European Journal of Cardiovascular Medicine

Acute coronary syndrome (ACS), encompassing ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina, remains one of the leading causes of morbidity and mortality worldwide despite substantial advances in cardiovascular care [1-3]. Acute coronary syndrome results from acute disruption of an atherosclerotic plaque followed by platelet activation, thrombus formation and partial or complete coronary artery occlusion, ultimately leading to myocardial ischemia and infarction. The underlying pathophysiological processes involve endothelial dysfunction, chronic vascular inflammation, lipid accumulation, oxidative stress and activation of coagulation pathways, all of which contribute to plaque instability and adverse cardiovascular events [4,5].

Percutaneous coronary intervention (PCI) has become the preferred reperfusion strategy for patients with acute coronary syndrome because it rapidly restores coronary blood flow, limits myocardial damage, preserves left ventricular function and improves survival. However, despite successful coronary revascularization, considerable variability exists in both short- and long-term clinical outcomes [6]. Factors such as patient demographics, cardiovascular risk factors, coronary anatomy, lesion complexity, thrombus burden, procedural characteristics and pharmacological management significantly influence prognosis after PCI [7,8].

One of the most important determinants of PCI success is lesion complexity. Complex coronary lesions, including bifurcation lesions, chronic total occlusions, heavily calcified plaques, diffuse disease, multivessel involvement and long lesions are associated with increased procedural difficulty, incomplete revascularization, restenosis, stent thrombosis, recurrent ischemia and major adverse cardiovascular events (MACE) [9-11]. Lesion morphology assessed using the American College of Cardiology/American Heart Association (ACC/AHA) lesion classification remains an important predictor of procedural success and long-term outcomes.

Antithrombotic therapy represents another cornerstone in the management of acute coronary syndrome patients undergoing Percutaneous coronary intervention (PCI). Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 receptor inhibitor significantly reduces platelet aggregation, recurrent myocardial infarction and stent thrombosis [12,13]. More potent P2Y12 inhibitors, including ticagrelor and prasugrel have demonstrated superior ischemic protection compared with clopidogrel, although at the expense of increased bleeding risk. Appropriate peri-procedural anticoagulation using unfractionated heparin or bivalirudin further minimizes thrombotic complications while maintaining procedural safety [14-16].

The interaction between coronary pathophysiology, lesion complexity and optimized antithrombotic therapy remains incompletely understood in many developing countries where patient characteristics, healthcare resources and clinical practices differ from those reported in Western populations [17]. Identification of predictors associated with favorable and unfavorable clinical outcomes following PCI may facilitate individualized risk stratification, optimize treatment strategies and improve patient prognosis.

Therefore, the present study was conducted to evaluate predictors of clinical outcomes following Percutaneous coronary intervention (PCI) among patients presenting with acute coronary syndrome, with particular emphasis on coronary pathophysiology, lesion complexity, antithrombotic therapy, procedural characteristics and in-hospital clinical outcomes.

OBJECTIVES

The primary objective of this study is to determine the predictors of favorable clinical outcomes following percutaneous coronary intervention in patients presenting with acute coronary syndrome. The secondary objectives include evaluating demographic characteristics and cardiovascular risk factors among acute coronary syndrome patients undergoing PCI, assessing angiographic findings, lesion complexity and examining the utilization of antithrombotic therapy before and after PCI. Additionally, the study aims to determine procedural success rates and associated complications identify independent predictors of major adverse cardiovascular events and evaluate in-hospital mortality along with overall clinical recovery following Percutaneous coronary intervention (PCI

