Search Results (210)

A 66-year-old man with hypertension, type 2 diabetes mellitus, and a 50-year smoking history was presented with acute chest pain clinically consistent with unstable angina. Coronary computed tomography angiography (CCTA) showed multivessel atherosclerosis and, more strikingly, diffuse sheath-like pericoronary soft-tissue cuffing around the major epicardial arteries—an appearance reported as the “mistletoe sign” and compatible with immunoglobulin G4 (IgG4)-related coronary periarteritis. CT-derived fractional flow reserve (CT-FFR) measured 0.75 in the left anterior descending artery, 0.68 in the left circumflex artery, and 0.94 in the right coronary artery. Invasive angiography identified a 90% proximal left circumflex stenosis as the flow-limiting lesion; drug-eluting stent implantation restored Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow. Serum IgG4 (145 mg/dL) was only marginally above the diagnostic threshold, and troponin was unavailable, so the diagnosis remained clinical. Without histopathology, the findings support possible rather than definite IgG4-related disease, and the contribution of the pericoronary process to the stenosis could not be established. The patient remained stable on conventional medical therapy. CCTA, CT-FFR, and angiography answer complementary questions; diffuse pericoronary change warrants serologic and systemic evaluation for inflammatory coronary involvement, with cautious etiologic attribution. Full article

Background/Objectives: The effect of cardiac motion on dynamic positron emission tomography (PET) myocardial perfusion imaging (MPI) could distort the quantitative perfusion indices during acquisition, depending on direction, magnitude, and vascular territory. This study aimed to assess the impact of motion correction (MC) and its influences on quantitative perfusion indices using a comprehensive range of established statistical methods. Method: We retrospectively analyzed 171 patients’ data who underwent ¹³N-ammonia dynamic PET/CT-MPI. All the rebinned listmode data were transferred to the dedicated workstation for MC and quantification, yielding paired MC and non-motion correction (NMC) datasets for both phases. Frame-by-frame post-MC vectors were used to characterize motion magnitude and direction. Paired comparisons, directional analysis, association, agreement, accuracy, precision, and clinical reclassification were performed. Results: Motion occurred during both acquisition phases, but it was more frequent, more heterogeneous, and generally greater during stress, with the most notable displacement along the Y-axis. MC had a limited impact on the rest myocardial blood flow (MBF) but showed more significant effects on stress MBF, myocardial flow reserve (MFR), and non-invasive fractional flow reserve (niFFR) -like index, especially in the left anterior descending artery (LAD). Although MC and NMC values remained strongly associated for MBF and MFR, they were not fully interchangeable. The bidirectional reclassification of MFR and niFFR-like index showed that MC responded to the direction and magnitude of motion rather than a simple increase the values. Conclusions: MC exerts a structured, bidirectional, and motion-dependent influence on quantitative dynamic PET-MPI and has an impact beyond simple numerical adjustment. Full article

Background: Perioperative cardiovascular complications remain a major concern in patients undergoing noncardiac surgery. Coronary computed tomography (CT)-based imaging, including coronary artery calcium (CAC) scoring, coronary CT angiography (CCTA), and CT-derived fractional flow reserve (CT-FFR), enables noninvasive assessment of coronary plaque burden, anatomic stenosis, and functional ischemia. However, the comparative prognostic value of these CT-based imaging markers for predicting perioperative major adverse cardiac events (MACE) has not been systematically evaluated. Methods: We performed a systematic review and meta-analysis of studies evaluating CT-based coronary imaging before noncardiac surgery. PubMed, Embase, and Cochrane CENTRAL were searched from inception through December 2025. Studies were included if they assessed CAC, CCTA, or CT-FFR and reported perioperative MACE. Risk of bias was independently assessed by two reviewers using the Quality In Prognosis Studies (QUIPS) tool. Pooled effect estimates were calculated using a random-effects model. The CT-FFR analysis was pre-specified as exploratory given the limited number of eligible studies. Results: A total of 13 studies including 10,100 patients undergoing noncardiac surgery were included in the systematic review, and 9 studies were eligible for quantitative meta-analysis. Obstructive coronary artery disease detected by CCTA was strongly associated with perioperative MACE (pooled odds ratio [OR] 7.18, 95% confidence interval [CI] 3.89–13.25). CAC burden was also significantly associated with perioperative cardiac risk (pooled OR 2.48, 95% CI 1.76–3.50). One study evaluating CT-FFR demonstrated a strong association between CT-FFR-defined ischemia and perioperative events (OR 10.77, 95% CI 4.64–25.02). These findings suggest that different CT-based imaging markers provide complementary prognostic information, with anatomic and functional assessment offering higher point estimates than plaque burden scoring. Conclusions: CT-based coronary imaging markers are significantly associated with perioperative MACE in patients undergoing noncardiac surgery. CAC burden and obstructive CAD detected on CCTA demonstrated consistent prognostic associations with perioperative cardiovascular events across multiple studies. CT-FFR showed a strong exploratory signal in a single eligible study, suggesting a potential additional role for functional ischemia assessment, although further validation in larger prospective cohorts is required. CT-based coronary imaging may therefore provide valuable complementary information for perioperative cardiovascular risk stratification. Full article

