📄 CTO-PCI: is ischaemia still the key for patient selection? 🔗 DOI: doi.org/10.1093/ehjimp/qyaf1… 🫀 Chronic total occlusion (CTO) PCI has evolved significantly, with high success rates—but patient selection remains the real challenge. This editorial questions a long-standing paradigm: 👉 Is ischaemia enough to guide revascularization? ✨ Key insights: 🔹 CTO-PCI is associated with: ✔ improved symptoms and quality of life ❗ but no clear reduction in mortality or major events 🔹 Randomized trials show: ➡️ similar hard outcomes vs optimal medical therapy ➡️ benefit mainly in angina relief 📊 Role of ischaemia: 👉 Imaging confirms ischaemia—but: ❗ baseline ischaemic burden does NOT predict outcomes after CTO-PCI 🔹 Even patients with ≥10% ischaemia: ➡️ no difference in mortality or MACCE ➡️ but fewer angina hospitalisations ⚠️ Why ischaemia alone is insufficient: 👉 CTO physiology is complex: collateral circulation multivessel disease microvascular dysfunction 👉 SPECT may underestimate disease 👉 PET provides better quantification (MBF, MFR) 💡 Clinical paradigm shift: 👉 From “ischaemia-driven” → “symptom-driven” selection ✔ Revascularize when: refractory angina significant functional limitation 👉 Imaging role: ➡️ confirm viable, ischaemic myocardium ➡️ support—not dictate—the decision 🧠 Future directions: 🔹 PET-based quantification (MBF/MFR) 🔹 Territory-specific ischaemia assessment 🔹 Integration of patient-reported outcomes 🚨 Bottom line: CTO-PCI is a tool to improve symptoms—not to change prognosis. 👉 Treat the patient, not just the ischaemia. #Cardiology #CTO #PCI #Ischaemia #CardiacImaging #PET #CoronaryArteryDisease #InterventionalCardiology #PrecisionMedicine 🫀📊