For those who are not from Scotland - I can confirm the weather is always this good! Incredible #visitscotland #skye #bike #patientwife

🫀 Can coronary atherosclerosis actually regress? Our new randomized FLOWPROMOTE trial analysis, published TODAY in JAMA Cardiology, shows remarkable coronary plaque regression with intensive LDL-C lowering! Atherosclerosis is not necessarily a one-way process. 📄 JAMA Cardiology: doi.org/10.1001/jamacardio.2… #Atherosclerosis #LDL #Cardiology #CCTA

Excited to host the inaugural Shock Scotland ⚡️ 🏴󠁧󠁢󠁳󠁣󠁴󠁿 complex PCI meeting in Edinburgh this September - we have an incredible faculty assembled and I am extremely grateful for their support. Hope to see many of you there - more information below millbrook-events.co.uk/event…

🫀⚠️ We used to say: “It’s non-obstructive, don’t worry.”
 This paper suggests we may have been… very wrong. Photon Counting CT answers NEW questions. A simple but powerful case: 👉 74-year-old patient 👉 unstable angina 👉 non-obstructive disease on CT And yet: 👉 Photon Counting CT detected plaque ulceration. Confirmed by OCT. Let that sink in. This was NOT a tight stenosis. This was: 👉 biologically dangerous plaque 👉 invisible to conventional paradigms 👉 clinically relevant The key finding Ultra-high-resolution PCCT showed: 👉 non-calcified plaque 👉 spotty calcification 👉 positive remodeling 👉 sharp angular protrusion (ulceration) —all non-invasively. Translation We are starting to see: 👉 plaque rupture biology without a catheter. And this matters. Because plaque ulceration (cap disruption + cavity formation) is: 👉 one of the main substrates of ACS Traditionally detected only with: ❌ invasive angiography ❌ OCT This is the real shift From: ❌ “Is there a stenosis?” To: 👉 “Is this plaque dangerous?” The uncomfortable implication A patient can have: 👉 “non-obstructive CAD” and still carry: 👉 rupture-prone disease. My take Photon Counting CT is not just improving image quality. It is: 👉 exposing the blind spots of lumen-based cardiology. Bottom line If you only look for stenosis: 👉 you will miss biology 👉 you will miss risk 👉 you will miss patients ⚡ The future is not: “better detection of narrowing” It is: 👉 detection of instability #PCCT #PhotonCounting #CCTA #PlaqueImaging #Atherosclerosis #Cardiology #PrecisionMedicine #CardiacCT

Peripheral vasopressors may be safer than we thought — only 1 major adverse event across 29,596 short PIV catheters in this meta-analysis of 49 studies.

🫀⚠️ SCOT-HEART changed cardiology with one simple idea: 👉 First scan. Then treat. This is going to generate some hitching to some colleagues within the community 😁. Sorry about that. And 10 years later… the message is even more disruptive. For decades, we built cardiology around: 👉 ischemia 👉 stress tests 👉 flow limitation Find ischemia. Open arteries. Simple. Except… it didn’t reduce hard events consistently. SCOT-HEART helped expose the problem: 👉 Atherosclerosis—not ischemia—is the real disease. At 10 years: 👉 coronary CT guidance reduced: - coronary death - non-fatal MI despite: ❌ NO increase in revascularization Let that sink in. Patients did better NOT because we opened more arteries. They did better because: 👉 we identified plaque 👉 intensified prevention 👉 treated biology earlier The most important number may not be stenosis anymore. It may be: 👉 total plaque burden 👉 plaque phenotype 👉 lipid-rich disease 👉 adverse plaque features The paper says it clearly: Patients with: ⚠️ low-attenuation plaque ⚠️ positive remodeling had dramatically higher event rates. This is the paradigm shift From: ❌ ischemia-centered cardiology To: 👉 plaque-centered prevention And the implications are enormous. Because suddenly: 👉 non-obstructive CAD matters 👉 “normal” stress tests become insufficient 👉 anatomy alone becomes incomplete Even more interesting The next frontier is already here: ⚡ Photon Counting CT ⚡ AI-driven plaque analysis ⚡ Radiomics ⚡ Quantitative phenotyping My take SCOT-HEART did not simply validate coronary CT. It challenged the entire logic of modern cardiology. We used to ask: 👉 “Is this lesion ischemic?” Now the real question is: 👉 “How biologically dangerous is this patient?” Bottom line The future is not: 👉 detect stenosis 👉 react late It is: 👉 detect atherosclerosis early 👉 personalize prevention aggressively ⚡ Because myocardial infarction often starts long before ischemia appears. #SCOTHEART #CCTA #Cardiology #Atherosclerosis #PlaqueImaging #Prevention #PhotonCounting #AI #PrecisionMedicine

