Despite improvements in the management of coronary artery disease, patients remain at risk for very late adverse cardiovascular events both arising from the stented regions and other untreated segments of the coronary tree. Further advancements focused on primary prevention, stent design and procedural technique, and secondary prevention will be crucial to reducing rates of very late events and improving symptoms and prognosis of patients after PCI.

Renovascular occlusive disease remains a common cause of resistant and rapidly progressive hypertension. The present review summarizes current practice regarding management of renovascular hypertension (RVH).

Current data using blood oxygen level dependent MR emphasize the tolerance of the kidney to moderate reductions in blood flow and the efficacy of antihypertensive drug therapy for many individuals. Prospective trials have failed to identify benefits of revascularization for moderate disease, either regarding blood pressure or renal function. Antihypertensive drug therapy including renin-angiotensin system blockade is central to management of RVH. Recent and ongoing observational studies report important improvements after revascularization regarding blood pressure, management of refractory or ‘flash’ pulmonary edema, and survival in specific ‘high risk’ clinical populations not included in randomized trials. Research directions underscore the role of adjunctive measures, including mitochondrial protection, therapeutic angiogenesis, and cell-based regenerative repair to protect kidney function in RVH.

Clinicians should recognize the potential for disease progression to threaten renal function with severe and prolonged renal ischemia. Improved patient selection for true resistant hypertension with RVH and ‘high-risk’ clinical manifestations is critical to identify those likely to benefit from renal revascularization.

Clinicians should recognize the potential for disease progression to threaten renal function with severe and prolonged renal ischemia. Improved patient selection for true resistant hypertension with RVH and ‘high-risk’ clinical manifestations is critical to identify those likely to benefit from renal revascularization.

Management of patients with coronary artery disease (CAD) has been based on identification of a coronary obstruction causing ischemia and performing a revascularization procedure to reduce that ischemia, with the goal of thereby preventing subsequent major adverse cardiac events (MACEs) in that vascular territory. Recent investigations demonstrate that preemptive percutaneous coronary intervention (PCI) of nonculprit coronary lesions (NCLs) that may not cause ischemia in patients with ST-segment elevation myocardial infarction (STEMI) reduces MACE. In this review, we focus on preemptive PCI, discuss its mechanistic benefits and speculate on its potential value for other coronary syndromes.

The COMPLETE trial in STEMI patients treated with primary PCI demonstrated that preemptive PCI of NCL obstructions, which may not cause ischemia, but often exhibit high-risk OCT plaque characteristics, reduced cardiovascular death or nonfatal myocardial infarction. Reduction in MACE from preemptive PCI of NCL was similareemptive PCI in patients with a variety of coronary syndromes.

In STEMI patients, preemptive PCI of high-risk NCL that may not cause ischemia improves long-term MACE. In stable CAD patients, MACE increases as the atherosclerotic burden increases, but PCI of the ischemia-producing lesion itself does not improve outcomes compared with optimal medical therapy. MS177 Adverse events likely originate in high-risk plaque areas that are distinct from ischemia-producing obstructions. Identification of highest-risk atherosclerotic lesions responsible for future MACE may provide an opportunity for preemptive PCI in patients with a variety of coronary syndromes.

Nearly one-third of patients presenting with angina have unobstructed epicardial coronary arteries and evidence of coronary microvascular disease. Up until recently, the pathophysiology of coronary microvascular disease has been poorly understood, resulting in limited effective therapeutic options in these patients. As a result, patients with coronary microvascular disease continue to suffer from a poor quality of life and adverse cardiovascular outcomes.

Recent mechanistic studies have improved our understanding of the pathophysiology underlying coronary microvascular dysfunction; these studies have implicated the nitric oxide and endothelin pathways as the main drivers. The aim of this article is to review our current understanding of the pathophysiology of ischaemia in patients with coronary microvascular disease.

Patients with angina who have coronary microvascular disease, but no obstructive coronary artery disease, are unable to augment their coronary blood flow in response to physiological stressischaemia as a result of supplydemand mismatch in the myocardium. In addition to abnormalities of vascular resistance, perturbations in cardiac-coronary coupling also contribute to ischaemia in these patients. Although impaired flow reserve is the diagnostic hallmark, mechanistic studies have demonstrated that the underlying pathophysiology is heterogeneous. At present, two main endotypes have been identified, which can be readily differentiated on the basis of minimal microvascular resistance. A better understanding of the pathophysiology and mechanisms driving ischaemia in coronary microvascular dysfunction may stimulate the development of individualised therapies that may lead to an improvement in patients’ quality of life and prognosis.

Myocardial infarction (MI) with nonobstructive coronary atherosclerosis (MINOCA) on invasive angiography (stenosis severity <50%) is a heterogenous clinical entity with a prevalence between 6 and 8% of all MI. Whereas the long-term prognosis of MINOCA is not benign, the identification of its underlying mechanism is critical for appropriate risk stratification and tailored secondary prevention strategies.

The current review summarizes the contemporary data on the mechanisms, diagnosis, management strategies and outcomes of MINOCA.

MINOCA is a relatively common form of MI with guarded prognosis. The use of additional diagnostic tests (particularly intracoronary imaging and cardiac magnetic resonance) is paramount to determine the exact cause of MINOCA and implement tailored medical interventions.

MINOCA is a relatively common form of MI with guarded prognosis. The use of additional diagnostic tests (particularly intracoronary imaging and cardiac magnetic resonance) is paramount to determine the exact cause of MINOCA and implement tailored medical interventions.