Search Results (190)

Background/Objectives: Patients undergoing carotid revascularization may show distinct patterns of bilateral carotid vulnerability and clinical risk. This study used latent class analysis (LCA) to identify high-resolution magnetic resonance imaging (HR-MRI)-based clinical–radiological phenotypes and evaluate their association with long-term major adverse cardiovascular events (MACE). Methods: This retrospective cohort included 289 patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between April 2017 and April 2024 and had preoperative carotid HR-MRI within 90 days. Ipsilateral and contralateral plaque features were assessed on multi-contrast vessel-wall HR-MRI. LCA included five indicators: ipsilateral intraplaque hemorrhage, ipsilateral lipid-rich necrotic core, contralateral intraplaque hemorrhage, cardiovascular disease history, and symptomatic status. MACE comprised cardiovascular death, nonfatal myocardial infarction, coronary revascularization, or stroke. Outcomes were assessed using Kaplan–Meier analysis and multivariable Cox regression. Results: Among 289 patients undergoing carotid revascularization, the mean age was 65.12 ± 9.46 years, and 237 (82.0%) patients were men. LCA identified three phenotypes: Systemic High-Risk (n = 128), Silent High-Risk (n = 37), and Stable/Moderate (n = 124). The Systemic High-Risk phenotype showed high probabilities of symptomatic presentation, cardiovascular disease history, and bilateral carotid vulnerability, whereas the Silent High-Risk phenotype showed marked ipsilateral plaque vulnerability despite lower clinical risk. During a median follow-up of 4.4 years, MACE-free survival differed significantly across phenotypes (log-rank p = 0.043). Compared with the Stable/Moderate phenotype, the Systemic High-Risk and Silent High-Risk phenotypes were both associated with increased MACE risk (HR 1.65, 95% CI 1.15–2.37, p = 0.039; HR 1.43, 95% CI 1.12–2.15, p = 0.034). Conclusions: HR-MRI-based LCA identified clinically meaningful carotid vulnerability phenotypes associated with long-term MACE after carotid revascularization. These findings support integrated assessment of bilateral plaque vulnerability and clinical risk for postoperative cardiovascular risk stratification. 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

Background: Coronary in-stent restenosis (ISR) remains a major limitation of percutaneous coronary intervention (PCI) with drug-eluting stents (DES), adversely affecting long-term outcomes. Most available prediction models rely on invasive procedural variables and have been developed predominantly in high-income populations, limiting their generalizability. This study aimed to identify independent predictors of coronary ISR and to develop and internally validate a clinically applicable risk stratification model based on routinely available clinical, laboratory, and procedural factors in a cohort of patients from Kazakhstan. Methods: In this retrospective case–control study, 910 patients with coronary artery disease (CAD) who underwent follow-up coronary angiography after PCI between January 2018 and July 2025 were included. The study comprised 455 patients with angiographically confirmed coronary in-stent restenosis and 455 patients without restenosis selected using a consecutive sampling approach. Clinical characteristics, laboratory parameters, echocardiographic findings, and angiographic data were analyzed. Independent predictors were identified using multivariable binary logistic regression. Model discrimination was assessed using receiver operating characteristic (ROC) curve analysis, and internal validation was performed using bootstrap resampling. Results: The mean age was 62.9 ± 8.9 years, and 75.2% of patients were male. Restenosis was independently associated with prior myocardial infarction (MI) (OR 2.20; 95% CI 1.65–2.80), type 2 diabetes mellitus (T2DM) (OR 2.60; 95% CI 1.93–3.47), and smoking (OR 1.40; 95% CI 1.01–1.89). Patients with restenosis demonstrated a less favorable inflammatory and metabolic profile, including higher NLR, MHR, atherogenic index, and TyG index (all p < 0.05). LVEF was significantly lower, while multivessel disease and the number of implanted stents was higher (p < 0.001). A risk stratification model incorporating T2DM, the number of implanted stents, MPV, neutrophil count, HDL-C, LVEF demonstrated good discrimination (AUC 0.828) and 74.4% accuracy. Conclusions: The proposed model demonstrated good discrimination and satisfactory internal validity with limited optimism after internal bootstrap validation. It may serve as a useful tool for patient risk stratification after PCI. External validation in independent cohorts is required before widespread clinical implementation. Full article

