), stent diameter, difference in postdilatation (percentage) between the groups, publication year, and geographic location. RESULTS:= 0%) compared with angiography-guided PCI. Trial sequential analysis confirmed evidence for at least a 20% reduction in all outcomes with ICI-guided PCI. The fragility index was robust, ranging from 9 to 50. The posterior probability for benefit was >99% for all outcomes. Trial differences in geography and lesion characteristics explained most of the between-trial variance (residual tau = 0). CONCLUSIONS:In this updated meta-analysis of RCTs, after accounting for modifier effects from recent studies, ICI-guided PCI was associated with significantly reduced cardiovascular events compared with angiography-guided PCI. Geographic heterogeneity across trials was present mainly for target vessel revascularization, explained in large part by differences in lesion characteristics and procedural technique.

BACKGROUND/UNASSIGNED:In-stent restenosis (ISR) remains an important cause of repeat revascularization despite advances in drug-eluting stent technology. Contemporary adoption patterns and outcomes of adjunctive plaque-modification strategies for ISR are incompletely characterized. We evaluated national trends and in-hospital outcomes of ISR percutaneous coronary intervention treated with adjunctive plaque-modification devices versus conventional plain old balloon angioplasty. METHODS/UNASSIGNED:All ISR percutaneous coronary intervention procedures in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to June 2024 were analyzed. Adjunctive ISR therapy was defined as use of excimer laser atherectomy, intravascular lithotripsy, cutting/scoring balloon angioplasty, or rotational/orbital atherectomy with or without stent implantation. Conventional plain old balloon angioplasty included balloon angioplasty with or without stent placement and no adjunctive devices. Multivariable logistic regression clustered by operator was used to assess adjusted in-hospital outcomes. RESULTS/UNASSIGNED:Among 1 065 354 ISR admissions (1 182 599 lesions), adjunctive devices were used in 26.5% of cases, increasing from 20.8% in 2018 Q1 to 40.7% by 2024 Q2. Intravascular lithotripsy showed the most rapid adoption, reaching 16.1% of ISR cases within 4 years of US introduction. Adjunctive therapy was associated with higher odds of in-hospital mortality (odds ratio, 1.25 [95% CI, 1.19-1.31]), myocardial infarction (odds ratio, 1.30 [95% CI, 1.24-1.35]), bleeding (odds ratio, 1.29 [95% CI, 1.26-1.33]), and stroke (odds ratio, 1.11 [95% CI, 1.02-1.22]). Recurrent ISR (14.3%) was more often managed with adjunctive therapy (34.2% versus 25.0% for initial ISR) yet had lower absolute complication rates. CONCLUSIONS/UNASSIGNED:ISR remains a major contributor to percutaneous coronary intervention volume. Use of adjunctive plaque-modification devices, especially intravascular lithotripsy, has risen sharply. Adjunctive therapy was associated with higher in-hospital event rates, likely reflecting lesion complexity.