The @JACCJournals focus issue on acute coronary syndrome and myocardial injury is just out. Not to be missed for anyone involved in cardiovascular care. We have come a long way in the past 50 years in the care of patients with myocardial infarction. Yet, it remains the leading cause of death worldwide. Understanding myocardial injury, how we define it, detect it, and risk stratify it, remains central to clinical practice. This issue highlights important updates for the care of patients with chest pain, from the ER to the cardiac care unit. Explore the full issue here: lnkd.in/ebSK8xNd Or read the original research in the links below: 🫀 The cTnI/cTnT Ratio in Myocardial Injury lnkd.in/ehYuaYa6 🫀 High-Sensitivity Cardiac Troponin T–Gen6 Assay in Suspected Myocardial Infarction lnkd.in/eyxfJr-T 🫀 Comparison of the European Society of Cardiology 0/1-Hour and High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome 0/2- or 0/3-Hour Algorithms for Rapid Myocardial Infarction Diagnosis lnkd.in/eUi7den9 🫀 Cardiovascular Risk Across Myocardial Injury and Infarction Categories Using the Universal Definition lnkd.in/eSAcCuaH Stay tuned for key takeaways from our Digital Media Creators.

We are currently recruiting for an Interventional Cardiologist to join our team at the Edinburgh Heart Centre. This is a high-volume interventional centre with strong academic links. You can find full details and apply here: apply.jobs.scot.nhs.uk/Job/J… Please share

It would seem that CMR and Cardiac CT capabilities are on a collision course! Photon-Counting Computed Tomography for Tissue Characterization in Patients With a Left Ventricular Hypertrophic Phenotype jacc.org/doi/10.1016/j.jcmg.…