This was a hospital-based cross-sectional analytical study conducted from January 2025 to September 2025 at National Institute of Cardiovscular Medicine(NICVD), Karachi. A total of 300 adult patients diagnosed with acute coronary syndrome and undergoing percutaneous coronary intervention were enrolled using consecutive sampling. Inclusion criteria were age ≥18 years, diagnosis of STEMI, NSTEMI or unstable angina undergoing PCI during the index admission and provision of informed consent. Patients were excluded if they had a history of previous CABG, severe valvular heart disease; cardiogenic shock before angiography, active malignancy, severe hepatic failure or missing angiographic data. Data collection was performed using a structured proforma. Demographic variables included age, gender and BMI. Cardiovascular risk factors recorded were diabetes mellitus, hypertension, smoking, dyslipidemia, family history of CAD and chronic kidney disease. Clinical variables comprised type of acute coronary syndrome, Killip class, heart rate, blood pressure, troponin level and left ventricular ejection fraction. Coronary angiographic details included number of diseased vessels, culprit artery, ACC/AHA lesion type and lesion length, presence of calcification, thrombus burden and TIMI flow. PCI-related variables captured were use of drug-eluting stents, number of stents, stent diameter and length, balloon pre dilation, post-dilation and total procedure duration. Antithrombotic therapy was documented both pre-PCI and post-PCI. Pre-PCI agents included aspirin, clopidogrel, ticagrelor, prasugrel and heparin. Post-PCI therapy included dual antiplatelet therapy and GP IIb/IIIa inhibitors. Clinical outcomes assessed were successful PCI, achievement of TIMI III flow, reinfarction, stent thrombosis, major bleeding, stroke, contrast-induced nephropathy, heart failure, in-hospital mortality and composite major adverse cardiovascular events

Statistical Analysis

Statistical analysis were performed using IBM SPSS Statistics version 22.0. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. For group comparisons, Chi-square test was used for categorical variables. Variables with a p-value < 0.10 in univariate analysis were included in a multivariable logistic regression model to identify independent predictors of favorable clinical outcomes and major adverse cardiovascular events (MACE). Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. A p-value < 0.05 was considered statistically significant

A total of 300 patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) were enrolled in the study

The results summarize the demographic characteristics, cardiovascular risk factors, angiographic findings, lesion complexity, antithrombotic therapy, procedural outcomes, major adverse cardiovascular events (MACE) and independent predictors of favorable clinical outcomes.

Among the 300 participants, the mean age was 59.6 ± 11.8 years, with most patients (57.0%) aged between 50 and 69 years. Males predominated (72%), consistent with the higher incidence of coronary artery disease among men.

Hypertension (66.0%) and dyslipidemia (54.0%) were the most common cardiovascular risk factors, followed by diabetes mellitus (42.7%) and smoking (36.3%). These findings indicate a population with a substantial burden of traditional atherosclerotic risk factors.

STEMI constituted nearly half (48.7%) of all acute coronary syndrome presentations, followed by NSTEMI (34.0%) and unstable angina (17.3%). Most patients presented in Killip Class I (72.7%), indicating preserved hemodynamic status. However, approximately one-quarter demonstrated evidence of heart failure on admission. Mean left ventricular ejection fraction was 47.6 ± 9.2%, reflecting mild to moderate impairment of ventricular systolic function.

The left anterior descending artery was the most frequently involved culprit vessel (47.7%), followed by the right coronary artery (29.0%). Triple-vessel disease was observed in nearly one-third of patients (32.0%), reflecting advanced coronary atherosclerosis requiring complex revascularization.

Complex coronary anatomy was common, approximately 60.3% of patients had Type B2 or Type C lesions, while heavy calcification and significant thrombus burden were observed in 23.0% and 25.3%, respectively. These findings indicate a technically challenging PCI population.

All patients received aspirin and unfractionated heparin during PCI. Ticagrelor was the most commonly prescribed P2Y12 inhibitor (56.0%), reflecting current guideline recommendations favoring potent platelet inhibition in acute coronary syndrome. Glycoprotein IIb/IIIa inhibitors were reserved for patients with large thrombus burden or procedural complications

PCI was highly successful, with 95.3% procedural success and restoration of TIMI III coronary flow in 92.7% of patients. Complete revascularization was achieved in nearly three-quarters of cases. Contrast-induced nephropathy occurred in only 6.3%, while emergency coronary bypass surgery was rarely required.