OBJECTIVES/OBJECTIVE:Anemia is common in critically ill patients. In prior trials, a restrictive transfusion strategy was at least as effective as, and possibly superior to, a liberal strategy in critically ill adult patients. However, the Transfusion Requirements in Critical Care (TRICC) trial suggested that a restrictive strategy might be harmful in critically ill patients with ischemic heart disease. Our objective was to compare outcomes for restrictive and liberal transfusion strategies in critically ill and noncritically ill patients with acute myocardial infarction (AMI) and anemia. DESIGN/METHODS:Subgroup analysis of a parallel, two-arm randomized, controlled trial. SETTING/METHODS:One hundred forty-four sites in the United States, Canada, France, Brazil, New Zealand, and Australia. PATIENTS/METHODS:Adult patients with AMI and anemia enrolled in the Myocardial Ischemia and Transfusion (MINT) trial. Patients being treated in an ICU at randomization were considered critically ill. INTERVENTIONS/METHODS:Patients were randomly assigned to a restrictive (transfuse when hemoglobin < 7-8 g/dL) or liberal (transfuse when hemoglobin < 10 g/dL) transfusion strategy. MEASUREMENTS AND MAIN RESULTS/RESULTS:We determined the effect of transfusion strategy on death and the composite of death/myocardial infarction (MI) at 30 days among critically ill and noncritically ill patients. Of 3504 patients enrolled in MINT, 1679 (47.9%) were critically ill. At 30 days, death (11.9% vs. 6.5%) and death/MI (18.9% vs. 12.7%) occurred more frequently in critically ill patients compared with noncritically ill patients. A restrictive, compared with a liberal, transfusion strategy resulted in a nonsignificant increase in the risk of death by 9% (risk ratio [RR], 1.09; 95% CI, 0.77-1.54) and death/MI by 9% (RR, 1.09; 95% CI, 0.85-1.38) in noncritically ill patients and a nonsignificant increase in the risk of death by 24% (RR, 1.24; 95% CI, 0.95-1.61; interaction p = 0.55) and death/MI by 21% (RR, 1.21; 95% CI, 0.99-1.47; interaction p = 0.52) in critically ill patients. CONCLUSIONS:There is no evidence that the overall MINT trial results, which generally favor a liberal transfusion strategy in AMI patients, apply differently to noncritically ill and critically ill patients.

BACKGROUND/UNASSIGNED:Randomized trials comparing radial and femoral access report access site crossover rates of 3% to 9% for radial access and 1% to 3% for femoral access. However, contemporary real-world crossover rates are not well characterized. The aim was to evaluate contemporary trends and predictors of vascular access site crossover during percutaneous coronary intervention (PCI). METHODS/UNASSIGNED:We analyzed index PCI procedures recorded in the National Cardiovascular Data Registry CathPCI Registry from 2018 to 2024. Access site crossover was identified using documented access data, with radial-to-femoral crossover inferred when the final successful access site was femoral. Temporal trends and clinical predictors of crossover were examined. Operator experience was assessed using cumulative total and radial PCI volumes from 2011 to 2024 as captured in CathPCI Registry versions 4 and 5. RESULTS/UNASSIGNED:Among 3 861 790 index PCIs, 192 902 (5.0%) involved access site crossover, with a modest increase over time. Radial-to-femoral crossover accounted for 81.2% of crossover events. Factors independently associated with crossover included older age, female sex, higher body mass index, and peripheral vascular disease. Operators with the lowest total PCI volume and the lowest radial PCI volume experienced the highest crossover rates. Notably, operators with low radial PCI volume demonstrated a substantial decline in radial-to-femoral crossover over the study period. CONCLUSIONS/UNASSIGNED:In contemporary clinical practice, access site crossover rates are consistent with those reported in randomized trials. Although crossover occurs more frequently among lower-volume operators, rates decline with increasing operator experience, supporting the presence of a radial access learning curve and improvement in procedural performance over time.

Transradial access (TRA) has been increasingly utilized for cardiac catheterization. Pursuit of faster patient throughput has generated a need for more rapid hemostasis protocols that are safe, effective and affordable. Patients undergoing diagnostic cardiac catheterization using TRA at two tertiary-care centers were randomized to receive the standard of care procedure utilizing 5/6 French hydrophilic introducer sheath, with 50 units/kg of heparin during the procedure and a 2-hour hemostatic compression using a single-balloon device (Group 1), or 25 units/kg of heparin, with 1-hour hemostatic compression using a dual-balloon device capable of simultaneous ipsilateral ulnar artery compression (UC) (Group 2). The primary study endpoint was a composite of radial artery occlusion (RAO), rebound bleeding or hematoma formation. 451 patients were randomized: 224 in Group 1 and 227 in Group 2. A significant reduction in the primary endpoint was observed in Group 2 as compared with Group 1 (4% vs 10.3%, P = 0.01). Patent hemostasis was achieved in 97% of patients in Group 2, compared with 81% in Group 1 P = 0.001), with fewer nursing visits in Group 2 (5.3 ± 0.8 vs 3.1 ± 0.3, P = 0.001). Group 2 patients also achieved successful hemostasis with a significant reduction in duration of compression (mean reduction = 62 minutes, P = 0.001). In conclusion, a strategy of using a lower dose of heparin with UC achieves shorter duration hemostasis after TRA with significantly less rebound bleeding and RAO, as compared with the conventional strategy.