Global value chains (GVCs) generate rising volumes of electronic waste (e-waste), of which only 22.3% is formally collected and recycled, and operationalizing circular economy principles within GVCs requires reverse logistics networks that existing optimization models only partially capture. This paper develops a multi-echelon mixed-integer linear programming (MILP) model for integrated forward–reverse e-waste network design that jointly optimizes facility locations, material flows, hybrid distribution–collection co-location, and the collection price offered to consumers. Returns follow uniformly distributed consumer reservation prices, and the resulting price-dependent return mechanism is linearized exactly through a discrete price menu, yielding a fully linear formulation without big-M constants; recyclable fractions re-enter manufacturing as secondary inputs, closing the material loop. The model is evaluated on thirty randomly generated instances of three sizes, with parameter ranges anchored to the literature, solved with the open-source HiGHS solver; the largest instances solve to within 0.1% of optimality in under two minutes. Endogenizing the collection incentive raises total profit by 4.5 to 20.1% over an exogenous-return baseline and lifts material recovery from roughly 25% to 36 to 49%, while co-location adds modest, scale-dependent value and the two mechanisms show a directionally consistent but not statistically significant tendency toward substitutability (Wilcoxon signed-rank test, p > 0.05 across all size classes). These figures characterize the calibrated synthetic instances studied here and should not be read as generalizable empirical estimates. Sensitivity analyses identify consumer responsiveness to incentives, rather than waste stream quality, as the binding determinant of achievable recovery. Full article

Background/Objectives: A novel CT dynamic angiographic imaging (CT-DAI) analytic algorithm was evaluated against the clinical gold standard for fractional flow reserve (FFR) measurement in patients with coronary artery disease (CAD) characterized by diffuse dense calcification and previous stent implantation. Methods: This retrospective feasibility study included 24 coronary arteries in 16 patients (age 69.9 ± 8.9 years, 11 males) with CAD who underwent dynamic CT myocardial perfusion scanning using a dual-source CT scanner after intravenous infusion of adenosine triphosphate. The included patients had analyzable proximal and distal coronary artery segments adjacent to the stenosis in the myocardial perfusion images and had corresponding invasive catheter-based FFR measurements for that stenosis. An in-house software based on the CT-DAI algorithm was used to compute FFR using the coronary time-enhancement curves sampled across the stenosis from stress myocardial CT perfusion images. The CT-DAI derived FFR values were then compared to the corresponding catheter-based FFR values. A coronary stenosis was considered functionally significant for FFR values below 0.8. Results: The mean axial length and calcium score of the coronary stenoses were 47.9 mm and 1911.63 Agatston Units, respectively. Eight coronary arteries received stents from previous treatments. The CT-DAI derived FFR values (0.822 ± 0.143) showed an excellent linear correlation (R = 0.974) with and were indifferent from the invasive FFR values (0.826 ± 0.147, p = 0.537), resulting in 100% per-vessel and per-patient sensitivity and specificity for the detection of functionally significant coronary stenosis. Bland–Altman analysis revealed a minimal mean difference in FFR measurements (0.004) between the two modalities with the lower and upper limits of agreement at −0.061 and 0.069, respectively. Conclusions: The findings suggest that CT-DAI can derive FFR for the coronary arteries with heavy calcification and stents from dynamic myocardial CT perfusion images. Full article

