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BACKGROUND Sex differences in the diagnostic yield of invasive coronary angiography (ICA) in non-ST-elevation acute coronary syndrome (NSTE-ACS) are well established, but contemporary population-level data incorporating high-sensitivity troponin era cohorts and cross-national validation remain limited.<br /> OBJECTIVES The objectives of the study were to assess sex differences in diagnostic yield, revascularization rates, and 1-year putcomes in patients undergoing first-time ICA for suspected NSTE-ACS.<br /> METHODS Using data from the Swedish Coronary Angiography and Angioplasty Registry with validation in the Western Denmark Heart Registry. Adults without previously known coronary artery disease (CAD) undergoing first-time ICA for suspected NSTE-ACS were included. The primary outcome was the absence of significant CAD, defined as a normal angiography or <50% stenosis in all major epicardial vessels. Multivariable Poisson regression models were used to estimalle adjusted risk ratios (aRRs). Secondary outcomes were 1-year major adverse cardiovascular events, comparing women and men with and without obstructive CAD using Kaplan-Meier estimates and adjusted Cox proportional hazards models.<br /> RESULTS A total of 74,883 and 17,863 patients were included from Sweden and Western Denmark. Women had approximately twice the proportion without significant CAD compared to men in Swedish Coronary Angiography and Angioplasty Registry (40.9% vs 17.2%; aRR: 2.59; 95% CI: 2.51-2.67) and Western Denmark Heart Registry (50.1% vs 25.2%; aRR: 2.01; 95% CI: 1.95-2.08). In women below the age of 50 without any traditional cardiovascular risk factors, 74.8% had no significant CAD.<br /> CONCLUSIONS In 2 population-based cohorts undergoing first-time ICA for suspected NSTE-ACS, 40 to 50% of women had no significant CAD, approximately twice the proportion to men, highlighting ongoing challenges in risk stratification of patients referred for ICA. (JACC Adv. 2026;5:102807) 2026 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license<br /> (http://creativecommons.org/licenses/by/4.0/).

BACKGROUND Coronary obstruction (CO) is a rare but life-threatening complication of transcatheter aortic valve replacement (TAVR). Leaflet modification techniques have been developed to mitigate this risk; however, real-world evidence remains scarce. OBJECTIVES The aim of this study was to report procedural and 30-day outcomes of patients at high risk for CO undergoing leaflet modification. METHODS LOFTER-TAVR (Leaflet mOdiFication Techniques to prEvent coRonary obstruction risk during Transcatheter Aortic Valve Replacement) was an international, multicenter registry of consecutive patients undergoing leaflet modification before TAVR (September 2019 to January 2026). Coprimary endpoints were leaflet modification-directed technical success and Valve Academic Research Consortium 3 (VARC-3) technical success. Secondary endpoints included in-hospital and 30-day outcomes. RESULTS A total of 293 patients underwent leaflet modification, including 202 (68.9%) through a leaflet-splitting approach and 91 (31.1%) through an intraleaflet disruption approach. Overall, 139 of 293 (47.4%) treated valves were natives. Successful leaflet traversal occurred in 310 of 318 leaflets (97.5%; 95% CI: 94.9%-98.9%) and successful leaflet modification in 306 of 318 leaflets (96.2%; 95% CI: 93.3%-97.9%). Leaflet modification-directed technical success was achieved in 251 of 293 patients (85.7%; 95% CI: 81.0%-89.4%) and VARC-3 technical success in 254 of 293 patients (86.7%; 95% CI: 82.1%-90.3%). Notably, 91.1% (95% CI: 87.1%-94.0%) of patients underwent TAVR without CO events. Delayed CO occurred in 3 of 293 patients (1.0%; 95% CI: 0.3%-3.0%). The median follow-up duration was 100 days (Q1-Q3: 30-443 days). At 30 days, freedom from VARC-3 early safety was achieved in 181 of 293 patients (61.8%; 95% CI: 56.5%-67.6%). CONCLUSIONS Leaflet modification techniques demonstrated high technical feasibility across a broad anatomical spectrum but carried considerable early clinical risk. These findings support its role as an adjunctive strategy for selected patients undergoing TAVR, although in the context of careful preprocedural planning and a structured multidisciplinary approach. (JACC Cardiovasc Interv. 2026;19:1639-1649) (c) 2026 by the American College of Cardiology Foundation.