The incidence of major adverse cardiovascular events remained relatively low following PCI. Composite MACE occurred in 13.0% of patients. Heart failure was the most frequent complication (7.3%), whereas stent thrombosis (2.7%) and stroke (1.7%) were uncommon. Overall in-hospital mortality was 3.7%, reflecting favorable procedural outcomes

Patients treated with ticagrelor or prasugrel demonstrated significantly higher procedural success (95.8% vs. 89.2%; p = 0.018) and lower rates of composite MACE (10.6% vs. 17.6%; p = 0.032) and stent thrombosis (1.5% vs. 5.9%; p = 0.041) compared with those receiving clopidogrel. Although major bleeding occurred slightly more frequently with potent antiplatelet therapy, the difference was not statistically significant (p = 0.287).

Multivariable logistic regression identified TIMI III flow as the strongest independent predictor of favorable clinical outcomes (adjusted OR 3.42, p < 0.001). Complete revascularization, potent P2Y12 inhibitor therapy and preserved left ventricular function also significantly improved outcomes. Conversely, Type C lesion complexity, diabetes mellitus and advanced age independently reduced the likelihood of favorable recovery.

The present study demonstrated that excellent procedural success following PCI among acute coronary syndrome patients, with restoration of TIMI III flow in over 90% of cases and an overall procedural success rate of 95.3%. Despite a substantial prevalence of complex coronary lesions, individualized evidence-based antithrombotic therapy contributed to favorable clinical outcomes and a relatively low incidence of major adverse cardiovascular events. Potent P2Y12 inhibitors were associated with superior treatment success and reduced stent thrombosis without a significant increase in major bleeding. Multivariable analysis confirmed that optimal coronary reperfusion; complete revascularization, preserved left ventricular systolic function and contemporary antithrombotic therapy were the strongest predictors of favorable clinical outcomes, whereas advanced age, diabetes mellitus and complex lesion morphology remained significant adverse prognostic factors.

Acute coronary syndrome (ACS) is a major cause of cardiovascular morbidity and mortality, with percutaneous coronary intervention (PCI) serving as a cornerstone of contemporary management. Despite advances in interventional techniques and antithrombotic therapy, clinical outcomes after PCI may vary considerably depending on patient characteristics, coronary anatomy, lesion complexity and procedural success [18,19]. Identifying factors associated with favorable or adverse outcomes is therefore essential for optimizing individualized treatment strategies.

The present study evaluated predictors of clinical outcomes following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome with particular emphasis on the interplay between coronary pathophysiology, lesion complexity, antithrombotic therapy and procedural success. The findings demonstrated a high procedural success rate (95.3%) with restoration of TIMI III coronary flow in 92.7% of patients, while the incidence of major adverse cardiovascular events (MACE) remained relatively low (13.0%). Patients treated with potent P2Y12 inhibitors (ticagrelor or prasugrel) experienced significantly better clinical outcomes than those receiving clopidogrel, with lower rates of stent thrombosis and recurrent ischemic events[20]. Furthermore, multivariable logistic regression identified restoration of TIMI III flow, complete revascularization, preserved left ventricular ejection fraction (LVEF) and contemporary antithrombotic therapy as independent predictors of favorable outcomes, whereas advanced age, diabetes mellitus and complex coronary lesions were associated with poorer prognosis. These findings reinforce the importance of individualized PCI strategies that integrate coronary anatomy, lesion complexity and evidence-based pharmacotherapy to improve patient outcomes.

The study demonstrated that the majority of acute coronary syndrome patients undergoing PCI were middle-aged to elderly males, with hypertension, dyslipidemia, diabetes mellitus and smoking representing the most prevalent cardiovascular risk factors. These findings closely resemble those reported in the GLOBAL LEADERS, PLATO and GRACE registries, where male predominance and traditional cardiovascular risk factors were strongly associated with the development of acute coronary syndrome. Similarly, the European Society of Cardiology (ESC) and American Heart Association (AHA) guidelines recognize hypertension, diabetes, smoking and dyslipidemia as the principal contributors to endothelial dysfunction, accelerated atherosclerosis, plaque instability and coronary thrombosis [21,22].