Complex percutaneous coronary intervention (PCI) represents a growing proportion of contemporary coronary revascularization, driven by aging populations, increasing comorbidity burden, and advances in interventional techniques. Complex PCI encompasses a spectrum of anatomically and procedurally challenging lesions, including left main disease, bifurcation lesions requiring two-stent strategies, chronic total occlusions, long stent lengths, severe calcification requiring atherectomy, and multivessel revascularization. Antithrombotic therapy, comprising antiplatelet and anticoagulant agents, is essential for preventing stent thrombosis and other ischemic events in both the early and long-term phases after PCI. While antithrombotic therapy mitigates ischemic risks associated with complex PCI, these patients frequently carry a high bleeding risk, thus making the choice of antithrombotic regimen challenging. Recent guideline recommendations emphasize balancing ischemic and bleeding risks rather than relying solely on procedural complexity. This review synthesizes contemporary evidence, guideline recommendations, and clinical considerations for antithrombotic therapy after complex PCI. Full article

Automated assessment of coronary artery disease (CAD) severity from invasive X-ray angiography is important for diagnostic accuracy, but there are limitations due to limited label data and privacy issues in multi-institutional collaboration. This research proposes a Federated Graph-Transformer Network (FGTN) that models coronary vessel compositions as graphs and uses a transformer unit of measurement to encode global anatomic circumstances for severity scaling. The publicly available X-ray angiography images and SYNTAX-Score dataset will be used, consisting of 232 X-ray coronary angiography images with analogous clinically calculated SYNTAX tons and angiographic factors from 231 patients, manually annotated by a competent cardiologist. The vascular tree is a primary segment that transforms inside the node-edge graph representing bifurcation and vessel sections, continuing topological features, and then processes by graph convolutions integrated with transformer self-attention to capture simultaneously the local stenosis features and global vessel relationships. A Horizontal Federated Learning Strategy allowing collaborative model training on clinical sites without sharing raw data. The intended FGTN achieved overall accuracy of 99.4%, precision of 97.6%, recall of 98.8%, and F1-score of 98.2%, exceeding the usual CNNs, Attention-UNet, and Capsule Connection baselines by a margin of 4–7%. For non-obstructive, mild, moderate, and severe stenosis classes, the AUC values were 0.98, 0.97, 0.96, and 0.95, respectively. Moreover, the Federated Learning framework shows firm convergence with lower, compared to 1.8% performance degradation, when compared to centralized training, and confirms robustness via heterogeneous data distribution. These results show that the proposed solution automatically calculates the CAD severity grading from coronary angiography images. Full article

Background and Clinical Significance: The Coronary Sinus Reducer (CSR) is a percutaneous therapeutic option for patients with refractory angina who are unsuitable for further myocardial revascularization. The procedure has a generally favorable safety profile, with a low rate of reported procedural complications. To our knowledge, major atrioventricular (AV) conduction disturbances during CSR implantation have not been previously described. This case highlights a rare but clinically relevant intraprocedural complication; Case Presentation: A 71-year-old man with multivessel coronary artery disease and previous coronary artery bypass grafting was referred for CSR implantation because of refractory angina despite optimal medical therapy and lack of further revascularization options. The procedure was performed via a right jugular venous approach. Baseline electrocardiography showed right bundle branch block and findings consistent with previous inferior myocardial infarction, without definite criteria for left anterior fascicular block. During coronary sinus cannulation, the patient developed transient complete AV block, resulting in an approximately 8–10-second ventricular pause without a stable ventricular escape rhythm. The conduction disturbance resolved after catheter withdrawal and repositioning. Given the severity of the event, a temporary transvenous pacemaker was inserted via the right femoral vein, allowing safe completion of CSR implantation. At three-month follow-up, angina had improved from Canadian Cardiovascular Society class III to class I, and no recurrent advanced AV block was documented; Conclusions: Transient complete AV block may occur during CSR implantation, particularly during coronary sinus manipulation and possibly in patients with pre-existing conduction disease. Careful catheter handling, prompt recognition of conduction disturbances, and immediate availability of temporary pacing support should be considered in selected high-risk patients undergoing CSR implantation. Full article