Koeckerling et al. just dropped in @JACCJournals: a reconstructed-IPD meta-analysis of all 5 RCTs comparing PCI vs CABG for left main disease (LE MANS, SYNTAX, PRECOMBAT, EXCEL, NOBLE). 4,499 patients pooled. The headline: 10-year all-cause mortality is virtually identical — 23.4% vs 23.3%, HR 1.02 (0.89–1.17), RMST difference of exactly 0.0 years. This is genuinely good news. For patients with left main disease and low-to-intermediate anatomic complexity who are eligible for both strategies, we can now tell them with reasonable confidence: your chances of being alive at 10 years are the same regardless of which path you choose. The methodology deserves praise. The team used reconstructed time-to-event IPD (via the IPDfromKM algorithm) with 98.7% fidelity, pooled in a 1-stage Cox model with γ-frailty for trial, verified proportional hazards (Schoenfeld P=0.59), ran RMST as a complementary analysis, and confirmed everything with conventional fixed/random effects meta-analysis. Every approach converges to the same number. That's reassuring. But as with any meta-analysis, the fine print matters. A few observations: 𝗧𝗵𝗲 𝗘𝗫𝗖𝗘𝗟 𝗾𝘂𝗲𝘀𝘁𝗶𝗼𝗻 EXCEL is the largest trial (n=1905, 23% of the weight) and the only one with contemporary 2nd-gen DES (everolimus). It's also the only trial censored at 5 years — no 10-year follow-up, none planned. And it was the only trial showing a statistically significant excess in all-cause mortality with PCI at 5 years (13.0% vs 9.9%, difference 3.1 pp). @GreggWStone et al. themselves wrote in NEJM 2019: "at this time point the hazard curves were continuing to diverge. Ten-year follow-up is needed." Administrative censoring at 5 years is statistically valid — it doesn't bias the HR within the observed window. But it removes the possibility of detecting whether the divergence continued or reversed. The other 4 trials that DO have 10-year data all used 1st-gen DES or BMS. So the question "what happens to everolimus-eluting stents in left main at 10 years?" remains genuinely unanswered. 𝗥𝗲𝗰𝗼𝗻𝘀𝘁𝗿𝘂𝗰𝘁𝗲𝗱 𝗜𝗣𝗗 ≠ 𝘁𝗿𝘂𝗲 𝗜𝗣𝗗 The reconstruction method is validated and reliable for time-to-event data. But it cannot recover individual covariates. This means the meta-analysis cannot test treatment-by-subgroup interactions for diabetes, acute coronary syndromes, or SYNTAX score at 10 years. The Sabatine et al. IPD meta-analysis (Lancet 2021) found no interaction at 5 years — but extrapolating that to 10 years is an assumption, not a finding. This matters because the NOBLE 10-year paper (Holck et al., Lancet 2026) found a significant interaction between ACS presentation and mortality (HR 0.57 favoring PCI in ACS, p_interaction=0.049). If confirmed, this would have major practical implications. But it couldn't be tested in the pooled analysis. 𝗠𝗼𝗿𝘁𝗮𝗹𝗶𝘁𝘆 𝗲𝗾𝘂𝗮𝗹 ≠ 𝗼𝘂𝘁𝗰𝗼𝗺𝗲𝘀 𝗲𝗾𝘂𝗮𝗹 The meta-analysis only reports mortality. No MI, no stroke, no repeat revascularization. This is a deliberate and defensible choice (mortality is the hardest endpoint, immune to ascertainment bias). But it leaves the conversation incomplete. As an exercise, I pooled the 3 trials that report non-mortality endpoints at their longest available follow-up (LE MANS 10yr, PRECOMBAT 10yr, EXCEL 5yr — ~2,610 patients). Exploratory, not definitive, but informative: → Repeat revascularization: RR 1.66 (1.36–2.03). Significantly and consistently higher with PCI. No surprise — but the magnitude matters for shared decision-making. → Total MI: RR 1.12 (0.87–1.46). Apparently neutral. But EXCEL shows why this is misleading: periprocedural MI favored PCI (RR ~0.66) while spontaneous MI favored CABG (RR ~1.92). They cancel out in the composite. Classic Simpson's-adjacent phenomenon — the total hides a divergence that matters clinically. → Spontaneous MI (EXCEL-driven): RR 1.64 (1.14–2.38), P=0.008. This is the trade-off the patient needs to hear. CABG appears to protect better against late spontaneous infarction — plausibly because grafts bypass vulnerable proximal plaques that stents don't address. Caveat: SYNTAX and NOBLE didn't collect these endpoints between 5–10 years, so this analysis is incomplete. It's a conversation starter, not a conclusion. 𝗛𝗼𝘄 𝗱𝗼𝗲𝘀 𝗢𝗣𝗧𝗜𝗠𝗔𝗟 𝗳𝗶𝘁 𝗶𝗻? The OPTIMAL trial (Testa et al., NEJM 2026) just showed that IVUS-guided PCI adds no benefit over angiography-guided PCI in left main (HR 1.11, 0.87–1.42). This seems to contradict the NOBLE IVUS substudy (20% vs 31% mortality with/without final IVUS). But there's no contradiction. The NOBLE observation was confounded by indication. OPTIMAL randomized the comparison and found that in expert hands — operators who already internalize IVUS-derived optimization criteria — the imaging itself doesn't add incremental value. The control arm had 96% post-dilation rates and 85% POT. That's not "angiography-naïve" PCI — it's PCI done by people who think with IVUS even when they don't use it. This actually reinforces the Koeckerling findings: PCI in the included trials, even without mandated imaging, achieved equivalent mortality to CABG. If even IVUS doesn't move the needle in expert centers, then the mortality equivalence reported in the meta-analysis is likely robust and not contingent on a hypothetical "better PCI." 𝗧𝗮𝗸𝗲-𝗮𝘄𝗮𝘆 My thoughts: 1. PCI and CABG offer the same probability of being alive at 10 years in patients with left main disease and SYNTAX ≤32. This is established. 2. But equal survival is not the same as equal outcomes. PCI means ~66% more repeat revascularization and likely more spontaneous MI. CABG means more periprocedural stroke and a harder early recovery. 3. The choice isn't about which is "better." It's about which set of trade-offs aligns with the patient sitting in front of you — their anatomy, their comorbidities, their values, their fear of surgery vs. their tolerance for reintervention. Equal mortality is the foundation. The rest is shared decision-making. Again, kudos to the authors. This is beautiful work! #CardiologyX #InterventionalCardiology #LeftMain