BACKGROUND:Transradial access (TRA) is a standard approach to cardiac catheterization. Following the procedure, air-filled compression bands are often used to achieve hemostasis at the access site. Despite research supporting early, gradual deflation to minimize complications, there is no established best practice for band deflation. At our urban academic medical center, the lack of a standardized compression band deflation protocol resulted in varied start times and amounts of air removed with each attempt, as well as inconsistent documentation. PURPOSE/OBJECTIVE:The aim of this quality improvement project was to develop and implement an evidence-based practice (EBP) initiative to standardize TR compression band deflation and documentation. METHODS:Nurses, who were primarily responsible for the TRA procedure, organized a multidisciplinary team to critically evaluate the literature, identify gaps in clinical practice, and develop and implement a practice change. EBP interventions centered on a TR compression band deflation algorithm that included specified wait times based on the procedure type and anticoagulation received and the criteria for reinserting air based on bleeding status. A standardized documentation process was also instituted. Deflation was initiated at 30 minutes for patients undergoing diagnostic procedures or receiving up to 5,000 units of heparin and at 60 minutes for patients undergoing advanced diagnostic procedures or percutaneous coronary intervention (PCI) and receiving more than 5,000 units of heparin or IV bivalirudin. Demographics, documentation, complications, time to remove the compression band, length of stay (LOS), patient satisfaction, and opportunity benefit were analyzed. RESULTS:The preintervention (n = 214) and postintervention (n = 255) groups were comparable in age, gender distribution, procedure type, and anticoagulant use. Following the rollout of the EBP initiative, there was a statistically significant reduction in the time required for successful compression band removal for both diagnostic procedures (P < 0.001) and PCIs (P < 0.001). LOS decreased across all procedure types. Specifically, diagnostic procedures had a statistically significant postintervention reduction in LOS (P < 0.001). In addition, clinical documentation (encompassing air removed, air reinserted, and complications) showed significant postintervention improvement (P < 0.001). Regarding safety outcomes, over 85% of patients in the postintervention group experienced no recorded complications during band removal, while 100% had no major bleeds or hematomas. CONCLUSIONS:This EBP initiative confirms that an early band deflation algorithm reduces time for band removal and LOS across diagnostic, advanced diagnostic, and PCI procedures without compromising patient safety. Furthermore, the initiative improved documentation, ensuring consistent monitoring and nursing transitions. These findings provide a clinical basis for adopting early compression band deflation for TRA procedures.

Health care professionals in fluoroscopic laboratories face significant occupational hazards, including cancer, cataracts, and reproductive concerns due to prolonged exposure to iodizing radiation, and orthopedic injuries stemming from long-term use of heavy aprons as protection from radiation. Despite substantial advancements in radiation protection technology, adoption of these advancements has been slow, hindered by the high upfront costs of implementation and the lag in revising institutional and regulatory radiation exposure thresholds to reflect the capabilities of contemporary enhanced radiation protection devices (ERPDs). This multisociety statement, endorsed by the Society for Cardiovascular Angiography & Interventions, American College of Cardiology, the American Society of Echocardiography, the Heart Rhythm Society, the Society of Interventional Radiology, and the Society for Vascular Surgery, calls for mandatory implementation of ERPDs to meet as low as reasonably achievable standards. This expert consensus statement outlines the ethical and legal responsibilities of government, fluoroscopy laboratory manufacturers, and health care institutions to protect all health care professionals from avoidable workplace hazards and the urgent need to implement ERPDs. The document does not promote or recommend any single ERPD system, and the choice of protection technology is left to department preference. It also addresses the importance of training, monitoring, and continuous research to optimize radiation safety practices. The document advocates for updated regulations and standardized practices across states to ensure comprehensive protection for all fluoroscopy laboratory personnel.