Non-ST-segment elevation myocardial infarction (NSTEMI) has become the predominant form of acute coronary syndrome (ACS) and is frequently associated with multivessel coronary artery disease (MVD). Patients presenting with NSTEMI and MVD represent a particularly high-risk population characterized by advanced age, comorbidities, and an increased atherosclerotic burden. Although advances in pharmacological therapy and early invasive management have improved prognosis, the optimal revascularization strategy in this setting remains uncertain. In contrast to ST-segment elevation myocardial infarction (STEMI), where randomized controlled trials consistently support complete revascularization, evidence in NSTEMI with MVD is limited and is largely derived from observational studies and registry data. This has generated ongoing debate regarding whether complete revascularization offers superior outcomes compared with culprit-only percutaneous coronary intervention (PCI), and whether non-culprit lesions should be treated during the index procedure (immediate strategy) or in a staged manner. Current data suggest that complete PCI is generally associated with reduced recurrent ischemia, reinfarction, and repeat revascularization, with potential long-term survival benefits. However, patient comorbidities, lesion complexity, and procedural risk continue to influence outcomes, highlighting the importance of individualized decision-making. This narrative review synthesizes contemporary evidence on PCI-based revascularization strategies in NSTEMI with MVD, focusing on two central aspects: the extent of revascularization (complete versus incomplete) and the timing of intervention (single-stage versus staged). By integrating findings from registries, randomized trials and guideline recommendations, the review identifies areas of consensus, persisting uncertainties, and key evidence gaps. Ultimately, it underscores the need for large, dedicated trials to guide practice and optimize outcomes for NSTEMI patients with multivessel coronary disease. Full article

Multivessel coronary artery disease is observed in a substantial proportion of patients presenting with ST-segment elevation myocardial infarction (STEMI) and identifies a higher-risk phenotype characterized by larger atherosclerotic burden, recurrent ischemic events, and greater need for subsequent revascularization. Over the past decade, randomized evidence has progressively shifted the interventional paradigm from culprit-lesion-only primary percutaneous coronary intervention (PCI) toward complete revascularization in hemodynamically stable STEMI patients with suitable non-culprit lesions. Nevertheless, several clinically relevant questions remain unresolved, including the optimal criteria for selecting non-culprit lesions, the relative value of angiography, coronary physiology, and intracoronary imaging, the timing of complete revascularization, and the management of patients presenting with cardiogenic shock. Angiography-guided complete revascularization has the strongest evidence base, while physiology-guided approaches may reduce unnecessary PCI but have not demonstrated superiority over angiography-guided strategies in direct randomized comparisons. Intracoronary imaging offers unique information on plaque vulnerability and PCI optimization, although dedicated outcome trials in STEMI remain limited. The timing of complete revascularization has also evolved, with contemporary trials supporting early treatment in selected stable patients but not establishing a universal immediate strategy. This review summarizes current evidence, unresolved controversies, and emerging directions regarding strategies and timing of complete revascularization in STEMI patients with multivessel disease. Full article