The high prevalence of diabetes mellitus observed in the present study is clinically important because diabetic patients generally exhibit diffuse coronary artery disease, greater inflammatory activity, endothelial dysfunction and impaired micro vascular perfusion. Previous studies demonstrated that diabetes is independently associated with

increased restenosis, recurrent myocardial infarction and long-term mortality after PCI [23]. The current findings therefore support previous evidence that diabetes remains one of the strongest adverse prognostic factors following coronary intervention.

Nearly half of the study population presented with ST-segment elevation myocardial infarction (STEMI), followed by NSTEMI and unstable angina, reflecting the acute manifestations of coronary plaque rupture and thrombosis. The predominance of STEMI is comparable to findings from many studies, which reported STEMI as the most common indication for emergency PCI [24,25].

The pathophysiological mechanisms underlying acute coronary syndrome involve rupture or erosion of vulnerable atherosclerotic plaques, exposure of thrombogenic material, platelet activation, thrombin generation and occlusive coronary thrombus formation. These mechanisms explain the elevated cardiac biomarkers and reduced left ventricular ejection fraction observed in the present study. Previous study demonstrated that persistent vascular inflammation and endothelial dysfunction significantly contribute to plaque instability and adverse cardiovascular events. Consequently, rapid coronary reperfusion remains essential for myocardial salvage and preservation of ventricular function.

Coronary angiography demonstrated that the left anterior descending artery was the most frequently involved culprit vessel, while nearly one-third of patients had triple-vessel disease. Furthermore, more than 60% exhibited complex ACC/AHA Type B2 or Type C lesions with significant calcification and thrombus burden [26].

These observations closely resemble the findings reported in the SYNTAX Trial, where increasing lesion complexity was associated with reduced procedural success, incomplete revascularization, recurrent ischemia and higher long-term mortality. Similarly, a study demonstrated that heavily calcified lesions, bifurcation disease, chronic total occlusions and diffuse coronary disease significantly increase procedural difficulty and adverse cardiovascular events after PCI [27,28].

The current study also demonstrated that Type C lesions independently reduced the likelihood of favorable clinical outcomes, emphasizing the importance of lesion morphology in determining procedural success. These findings support the current recommendations of the ACC/AHA Coronary Revascularization Guidelines, which emphasize comprehensive angiographic assessment before intervention [29].

Antithrombotic therapy remains one of the most important determinants of successful PCI outcomes. In the present study, patients receiving potent P2Y12 inhibitors (ticagrelor or prasugrel) achieved significantly higher treatment success and lower rates of stent thrombosis and MACE than those receiving clopidogrel [30]. These findings are highly consistent with the PLATO Trial, where ticagrelor significantly reduced cardiovascular death, myocardial infarction and stroke compared with clopidogrel without an unacceptable increase in major bleeding [31,32]. Likewise, many studies demonstrated superior ischemic protection with prasugrel among acute coronary syndrome patients undergoing PCI. Both studies established potent platelet inhibition as the standard of care for moderate- and high-risk acute coronary syndrome patients [33].

Although a slightly higher incidence of bleeding was observed among patients receiving potent antiplatelet agents in the present study, this difference did not reach statistical significance. Similar observations have been reported by Wallentin et al. and Wiviott et al., suggesting that the overall clinical benefit of potent platelet inhibition generally outweighs the modest increase in bleeding risk when patients are appropriately selected.

One of the most important findings of this study was the excellent procedural success rate, with restoration of TIMI III coronary flow in more than 90% of patients. Restoration of normal epicardial coronary blood flow remains the primary objective of PCI because it limits infarct size, preserves myocardial function and improves survival.The present findings are consistent with those reported by previous studies which demonstrated that successful reperfusion significantly reduces recurrent myocardial infarction, heart failure and mortality[34,35]. Furthermore, multivariable analysis identified TIMI III flow as the strongest independent predictor of favorable clinical outcomes, increasing the probability of successful recovery by more than threefold.