Background/Objectives: Coronary microvascular dysfunction (CMD) is considered a key mechanism of Takotsubo syndrome (TTS), but its phenotype-specific territorial distribution remains unclear. This study investigated CMD within the left anterior descending artery (LAD) and left circumflex/obtuse marginal/ramus intermedius (LCx/OM/RI) territories in apical (AP) and midventricular (MV) TTS. Methods: In this prospective single-centre study, 31 patients with acute TTS were enrolled (median age, 71 years; 93.5% women; 20 AP and 11 MV). During the acute phase, coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and fractional flow reserve (FFR) were assessed invasively in both territories. CMD was defined as CFR ≤ 2 and/or IMR > 25; the neutral descriptive subtypes Pattern A (CFR ≤ 2 with IMR ≤ 25) and Pattern B (CFR ≤ 2 with IMR > 25) were distinguished. Results: FFR was ≥0.80 in all patients, excluding haemodynamically significant epicardial disease; at least one abnormal microvascular parameter was present in 26/31 patients (83.9%). LAD-CFR was significantly lower in AP than in MV TTS (1.6 vs. 2.6; p = 0.003), whereas LCx/OM/RI-CFR did not differ (1.6 vs. 1.5; p = 0.679). Bifocal CFR reduction predominated in AP TTS (55.0% vs. 9.1%; p = 0.020), whereas isolated LCx/OM/RI involvement occurred only in MV TTS (45.5% vs. 0.0%; p = 0.003). Pattern B in the LAD territory was more common in AP TTS (50.0% vs. 9.1%; p = 0.047). Conclusions: In this cohort, TTS showed a phenotype-specific territorial distribution of CMD: the apical phenotype predominantly involved Pattern B in the LAD territory, whereas the midventricular phenotype showed isolated LCx/OM/RI involvement within the interrogated left coronary circulation. These hypothesis-generating findings suggest phenotype-associated differences that require confirmation in larger, adequately powered cohorts. Full article

Background/Objectives: Myocardial perfusion PET/CT, e.g., using Rb-82, enables the measurement of absolute myocardial blood flow (MBF) and, hence, the blood flow reserve, which plays a crucial role in the diagnosis of coronary artery disease. However, the values might depend on the observer’s analysis and, thus, depend on the observer’s experience. We investigated the inter-observer reliability of MBF measurements in Rb-82-PET/CT. Methods: Thirty consecutive patients who underwent Rb-82-PET/CT for suspected myocardial ischemia were analyzed. Stress conditions were simulated using 400 µg Regadenoson. MBF was measured using Corridor 4DM software. Myocardial flow reserve (MFR) is the ratio of absolute flow measurements under stress and rest conditions. Four different physicians with different levels of experience (two senior physicians and two residents) measured the MBF. The experience of the two residents was one year of experience and no previous experience, respectively. Intraclass correlation coefficients (ICC) were calculated for MBF and MFR in the three main vascular territories as well as in the whole left ventricle. Additionally, the left ventricular ejection fraction (EF) was determined. Results: The evaluation of MBF showed an excellent correlation between all observers, indicated by a low inter-observer variability. Comparing the two different levels of experience, senior physicians showed a slightly higher accordance in MBF assessment (ICC ranging from 0.9 to 0.98) than the residents (ICC ranging from 0.86 to 0.94). The MFR calculations showed a slightly lower reliability due to the accumulation of variability in rest and stress measurements (ICC between 0.78 and 0.81), still indicating a good reliability. The EF calculations also showed a good reliability among the different observers (ICC 0.83). Conclusions: Measurement of MBF, MFR and EF in Rb-82-PET/CT is highly robust with a very low inter-observer variability. A slightly higher inter-observer reliability was found for more experienced physicians. Full article

Background: Invasive coronary angiography has historically been the reference standard for coronary, valvular, and structural heart disease. Over the past decade, coronary computed tomography angiography (CCTA), CT-derived fractional flow reserve (CT-FFR), photon-counting detector computed tomography (PCCT), and cardiac magnetic resonance (CMR) have expanded the range of clinical questions answerable without an intra-arterial catheter, but this shift has been uneven across clinical domains. Methods: We performed a narrative review and synthesis of randomized trials, registries, society guidelines, and consensus documents (2009–2026) identified through PubMed and major cardiovascular guideline databases, written from a joint cardiology and cardiac-surgical standpoint. Results: The boundary has shifted asymmetrically, by which we mean a domain-dependent rather than uniform displacement of invasive angiography. Non-invasive imaging is now established as the first-line approach for stable chest pain at low-to-moderate pretest probability, for pre-transcatheter aortic valve replacement (TAVR) and structural procedural planning, and for aortic disease. It remains contested for stable multivessel disease and pre-coronary artery bypass grafting (CABG) planning, where CCTA- or CT-FFR-only planning is still investigational. Invasive angiography stays first-line for ST-elevation myocardial infarction (STEMI), cardiogenic shock, and complex percutaneous coronary intervention (PCI), where diagnosis and therapy are inseparable. Conclusions: Invasive and non-invasive modalities are complementary rather than competing. The appropriate first-line investigation depends on the disease domain, pretest probability, anatomical complexity, imaging quality, and whether diagnosis and treatment can be separated. We propose a complexity-stratified, heart-team framework and identify the surgical research gaps that remain. Full article