Background: Carotid atherosclerosis is a recognised manifestation of systemic vascular disease, and its association with coronary artery disease (CAD) has been well described. However, previous studies have largely been conducted under conventional diagnostic conditions and have focused on carotid plaque, intima–media thickness, or simple present-versus-absent stenosis classifications, rather than duplex-derived haemodynamic markers across the spectrum of angiographic CAD burden. The COVID-19 pandemic and post-pandemic period changed referral patterns and created more variable cardiovascular presentations, including symptoms that could resemble or mask obstructive CAD. Therefore, we investigated whether the established association between carotid stenosis severity and CAD burden remains detectable in a diagnostically heterogeneous real-world cohort, and whether routinely available carotid duplex haemodynamic parameters provide a clinically relevant signal in this setting. Methods: This single-centre, cross-sectional study was performed as a carotid-focused secondary analysis of the BG Study cohort. We included 902 consecutive patients who underwent invasive coronary angiography between 2021 and 2023 and carotid duplex ultrasonography during the same hospitalisation. CAD burden was defined according to the number of major coronary vessels with ≥70% diameter stenosis and classified as no CAD, one-vessel, two-vessel, or three-vessel disease. Carotid duplex parameters included peak systolic velocities of the common, internal, and external carotid arteries, as well as ICA stenosis severity graded according to NASCET criteria. Associations with CAD burden were assessed using a staged statistical approach combining χ² tests, Kruskal–Wallis tests with post hoc pairwise comparisons, Spearman correlation, inverse probability weighting, and ordered logistic regression. Results: The prevalence of measured ICA stenosis of any grade and severe ICA stenosis increased with greater CAD burden (both p < 0.001). Median PSV values of the bilateral ICAs and ECAs differed significantly across CAD groups on global intergroup testing. Post hoc pairwise analyses showed that significant corrected differences were concentrated between patients without CAD and those with multivessel or three-vessel CAD, particularly for ICA stenosis measures and bilateral ECA PSV. Spearman analysis demonstrated weak but statistically significant correlations between carotid parameters and CAD burden (ρ = 0.085–0.134). After inverse probability weighting, covariate balance was achieved, with all post-IPW standardised mean differences being <0.01. In ordered logistic regression (OLR) analysis, patient-reported history of carotid stenosis (OR 2.25, 95% CI 1.38–3.67; p < 0.001), right external carotid artery PSV per 10 cm/s (OR 1.31, 95% CI 1.09–1.57; p = 0.004), left ICA PSV per 10 cm/s (OR 1.17, 95% CI 1.01–1.36; p = 0.034), and left ICA stenosis per 10% (OR 1.24, 95% CI 1.11–1.39; p < 0.001) were independently associated with higher CAD burden. Exploratory ratio-based analyses showed that the ECA/CCA PSV ratio was associated with CAD presence and higher CAD burden, whereas the ICA/CCA ratio showed weaker associations; neither ratio-based index outperformed absolute ECA PSV. Conclusions: In this carotid-focused secondary analysis of a pandemic-era angiography cohort, carotid stenosis severity and duplex-derived haemodynamic parameters were independently but modestly associated with increasing angiographic CAD burden. These findings support carotid duplex markers as adjunctive indicators of systemic atherosclerotic burden rather than standalone tools for CAD detection or treatment decision-making. Future validation in vascular surgery populations is warranted to determine whether routinely available carotid duplex parameters can contribute to targeted cardiovascular risk recognition before major vascular procedures. Full article

Background: Left ventricular outpouchings remain among the most difficult structural abnormalities to classify in clinical practice. The differential diagnosis usually includes true aneurysm, pseudoaneurysm, diverticulum, and less clearly defined chronic post-ischemic remodeling patterns. Although multimodality imaging is central to preoperative assessment, it may still overstate diagnostic certainty in complex chronic lesions. Case Presentation: We report the case of a 66-year-old man with chronic coronary syndrome and severe multivessel coronary artery disease in whom transthoracic echocardiography, computed tomography, ventriculography, and cardiac magnetic resonance consistently suggested a basal lateral left ventricular pseudoaneurysm, with imaging findings compatible with an associated mural thrombotic component. Because of the coexistence of surgically significant coronary disease, the patient was referred for operative treatment. Intraoperatively, however, the expected pseudoaneurysmal cavity was not identified. Instead, two posterolateral fibro-calcific left ventricular formations were found in a surgically difficult area, with an appearance that did not correlate convincingly with any preoperative imaging study. Given their calcified aspect, difficult exposure, and the high risk of additional surgical manipulation, no direct intervention was performed on these structures, and only myocardial revascularization was undertaken. The postoperative course was favorable. Discussion: The case highlights a clinically important limitation of multimodality imaging: concordant imaging does not necessarily equal an anatomically correct diagnosis. The discrepancy between imaging and operative findings raises unresolved questions as to whether the lesion represented small chronic aneurysmal formations, an unusual chronic pseudoaneurysm, a calcified diverticular process, multiple fibro-calcific post-infarction outpouchings, or another form of chronic left ventricular remodeling. Rather than forcing a definitive label unsupported by pathology, the case is better understood as a diagnostic gray-zone lesion. Conclusions: Even comprehensive imaging may remain incomplete when evaluating unusual left ventricular outpouchings in ischemic patients. This case underscores the need for cautious diagnostic language, close correlation with operative findings, and broader discussion regarding the classification of chronic left ventricular parietal lesions. Full article