BACKGROUND: The REC-CAGEFREE trial showed that drug-coated balloons (DCB) did not achieve non-inferiority in the treatment of non-complex de novo lesion compared to a strategy of drug-eluting stents (DES). However, a prespecified subgroup analysis of arteries sized <3.0 mm revealed no difference in the device-oriented outcome compared to DES. The aim of present study was to validate that finding in a real-world registry by comparing DCB and DES in non-complex lesions with arteries <3.0 mm.

METHODS: The Swedish Coronary Angiography and Angioplasty registry (SCAAR) was used to identify all segments with small non-complex coronary artery lesions treated with DCB or DES between January 2016 and May 2024. One-to-one propensity score (PS) matching was used to address confounding. The primary outcome comprised the composite of target lesion revascularization (TLR), target vessel myocardial infarction (TV-MI) and all-cause mortality after 5 years. Outcome was assessed using Kaplan-Meier estimates and univariable Cox proportional analysis.

RESULTS: After PS-matching, 1439 pairs of DCB and DES treated segments where formed and baseline characteristics were similar across the two groups. Compared to DCB, treatment with DES was associated with lower rates of the primary outcome 19.2 % vs 14.7 % (HR, 0.76; 95 % CI, 0.61-0.95; P = 0.016) and TV-MI 3.4 % vs 1.3 % (HR, 0.52; 95 % CI, 0.29-0.94; P = 0.029). No statistically significant difference was observed for TLR or all-cause mortality.

CONCLUSIONS: In this nationwide observational segment-level analysis comparing the use of DCB to DES on small (<3.0 mm) non-complex coronary artery lesions, DES was associated lower rates of the primary composite outcome.

BACKGROUND

Randomized trials support angiographic and physiology-guided complete revascularization (CR) vs incomplete revascularization (IR) in ST-segment elevation myocardial infarction (STEMI) with multivessel disease (MVD). The implementation of these strategies in clinical practice is uncertain.

OBJECTIVES

In patients undergoing percutaneous coronary intervention for STEMI with MVD, we assessed temporal trends in the utilization of different revascularization strategies and associated outcomes.

METHODS

We included 20,131 patients from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry who underwent primary percutaneous coronary intervention for STEMI with MVD between 2009 and 2021. Primary outcome was a composite of all-cause mortality, myocardial infarction, or unplanned revascularization, landmarked at 90 days postindex to account for staged procedures during this time. RESULTS We observed increased adoption of CR (2009: 33% [n = 397 of 1,217]; 2015: 46% [n = 767 of 1,658]; 2021: 51% [n = 816 of 1,603]; P-trend <0.001) and physiology-guided CR (2009: 0% [n = 0 of 1,217]; 2015: 7% [n = 119 of 1,658]; 2021: 14% [n = 218 of 1,603]; P-trend < 0.001). Over a median follow-up of 4.2 years (Q1-Q3: 1.8-7.1 years), the adjusted risk of a primary event was lower with angiographic CR vs IR (adjusted HR [aHR]: 0.84, 95% CI: 0.79-0.89) and physiology-guided CR vs IR (aHR: 0.80, 95% CI: 0.69-0.93) but not physiology-guided CR vs angiographic CR (aHR: 0.94, 95% CI: 0.80-1.11).

CONCLUSIONS

In patients with STEMI and MVD, the implementation of CR and physiology-guided procedures increased over time. As of 2021, 51% of patients underwent CR and 14% physiology-guided CR. CR, whether angiographically or physiology guided, was independently associated with favorable outcomes, including mortality. (JACC Cardiovasc Interv. 2025;18:1246-1259) (c) 2025 Published by Elsevier on behalf of the American College of Cardiology Foundation.

Background: In recent years, transcatheter aortic valve implantation (TAVI) has rapidly emerged as a key treatment option for aortic stenosis. TAVI has been performed at Uppsala University Hospital since 2009. Data on TAVI procedures have been collected in a nation-wide all-comer registry, the Swedish Transcatheter Cardiac Intervention Registry (SWENTRY). However, only limited analysis has been conducted on trends in short- and long-term outcomes of TAVI patients in Sweden.

Methods: This registry-based cohort study aims to evaluate outcome trends and long-term prognosis in patients who underwent TAVI in a Swedish single center between 2009 and 2023. Survival outcomes were studied using the Kaplan-Meier method. Cox Proportional Hazards models were used to adjust for differences in patient characteristics over time.

Results: In total, 1,741 TAVI procedures were performed between 2009 and 2023. Immediate procedural mortality and 1-year mortality averaged at 0.9 and 8.1%, respectively. Both procedural and long-term mortality showed a decreasing trend over time. Similar results were observed when controlling for comorbidities and age.