The coexistence of severe aortic stenosis (AS) and coronary artery disease (CAD) is common and presents important diagnostic and therapeutic challenges, particularly in patients being considered for transcatheter aortic valve replacement. Accurate assessment of coronary lesion significance in this setting is difficult because severe AS alters coronary haemodynamics, myocardial oxygen demand, microvascular function, and the balance between resting and hyperaemic flow. These changes may influence the interpretation of conventional physiological indices and complicate decisions regarding revascularisation. This narrative review summarises the pathophysiological interaction between severe AS and CAD and examines the contemporary evidence supporting invasive and non-invasive approaches to coronary assessment. We review the limitations and potential utility of fractional flow reserve, and non-hyperaemic pressure ratios, highlighting the frequent discordance observed between indices and the uncertainty regarding optimal thresholds in severe AS. Importantly, identification of physiologically significant lesions should be distinguished from evidence that revascularisation of these lesions improves clinical outcomes, as prospective outcome data remain limited. While recent trials support physiology-guided revascularisation in patients undergoing TAVR, outcome data remain linked primarily to conventional FFR thresholds rather than proposed AS-specific cutoffs. We also discuss emerging non-wire-based approaches, including quantitative flow ratio and computed tomography-derived fractional flow reserve, which may offer complementary value in selected patients. In addition, we examine the practical implications of coronary physiology for clinical decision-making before and after valve intervention, including the timing of percutaneous coronary intervention and the need to distinguish lesion-level diagnostic performance from evidence of clinical benefit. Current data suggest that no single modality is universally applicable and that assessment should be individualised according to lesion characteristics, clinical context, and procedural strategy. Proposed severe AS-specific thresholds for FFR and NHPR are derived from small predominantly observational studies, have not been prospectively validated against clinical outcomes and should be hypothesis-generating. A hybrid approach integrating angiographic, physiological, and computed tomography-based information may be most useful. Further prospective studies are needed to define optimal thresholds, validate management algorithms, and clarify whether physiology-guided strategies improve outcomes in severe AS. Full article

Cardiac computed tomography (CT) has evolved into a pivotal tool in precision cardiology, enabling comprehensive, non-invasive evaluation of coronary anatomy, plaque composition, vascular function, and inflammation. From calcium scoring to advanced physiological imaging, CT now integrates multiple layers of cardiovascular information within a unified diagnostic framework. Coronary artery calcium (CAC) quantification provides a robust, reproducible measure of atherosclerotic burden and refines risk estimation beyond traditional algorithms, particularly in asymptomatic individuals with an intermediate likelihood. Building upon this anatomical foundation, coronary CT angiography (CCTA) extends evaluation to the anatomical and morphological characterization of coronary artery disease (CAD), identifying both obstructive and non-obstructive plaques with high prognostic accuracy. The addition of CT-derived fractional flow reserve (FFR-CT) and stress perfusion CT (CTP) bridges anatomy and physiology, improving identification of flow-limiting stenoses and guiding revascularization decisions while reducing unnecessary invasive procedures. Beyond luminal assessment, CT-derived biomarkers such as the perivascular fat attenuation index (pFAI) have introduced a new dimension of vascular inflammation imaging, revealing residual risk even in patients without significant stenosis and suggesting novel pathways for individualized therapeutic targeting. Driven by advances in artificial intelligence and photon-counting detector technology, cardiac CT is transitioning from a purely diagnostic modality to an integrative platform for cardiovascular phenotyping. Taken as a whole, this integration of structural, functional, and biological data provides a genuinely holistic view of coronary health. In practical terms, it shifts clinical decision-making from population-based risk models toward precision-guided patient-specific strategies. Full article

