Precision over prevalence: moving beyond binary risk stratification after PCI

The management of chronic coronary syndromes (CCS) continues to evolve with advances in interventional techniques and pharmacotherapies, yet recurrent ischaemic events remain a significant concern after percutaneous coronary intervention (PCI). Despite improvements in drug-eluting stents (DES) and antiplatelet regimens, long-term outcomes remain suboptimal for many, driven by persistent risks of myocardial infarction, stroke, and death. The 2024 European Society of Cardiology (ESC) guidelines for CCS management define high ischaemic risk (HIR) as coronary atherosclerosis plus at least one risk enhancer or procedural factor from a detailed list1. They recommend personalised antithrombotic strategies, such as extending dual antiplatelet therapy (DAPT) or switching to long-term P2Y12 inhibitor monotherapy for HIR patients after PCI to reduce the risk of recurrent events.

In this issue of EuroIntervention, Raona et al provide an in-depth analysis from Mount Sinai Fuster Heart Hospital in New York, USA, that questions the practical applicability of these HIR criteria in a real-world, diverse patient population2. They retrospectively assessed the prevalence and prognostic impact of HIR criteria, as defined by the 2024 ESC guidelines, in a large all-comer cohort of...