Similarly, complete revascularization independently improved clinical outcomes in the present study. This observation closely resembles the results of the COMPLETE Trial, which demonstrated that complete coronary revascularization significantly reduces cardiovascular death and recurrent myocardial infarction compared with culprit-only PCI in patients with multivessel disease.

The incidence of major adverse cardiovascular events in the present study remained relatively low despite the inclusion of patients with complex coronary anatomy. Heart failure represented the most common adverse event, whereas reinfarction, stent thrombosis, stroke and mortality occurred infrequently [35].

Comparable event rates have been reported in the EXCEL, SYNTAX and ISCHEMIA trials, where advances in second-generation drug-eluting stents, improved procedural techniques, intravascular imaging and optimized pharmacotherapy substantially reduced post-PCI complications. The low incidence of stent thrombosis observed in the present study further reflects the effectiveness of contemporary dual antiplatelet therapy and high procedural success [36,37].

Multivariable logistic regression identified restoration of TIMI III flow, complete revascularization, preserved left ventricular systolic function and potent antiplatelet therapy as independent predictors of favorable clinical outcomes. Conversely, advanced age, diabetes mellitus and Type C coronary lesions significantly reduced the probability of successful recovery.

These findings closely parallel previous investigations from the SYNTAX, GRACE and

PLATO studies, which consistently identified successful myocardial reperfusion, preserved ventricular function and optimal pharmacological therapy as major determinants of long-term survival after PCI [38]. Advanced age and diabetes have repeatedly been associated with diffuse coronary disease, impaired endothelial repair, greater inflammatory burden and increased susceptibility to recurrent ischemic events.

The findings of the present study have important implications for contemporary interventional cardiology practice. Early coronary angiography with prompt PCI should remain the preferred reperfusion strategy for eligible acute coronary syndrome patients. Comprehensive assessment of lesion complexity, thrombus burden and coronary anatomy before intervention is essential for procedural planning and risk stratification [39,40]. Guideline-directed dual antiplatelet therapy using ticagrelor or prasugrel should be considered whenever appropriate because of its superior efficacy in reducing recurrent ischemic events and stent thrombosis. Furthermore, achieving complete revascularization and optimal myocardial reperfusion should remain primary procedural goals to maximize long-term cardiovascular outcomes. High-risk patients—including elderly individuals, diabetics and those with complex coronary lesions require closer follow-up and individualized management to reduce future cardiovascular events.

STRENGTHS AND LIMITATIONS

The strengths of the study include the comprehensive evaluation of coronary pathophysiology, angiographic lesion complexity, antithrombotic therapy, procedural outcomes and multivariable predictors within a single cohort of acute coronary syndrome patients undergoing PCI. The study also provides clinically relevant evidence regarding factors influencing successful coronary intervention.

However, several limitations should be acknowledged. The cross-sectional design precludes determination of long-term causal relationships. Clinical outcomes were limited to the in-hospital period, long-term follow-up for recurrent myocardial infarction, repeat revascularization and cardiovascular mortality was not available. Additionally, the single-center design may limit generalizability to other populations. Future multicenter prospective studies with extended follow-up are warranted to validate these findings and further define optimal strategies for improving PCI outcomes in acute coronary syndrome patients.

The study concluded that patients with acute coronary syndrome undergoing percutaneous coronary intervention, successful myocardial reperfusion, complete revascularization, guideline-directed antithrombotic therapy were associated with significantly improved in-hospital outcomes and reduced major adverse cardiovascular events. Lesion complexity and patient-related factors such as advanced age and diabetes mellitus adversely influenced prognosis. These findings underscore the importance of individualized risk stratification, careful assessment of coronary lesion characteristics, optimization of antithrombotic therapy to maximize procedural success, improve both short-term and long-term cardiovascular outcomes following PCI.

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