The evaluation of stents in coronary computed tomography angiography (CCTA) is still a major topic in cardiovascular imaging. Using Photon-Counting Detector CT (PCCT) may improve the assessment of coronary stents and make on-site CT-FFR analysis feasible for ruling out in-stent restenosis (ISR). In this study, patients with previous coronary stent implantation who underwent CCTA using PCCT and subsequent invasive catheter angiography (ICA) were included. Stent characteristics such as location and length were reported. CT-FFR measurements were taken 1.8 cm before and after the stent, with a value of ≤0.80 defined as hemodynamically significant under respecting the diagnostic accuracy drop in the gray zone between 0.76 and 0.80. Delta CT-FFR with a cut-off value of ≥0.06, indicating hemodynamic significance, was determined. Any ISR and interventional treatment during the following ICA was recorded. Diagnostic performance metrics, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for post-stent CT-FFR and Delta CT-FFR in detecting ISR. Patients were followed up to evaluate the rate of major adverse cardiovascular events (MACE) 6 months after CCTA. A total of 19 patients (5 female, 14 male, median age 69 years) were enrolled in this study. In most cases, coronary stents were located in the proximal LAD with a median stent length of 70.2 mm. Pathological CT-FFR < 0.76 distal to the stent was detected in 6 cases (31.6%), while pathological Delta CT-FFR ≥ 0.06 occurred in 14 cases (73.7%). ICA was performed in three of these patients, with ISR confirmed in two cases. These findings yield sensitivity and NPV of 100% for both post-stent CT-FFR and Delta CT-FFR for excluding ISR with a superior specificity (76.5% vs. 29.4%) and overall diagnostic accuracy (78.9% vs. 36.8%) for post-stent CT-FFR. Two patients reported a myocardial infarction in follow-up; however, neither of them was located in the territory of the stented coronary artery. This study outlines the feasibility of on-site CT-FFR analysis using PCCT in excluding ISR in coronary stents with a high diagnostic accuracy. These findings highlight the need to extend the benefits of CT-FFR analysis for non-invasive assessment of possible ISR regarding personalized risk stratification and therapy planning. Full article

Background/Objectives: Angiographic stenosis severity and functional significance are discordant in up to 65% of intermediate coronary lesions. Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) has shown better clinical outcomes than standard angiography-guided PCI, therefore functional significance defines revascularization. This review evaluates the contemporary evidence for intracoronary physiology assessment tools, such as FFR, non-hyperemic pressure ratios (NHPRs), angiography-derived wire-free indices, and microvascular function testing, and proposes a framework for their implementation into clinical practice. Methods: We conducted a narrative review, synthesizing data from landmark randomized controlled trials (DEFER, FAME I–III, DANAMI-3-PRIMULTI, COMPARE-ACUTE, DEFINE-FLAIR, iFR-SWEDEHEART, iMODERN, FAVOR III China and Europe, FAST III, ALL-RISE, CorMicA), along with pooled analyses, meta-analyses, position papers, and relevant guidelines. Results: FFR-guided revascularization resulted in a 28% reduction in cardiac death or myocardial infarction in pooled analyses (HR 0.72, 95% CI 0.54–0.96). leading to a Class I, Level A indication. NHPRs, including iFR, achieved non-inferiority to the FFR at 1 year; however, a 5-year pooled meta-analysis raised concerns of increased all-cause mortality with iFR guidance compared to the FFR (HR 1.34, 95% CI 1.08–1.67). Approximately 20% of lesions show FFR–iFR discordance, driven by vessel-specific physiology and microvascular factors. Wire-free technologies yielded conflicting results: the FAVOR III China trial favored the QFR over angiography, yet FAVOR III Europe failed non-inferiority versus the FFR, while the recent FAST III and ALL-RISE trials demonstrated the non-inferiority of angiography-derived physiology at 1 year. Up to 40% of patients with angina have non-obstructed coronary arteries, and coronary vasomotor function testing can identify treatable microvascular endotypes improving symptoms and quality of life. Conclusions: Functional invasive coronary angiography is advocated to decipher vessel hemodynamics and to guide treatment. The FFR remains the gold standard for invasive physiological assessments, while NHPRs and wire-free technologies are valuable adjuncts with specific indications and limitations. A thorough microvascular evaluation is essential for differentiating between various INOCA endotypes and is gradually being adopted by the interventional community. While NHPRs and virtual technologies struggle to dethrone the king FFR, a comprehensive intracoronary physiology assessment is essential to guide treatment. Full article