Why does the most critical data , 61% increased risk of ischemic stroke in the device arm, is hidden in supplementary table 17 ? This should be in the abstract , main figures and main tables.

Silent plaque ruptures in non-obstructive lesions of non–infarct-related arteries. Read the results of a multimodality, serial intracoronary imaging study in #EHJ 👉 ow.ly/NKGM50YuA7a @RoccoMontone @ehj_ed

This is one of the best rugby performances by any side I’ve ever seen in my life. Scotland absolutely unbelievably good.

Revascularization in severe LV dysfunction: State of Art paper just out in @JACCJournals @ACCinTouch doi.org/10.1016/j.jcin.2025.… CABG or PCI or OMT? When to use MCS? Does RHC help? Pre-procedure planning Ideal teams/skill sets Major upcoming trials piped.video/nmnMSXvZcnU?si=Qa7b…

Current and future applications of photon-counting computed tomography in cardiovascular medicine Learn more about this fascinating technique which is coming to cardiovascular medicine: Paper: bit.ly/4r8U8W3 Podcast with the authors: bit.ly/49oxvq9

Fractional flow reserve vs angiography in non-ST- elevation myocardial infarction: long-term results of the FAMOUS-NSTEMI trial | European Heart Journal | Oxford Academic academic.oup.com/eurheartj/a…

The BCIS Research Day takes place 2nd December in Leeds and is key to driving forward UK interventional cardiology research. This year’s Keynote Address will be delivered by Professor Shamir Mehta, sharing insights on: “Two Decades of Advances in the Management of Acute Coronary Syndromes” A fantastic opportunity to learn from one of the field’s global leaders and reflect on how far ACS management has come — and where it’s heading next. Full programme & registration: bit.ly/4912AQv

Interventional cardiology fellowship university hospital Hairmyres 2026. ⁦@chapdoc1⁩⁦@TomJFord⁩⁦@AriotiManfredi⁩⁦@AntonioMariaLe2⁩⁦@wearehairmyres⁩ NHS Scotland | Jobs | Information | Apply for Clinical Fellow in Cardiology apply.jobs.scot.nhs.uk/Job/J…

Our August 2025 Literature Review is here! Highlights include: 💊 SGLT2 inhibitors post-TAVI – game changer for HF events? 🫀 5-year outcomes of TAVI vs surgery in low-risk patients 🧠 Does cerebral embolic protection make a difference in TAVI? 💉 Rivaroxaban or warfarin for LV thrombus – which is best? BCIS members can read the full review now: bcis.org.uk/resource/rd-lite…

Are you a BCIS member in training, on a fellowship, or in a locum post ahead of a substantive consultant role? We’re excited to announce that submissions are now open for the BCIS Young Investigator Award 2026! 🏆 This prestigious award celebrates outstanding original research led by emerging talent in the field. 📌 Key details: Who can apply: BCIS members in training or pre-consultant roles. What to submit: An abstract of original research where you’ve played a central role. BCIS Research Day: Top 5 finalists will present in Leeds on Tuesday, 2 Dec 2025. Final Presentation: Winner announced at Research Day & will present at ACI 2026 on 29 Jan 2026. Deadline: Monday, 13 Oct 2025, 5:00 PM ⏳ Submit here: bcis.org.uk/news/bcis-young-…