Background: Accurate evaluation of stent implantation during percutaneous coronary intervention (PCI) is essential to reduce both early and late adverse events. Conventional coronary angiography, although routinely used, has limited spatial resolution and may fail to detect subtle mechanical abnormalities in implanted stents. Enhanced stent visualization (ESV) is an X-ray-based post-processing technique that improves delineation of stent struts without additional contrast or intracoronary instrumentation. Methods: We report a retrospective case series of five patients who underwent complex PCI where ESV was used as an adjunctive imaging modality. Clinical scenarios included left main interventions, bifurcation lesions, multivessel disease, and acute coronary syndromes. The ability of ESV to detect mechanical complications not evident on angiography was assessed. The impact of ESV on procedural decision-making was also assessed. Results: ESV enabled identification of mechanical complications in all cases, including stent fracture, stent loss, stent dislodgement, stent underexpansion, and geographical miss. These findings were not clearly appreciable when using angiography alone. In each case, ESV directly influenced intraprocedural management, prompting immediate corrective actions such as additional stent implantation, stent retrieval, or further optimization with post-dilatation or intravascular lithotripsy. This resulted in improved procedural outcomes and optimized stent deployment. Conclusions: In this small retrospective case series, ESV provided incremental diagnostic value over conventional angiography by detecting otherwise unrecognized mechanical complications and guiding real-time procedural optimization. While these findings suggest a potential role for ESV in complex PCIs, larger prospective studies are required to confirm its clinical impact. Full article

Background: The extent of coronary artery disease (CAD) is a major determinant of prognosis in patients with myocardial infarction (MI). While structured exercise is known to be cardioprotective, the association between habitual daily physical activity and angiographic CAD extension remains insufficiently characterized. Methods: In this prospective observational study, 269 patients were hospitalized with acute MI underwent coronary angiography. Habitual daily physical activity during the four weeks preceding admission was assessed using 10-point self-reported daily preadmission effort questions to help the patients to report a final effort score. CAD extension was classified as single-, double- or triple-vessel disease. Differences in daily effort across CAD categories were evaluated using the Kruskal–Wallis test. Independent predictors of CAD extension were identified using ordinal logistic regression adjusted for age, sex, smoking, hypertension, diabetes mellitus, hyperlipidemia and body mass index. Results: Daily preadmission effort decreased progressively with increasing CAD severity (mean scores: 7.44 in single-vessel, 4.93 in double-vessel and 3.69 in triple-vessel disease; p < 0.0001). In multivariable ordinal logistic regression analysis, older age, hypertension, diabetes mellitus and hyperlipidemia were independently associated with greater CAD extension. Higher daily preadmission effort was strongly and independently associated with lower CAD severity; each one-point increase in effort score was associated with a 46% reduction in the odds of more extensive CAD (odds ratio 0.54, 95% confidence interval 0.45–0.64; p < 0.0001). Conclusions: Greater habitual daily physical activity prior to myocardial infarction is independently associated with less extensive coronary artery disease. Assessment of daily preadmission effort may provide clinically useful information regarding coronary disease burden and highlights the potential importance of everyday physical activity in cardiovascular prevention. These findings should be interpreted with caution given the use of a non-validated, self-reported measure of physical activity and the observational study design. Full article

Coronary artery disease (CAD) often coexists with severe aortic stenosis (AS) in patients undergoing transcatheter aortic valve implantation (TAVI), posing a complex diagnostic and therapeutic challenge. As TAVI is increasingly used for younger, lower-risk patients, managing CAD is becoming a personalized, long-term clinical concern. This narrative review summarizes the current evidence on coronary assessment and revascularization strategies in individuals with severe AS. Invasive coronary angiography remains the leading method for anatomical coronary imaging, but coronary computed tomography angiography is emerging as a reliable alternative that may reduce unnecessary invasive procedures in certain patients. The routine performance of PCI before TAVI is under increasing scrutiny, and available data support a more selective approach based on lesion significance, CAD complexity, procedural timing, and anticipated need for future coronary access. Significant uncertainties remain concerning the physiological evaluation of lesions, the timing and completeness of revascularization, and the treatment of left main or multivessel disease. Additional phenotype-specific and longitudinal studies are needed to improve management algorithms for this population. Full article