Conclusions: Short-term outcomes and long-term prognosis have been constantly improving for patients undergoing TAVI within this study. Similar mortality and complication trends have been observed in other registry studies. These trends may be attributed to improvements in the quality of care, and the increased use of TAVI in lower risk patients.

Background: A history of hypertensive disorders of pregnancy is associated with at least twice the risk of incident ischemic heart disease. Whether the long-term outcome following treatment with coronary artery stenting is associated to the history of hypertensive disorders of pregnancy is unknown.

Methodsand Results: We included 8364 women (age <= 65 years) undergoing first coronary artery stenting 2006 to 2022 following their first delivery in 1973 or later, linking nationwide data on percutaneous coronary intervention and delivery history. In total, 1122 women (13.4%) had a history of hypertensive disorders of pregnancy. The main outcome, a major adverse cardiovascular event, was defined as any incident myocardial infarction, ischemic heart disease, cardiac arrest, arrhythmias, angina pectoris, heart failure, cerebral infarction, or sudden death. During a median follow-up time of 5 years, 258 women with a history of hypertensive disorders of pregnancy had a major adverse cardiovascular event, compared with 1465 women without a history of hypertensive disorders of pregnancy (23% versus 20.2%, P=0.028 for log-rank test). Estimates adjusted for patient- and procedural characteristics in proportional hazards regression models suggested that the hazard rate increased only after 4-8 years of follow-up (hazard ratio [HR], 1.36 [95% CI, 1.05-1.78]) and was primarily driven by women with history of gestational hypertension (HR, 2.15 [95% CI, 1.49-3.11]).

Conclusions: Women with a history of hypertensive disorders of pregnancy have an increased risk of a major adverse cardiovascular event following coronary artery stenting compared with other parous women. A history of hypertensive disorders of pregnancy warrants further attention in the secondary prevention setting of coronary artery disease.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an increasingly important treatment option for patients with severe aortic stenosis. Its best implementation is debated, as few centres with high volumes are associated with better outcomes, while centralization might lead to an inferior availability of treatment for patients living far away. The aim of this study was to investigate the implementation of TAVI in Sweden with a focus on regional differences in terms of availability, short-term mortality, and waiting times.

METHODS: All patients undergoing TAVI between 2008 and 2020 from the Swedish Transcatheter Cardiac Intervention Registry (SWENTRY) were included. SWENTRY was linked to the National Cause of Death Registry and to publicly available geospatial data from Statistics Sweden.

RESULTS: A total of 7280 patients were included. Over time, TAVI interventions increased markedly, while surgical aortic valve replacement (SAVR) remained constant. There were no statistically significant regional differences in incidence between counties with or without a local TAVI centre (P = 0.7) and no clustering tendencies around regions with a local TAVI centre (P = 0.99). Thirty-day mortality improved over time without evidence of regional differences. No regional differences in waiting time from decision to intervention were found for TAVI centre regions and non-TAVI centre regions (P = 0.7).

CONCLUSION: This nationwide study indicated no regional differences in terms of availability, short-term mortality, or waiting times. An organization with a few specialized centres was found to be sufficient to provide national coverage of TAVI interventions.

Background

Women with a history of adverse pregnancy outcomes have a higher risk of coronary heart disease. Emerging evidence suggests that women with a history of preeclampsia have a different pattern of overall coronary atherosclerosis and that they at the time of myocardial infarction (MI) more frequently present with ST-segment elevation MI (STEMI) compared to women with no such history.

Objectives

The purpose of this study was to determine whether among women with MI, those with a history of adverse pregnancy outcomes are more likely to present with STEMI or other clinical characteristics indicating a more severe myocardial injury.

Methods

The study sample consisted of 8,320 women aged ≤65 years with first MI in Sweden 2007 to 2022. Regression models were used to estimate the association between adverse pregnancy outcomes (hypertensive disorders of pregnancy [non-preeclamptic hypertension and preeclampsia], small for gestational age [SGA] infant, and preterm delivery) and STEMI, invasive revascularization, and high troponin, while considering known predictors of coronary heart disease.

Results

In total, 3,128 (38%) of women suffered STEMI. The adjusted OR of presenting with STEMI were higher in women with a history of preterm preeclampsia (OR: 1.40; 95% CI: 1.05-1.88), or an SGA infant (OR: 1.30; 95% CI: 1.13-1.50) compared to women with no such history, as well as for in-hospital revascularization. Stratified by infarct type, troponin levels did not differ by adverse pregnancy outcome history.

