30-Second Takeaway
- Adolescent “elevated” blood pressure tracks to midlife CT-defined coronary atherosclerosis in a dose–response fashion.
- Remnant cholesterol independently predicts MACE, with the strongest relative risks in young adults, even when LDL-C is optimal.
- In older adults, coronary revascularization decisions should integrate frailty, cognition, life expectancy, and patient goals.
- In ACS PCI, intravascular imaging–guided stent optimization most benefits high-risk or anatomically complex lesions.
- Heart failure patients with CKD and elderly AF patients remain undertreated or cautiously treated despite substantial potential benefit from guideline therapies.
Week ending November 22, 2025
Early risk signals and procedural optimization in contemporary cardiovascular practice
Adolescent blood pressure predicts CT-defined coronary stenosis in middle age
In over 10,000 Swedish men followed from adolescence to late middle age, higher adolescent BP predicted more CCTA-defined coronary atherosclerosis after ~40 years. Stage 2 hypertension in adolescence nearly doubled the odds of severe (≥50%) coronary stenosis versus normal BP (adjusted prevalence 10.1% vs 6.9%). Even guideline-defined "elevated" systolic BP (around 120–129 mm Hg) in adolescence was associated with higher severe coronary atherosclerosis in midlife. Associations were stronger for systolic than diastolic BP, suggesting systolic control in youth is particularly important for lifelong coronary risk.
Remnant cholesterol independently drives MACE risk, especially in young adults
This nationwide cohort of over 4.3 million adults without prior MI or stroke linked higher fasting remnant cholesterol to increased MACE across all ages. Relative risks were greatest in 20–39-year-olds, with high vs low remnant-C yielding HRs of 1.42 for MI and 1.30 for ischemic stroke. Cardiovascular mortality risk was more than doubled in young adults with high remnant-C, while effects were modest in those ≥65 years. Among 20–39-year-olds with LDL-C <100 mg/dL, high remnant-C still conferred excess MI, stroke, and cardiovascular mortality risk. These data support measuring and targeting remnant-C for earlier preventive intervention, beyond standard LDL-C–focused assessment.
AHA framework for coronary revascularization in older adults
This AHA scientific statement emphasizes that older adults (especially ≥75 years) carry a disproportionate burden of ACS and complex CAD. Geriatric syndromes—frailty, cognitive impairment, multimorbidity—substantially modify procedural risk and should inform PCI vs CABG vs medical therapy choices. The statement advocates individualized decisions that integrate life expectancy, functional status, and patient goals rather than chronological age alone. It highlights gaps in evidence because current revascularization guidelines largely derive from younger, less comorbid trial populations. Clinicians are urged to incorporate geriatric assessment and structured shared decision-making when planning coronary revascularization in older adults.
References
Numbered in order of appearance. Click any reference to view details.
Additional Reads
Optional additional studies from this edition.