Background/Objectives: Cardiovascular disease (CVD), particularly coronary artery disease (CAD), is increasingly linked to microvascular inflammation driven by interactions between immune, vascular, and neuroendocrine systems. Mast cells (MCs), strategically positioned near blood vessels, play pivotal roles in this process through the release of inflammatory and vasoactive mediators, contributing to increased vascular permeability, endothelial dysfunction, and tissue inflammation in conditions including ischemia–reperfusion (I/R) and CVD. This comprehensive review examines the cellular and molecular mechanisms underlying MC-mediated microvascular inflammation, with emphasis on neuroimmune regulation through the heart–brain axis, and evaluates the therapeutic potential of flavonoids. Methods: A review of in vitro, animal, and clinical studies was conducted to assess MC-mediated cardiovascular pathology and the pharmacological effects of natural flavonoids on MC activation and microvascular inflammation. Results: Psychological and physical stress activates hypothalamic corticotropin-releasing hormone (CRH) signaling, directly triggering coronary MC degranulation via CRHR-1 and CRHR-2 receptors, while co-released neuropeptides, including neurotensin and urocortin, amplify this neuroimmune cascade. Traumatic brain injury, autonomic dysregulation, and atrial fibrillation further perpetuate this bidirectional heart–brain axis, linking neurological stress to microvascular injury and adverse cardiac remodeling. An autocrine–paracrine CRH amplification loop sustains chronic coronary microvascular inflammation, contributing to heart failure with preserved ejection fraction (HFpEF) and MC activation disease (MCAD)-related cardiovascular manifestations. Natural flavonoids were found to inhibit MC activation, suppress inflammatory mediator synthesis, and protect microvascular integrity through multiple molecular targets, including calcium signaling, transcription factors, oxidative stress pathways, and CRHR-1-mediated neuroimmune signaling. Conclusions: While challenges remain regarding bioavailability and standardization, multi-compound formulations targeting multiple risk factors hold promise for preventing CVD progression. Future research directions for advancing these natural compounds toward clinical implementation are identified. Full article

Background. Despite technological innovations and improvements in stents and devices, sex-related discrepancies are still reported in the outcomes after ST-segment elevation myocardial infarction (STEMI), depending on biological and sex-specific pathophysiological differences, which have not been completely understood. The aim of the present study was to provide real-world data on the prognostic role of sex among patients with STEMI, enclosed into a recent up-to-date international registry. Methods. The ISACS-STEMI COVID-19 is a large-scale retrospective registry, including STEMI patients treated with mechanical reperfusion between 1 March and 30 June, 2019 and 2020. Patients, treated in 109 centers across Europe, Latin America, Southeast Asia, and North Africa, were grouped according to sex. Primary endpoint: In-hospital mortality; secondary endpoints: Time delay, 30-day mortality, and postprocedural Thrombolysis In Myocardial Infarction (TIMI) 3 flow. Results. We included 16,083 patients, 24.3% females (54.3% hospitalized in 2019, 45.7% in 2020). Women with STEMI were older, more often diabetic and hypertensive (p < 0.001), with a higher prevalence of hypercholesterolemia (p = 0.02), longer ischemia time (p = 0.01), ambulance referral (p = 0.03) and cardiogenic shock at presentation (p = 0.05), but less frequently smokers, with a previous cardiovascular event (p < 0.001) or anterior STEMI (p = 0.03) as compared to males. Preprocedural TIMI 0 flow, multivessel disease, need for thrombectomy (p < 0.001 and p = 0.001, respectively), use of Glycoprotein IIbIIIa inhibitors or cangrelor, radial access and implantation of drug-eluting stents (p < 0.001, p < 0.001 and p = 0.001, respectively) were also more common in men. Impaired postprocedural epicardial reperfusion (TIMI flow 0–2) was observed more frequently in females as compared to males (10% vs. 7.2%; adjusted OR [95% CI] = 1.30 [1.13–1.49], p = 0.01). In-hospital mortality was 5.8%, significantly higher among women (8.3% vs. 5%, p < 0.001, adjusted HR [95% CI] = 1.26 [1.06–1.5], p = 0.01). Similar data were observed for 30-day mortality (10.3% vs. 6.2%, p < 0.001, adjusted HR [95% CI] = 1.22 [1.06–1.38], p = 0.007). Conclusions. Among STEMI patients being treated with the most updated standard of care for primary percutaneous coronary intervention, female sex is still associated with higher complexity and impaired prognosis, displaying suboptimal epicardial reperfusion and increased in-hospital and 30-day mortality. Full article