Conclusions

Among women with a first MI, a history of preterm preeclampsia or SGA infant were associated with STEMI and invasive revascularization.

Importance Adverse pregnancy outcomes are recognized risk enhancers for cardiovascular disease, but the prevalence of subclinical coronary atherosclerosis after these conditions is unknown.Objective To assess associations between history of adverse pregnancy outcomes and coronary artery disease assessed by coronary computed tomography angiography screening.Design, Setting, and Participants Cross-sectional study of a population-based cohort of women in Sweden (n = 10 528) with 1 or more deliveries in 1973 or later, ascertained via the Swedish National Medical Birth Register, who subsequently participated in the Swedish Cardiopulmonary Bioimage Study at age 50 to 65 (median, 57.3) years in 2013-2018. Delivery data were prospectively collected.Exposures Adverse pregnancy outcomes, including preeclampsia, gestational hypertension, preterm delivery, small-for-gestational-age infant, and gestational diabetes. The reference category included women with no history of these exposures.Main Outcomes and Measures Coronary computed tomography angiography indexes, including any coronary atherosclerosis, significant stenosis, noncalcified plaque, segment involvement score of 4 or greater, and coronary artery calcium score greater than 100.Results A median 29.6 (IQR, 25.0-34.9) years after first registered delivery, 18.9% of women had a history of adverse pregnancy outcomes, with specific pregnancy histories ranging from 1.4% (gestational diabetes) to 9.5% (preterm delivery). The prevalence of any coronary atherosclerosis in women with a history of any adverse pregnancy outcome was 32.1% (95% CI, 30.0%-34.2%), which was significantly higher (prevalence difference, 3.8% [95% CI, 1.6%-6.1%]; prevalence ratio, 1.14 [95% CI, 1.06-1.22]) compared with reference women. History of gestational hypertension and preeclampsia were both significantly associated with higher and similar prevalence of all outcome indexes. For preeclampsia, the highest prevalence difference was observed for any coronary atherosclerosis (prevalence difference, 8.0% [95% CI, 3.7%-12.3%]; prevalence ratio, 1.28 [95% CI, 1.14-1.45]), and the highest prevalence ratio was observed for significant stenosis (prevalence difference, 3.1% [95% CI, 1.1%-5.1%]; prevalence ratio, 2.46 [95% CI, 1.65-3.67]). In adjusted models, odds ratios for preeclampsia ranged from 1.31 (95% CI, 1.07-1.61) for any coronary atherosclerosis to 2.21 (95% CI, 1.42-3.44) for significant stenosis. Similar associations were observed for history of preeclampsia or gestational hypertension among women with low predicted cardiovascular risk.Conclusions and Relevance Among Swedish women undergoing coronary computed tomography angiography screening, there was a statistically significant association between history of adverse pregnancy outcomes and image-identified coronary artery disease, including among women estimated to be at low cardiovascular disease risk. Further research is needed to understand the clinical importance of these associations.

BackgroundWomen's pregnancy history is associated with incident risk of coronary artery disease with some evidence also suggesting a relevance for prognosis following treatment.ObjectivesTo study the associations between maternal history of preterm delivery, a history of small for gestational age infant, parity and age at first delivery with clinical restenosis after percutaneous coronary intervention (PCI).MethodsIn this prospective cohort study, we included 6027 women <65 years undergoing their first PCI 2006-2017, merging clinical register data on PCI procedures in Sweden with comprehensive registry data on deliveries since 1973. We used proportional hazards regression to study the association between aspects of pregnancy history and clinical restenosis in per-segment analyses, and with target lesion revascularisation (TLR) in per-patient analyses. We adjusted models for procedural-related and patient-related predictors of restenosis.ResultsDuring 15 981 segment-years of follow-up, 343 (3.7%) events of clinical restenosis occurred. We found no strong evidence of associations between the studied aspects of pregnancy history and clinical restenosis following PCI. For example, the restenosis HR for a history of preterm delivery in the fully adjusted model was 1.09 (95% CI 0.77 to 1.55) and the TLR HR was 1.18 (95% CI 0.91 to 1.52).ConclusionRisk of restenosis following treatment with PCI did not differ by the studied aspects of pregnancy history, including preterm delivery, in young and middle-aged women. Larger studies are needed to obtain more precise estimates.