Current acute coronary syndrome (ACS) care relies on sequential, single-modality diagnostics, in which the electrocardiogram, the troponin trajectory, and the coronary angiogram are interpreted independently rather than as a joint signal. This narrative review maps rather than pools the evidence. We selectively searched PubMed, EMBASE, Cochrane CENTRAL, and Web of Science (January 2015–February 2026); study selection was performed by a single reviewer, without duplicate screening, a PRISMA flow diagram, or a formal risk-of-bias assessment. The three key findings are as follows: A machine learning-enabled electrocardiogram (ECG) for diagnosing occlusion due to myocardial infarction achieved an AUC of 0.938 (95% CI = 0.924–0.951) on data not seen during training and correctly diagnosed 42% of patients that expert interpreters missed. A machine learning-enabled high-sensitivity troponin interpretation method, CoDE-ACS, reported an AUC of 0.953 and increased the number of patients ruled out at initial evaluation from 27% to 61%. Angiographically derived physiological methods produced conflicting results—quantitative flow ratios reduced major adverse cardiovascular events (MACE) in the FAVOR III China trial (HR 0.65), but in FAVOR III Europe the angiography-derived approach did not prove non-inferior to FFR; if anything, QFR guidance led to more events (6.7% vs. 4.2%, an event rate about 60% higher in the QFR arm; HR 1.63; 95% CI 1.11–2.41). There was no difference between FFR-angio and FFR in the ALL-RISE trial. These are diagnostic-accuracy and prognostic-association findings; no trial has yet shown that AI-guided ACS care reduces death, reinfarction, or ischemia-driven revascularization. Full article

Background: Patients with diabetes mellitus and nonobstructive coronary artery disease (NOCAD) may remain at increased cardiovascular risk despite the absence of flow-limiting stenosis. Quantitative coronary CT angiography (CCTA) enables comprehensive assessment of anatomical, functional, and inflammatory imaging biomarkers beyond luminal stenosis. This study aimed to evaluate the prognostic value of an automated multiparametric CCTA-derived imaging framework for risk stratification in patients with NOCAD, with exploratory assessment in those with diabetes mellitus. Methods: This retrospective single-center study included 485 patients with NOCAD who underwent CCTA between January 2020 and December 2021. Automated CCTA analysis was performed to quantify plaque burden, high-risk plaque features, CT-derived fractional flow reserve (CT-FFR), and perivascular fat attenuation index. The primary endpoint was major adverse cardiovascular events (MACE) during follow-up. Prognostic associations were assessed using Kaplan–Meier analysis, Cox regression, and hierarchical models. Results: During a median follow-up of approximately three years, MACE occurred in 56 patients. Patients with diabetes had a higher event rate than those without diabetes. Increased plaque burden, high-risk plaque features, elevated perivascular fat attenuation index, and reduced CT-FFR were associated with adverse outcomes. The fully integrated model combining anatomical, functional, and inflammatory CCTA-derived biomarkers improved risk stratification compared with plaque-based assessment alone. Conclusions: Automated multiparametric CCTA phenotyping may provide complementary prognostic information for risk stratification in patients with NOCAD. The diabetes-specific findings should be considered exploratory and require validation in larger prospective cohorts. Full article

Background/Objectives: Invasive coronary physiology has evolved from a tool for assessing intermediate stenoses to a comprehensive framework for guiding diagnosis and treatment across the spectrum of coronary artery disease (CAD). This review aims to provide an updated, catheterization laboratory-centered overview of contemporary invasive coronary physiology, emphasizing its role in optimizing percutaneous coronary intervention (PCI) and in evaluating patients with angina and non-obstructive coronary arteries (ANOCA/INOCA). Methods: A narrative review of contemporary evidence, including randomized trials, consensus documents, and guideline recommendations, was conducted. Key physiological indices—fractional flow reserve (FFR), non-hyperemic pressure ratios (NHPRs), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR)—were examined alongside emerging tools such as longitudinal vessel analysis and the pullback pressure gradient (PPG). Applications in pre- and post-PCI assessment, physiology–imaging integration, and comprehensive functional testing in ANOCA/INOCA were evaluated. Results: Physiology-guided PCI improves clinical outcomes and resource utilization compared with angiography-guided strategies. Longitudinal vessel assessment and PPG enable characterization of focal versus diffuse CAD, improving procedural planning and prediction of post-PCI physiological results. Post-PCI physiological assessment identifies residual ischemia and guides optimization strategies. In patients without obstructive CAD, combined assessment of microvascular function and vasomotor reactivity allows identification of distinct pathophysiological endotypes, supporting mechanism-based, individualized therapy. Integration with intracoronary imaging further enhances procedural precision. Conclusions: Contemporary invasive coronary physiology provides a multidimensional approach integrating epicardial, microvascular, and vasomotor domains. This framework supports personalized decision-making, optimizes revascularization, and reduces unnecessary interventions, representing a cornerstone of modern coronary care. Full article