{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T09:08:59Z","timestamp":1779872939792,"version":"3.53.1"},"reference-count":7,"publisher":"Oxford University Press (OUP)","issue":"5","license":[{"start":{"date-parts":[[2026,5,14]],"date-time":"2026-05-14T00:00:00Z","timestamp":1778716800000},"content-version":"vor","delay-in-days":14,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,4,30]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Intermediate coronary lesions without clear ischaemia should prompt physiological assessment during angiography. Angiography-derived fractional flow reserve enables rapid, wire-free evaluation of lesion significance and can guide revascularization decisions. Persistent angina despite successful percutaneous coronary intervention (PCI) should raise suspicion for concomitant microvascular dysfunction, warranting microcirculation assessment to identify the mechanism and tailor therapy. When no further epicardial target exists and symptoms remain refractory despite comprehensive medical management, coronary sinus reducer (CSR) implantation can be considered. Although these three domains have rapidly evolved over the past few years, they are rarely combined sequentially. This case report illustrates how the stepwise use of these contemporary tools, each addressing a distinct pathophysiological mechanism, led to a marked improvement in the patient\u2019s symptoms and overall clinical course.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case summary<\/jats:title>\n                    <jats:p>A 45-year-old man presented with acute coronary syndrome and underwent multivessel PCI in 2023. One year later, he re-presented with unstable angina and received optical coherence tomography-guided left main to left anterior descending artery stenting. However, symptoms persisted (Canadian Cardiovascular Society class II). Invasive coronary function testing revealed impaired vasodilatory reserve with preserved microvascular resistance and no inducible spasm, suggesting functional impairment of vasodilatory capacity. Mechanism-matched therapy with calcium-channel blockade and angiotensin-converting enzyme inhibition provided partial relief. Refractory angina ultimately led to CSR implantation with complete resolution of symptoms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>This case highlights a stepwise physiology-first approach, progressing from epicardial revascularization to ischaemia with no obstructive coronary arteries phenotyping and ultimately venous outflow modulation for refractory angina.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ehjcr\/ytag331","type":"journal-article","created":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T12:28:24Z","timestamp":1778675304000},"source":"Crossref","is-referenced-by-count":0,"title":["From angiography-derived physiology guided PCI to INOCA treatment and to coronary sinus reducer: navigating multiple pathophysiological targets in a single patient: a case report"],"prefix":"10.1093","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-9985-0776","authenticated-orcid":false,"given":"Jeremie","family":"Buri","sequence":"first","affiliation":[{"name":"Department of Cardiology, Lausanne University Hospital (CHUV) , Rue du Bugnon 46, Lausanne, Vaud CH-1011 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9659-0396","authenticated-orcid":false,"given":"Adil","family":"Salihu","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Lausanne University Hospital (CHUV) , Rue du Bugnon 46, Lausanne, Vaud CH-1011 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3637-1164","authenticated-orcid":false,"given":"Marion","family":"Dupr\u00e9","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Lausanne University Hospital (CHUV) , Rue du Bugnon 46, Lausanne, Vaud CH-1011 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandre","family":"Berger","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Lausanne University Hospital (CHUV) , Rue du Bugnon 46, Lausanne, Vaud CH-1011 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9422-9521","authenticated-orcid":false,"given":"Stephane","family":"Fournier","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Lausanne University Hospital (CHUV) , Rue du Bugnon 46, Lausanne, Vaud CH-1011 ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,5,14]]},"reference":[{"key":"2026052704520862000_ytag331-B1","first-page":"308","article-title":"Diagnostic performance of angiography-derived fractional flow reserve in patients with NSTEMI","volume":"101","author":"Skalidis","year":"2023","journal-title":"Catheter Cardiovasc Interv"},{"key":"2026052704520862000_ytag331-B2","doi-asserted-by":"crossref","first-page":"131663","DOI":"10.1016\/j.ijcard.2023.131663","article-title":"Head-to-head comparison of two angiography-derived fractional flow reserve techniques in patients with high-risk acute coronary syndrome: a multicenter prospective study","volume":"399","author":"Skalidis","year":"2024","journal-title":"Int J Cardiol"},{"key":"2026052704520862000_ytag331-B3","first-page":"692","article-title":"Head-to-head comparison of learning curves between QFR and FFRangio software users","volume":"105","author":"Salihu","year":"2025","journal-title":"Catheter Cardiovasc Interv"},{"key":"2026052704520862000_ytag331-B4","doi-asserted-by":"crossref","first-page":"oeaf105","DOI":"10.1093\/ehjopen\/oeaf105","article-title":"The impact of virtual fractional flow reserve on revascularization strategy in ST-elevation myocardial infarction with multivessel disease","volume":"5","author":"Skalidis","year":"2025","journal-title":"Eur Heart J Open"},{"key":"2026052704520862000_ytag331-B5","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1056\/NEJMoa0807611","article-title":"Fractional flow reserve versus angiography for guiding percutaneous coronary intervention","volume":"360","author":"Tonino","year":"2009","journal-title":"N Engl J Med"},{"key":"2026052704520862000_ytag331-B6","doi-asserted-by":"crossref","first-page":"709","DOI":"10.1016\/j.cjco.2022.04.009","article-title":"A practical approach to invasive testing in ischemia with no obstructive coronary arteries (INOCA)","volume":"4","author":"Bastiany","year":"2022","journal-title":"CJC Open"},{"key":"2026052704520862000_ytag331-B7","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1056\/NEJMoa1402556","article-title":"Efficacy of a device to narrow the coronary sinus in refractory angina","volume":"372","author":"Verheye","year":"2015","journal-title":"N Engl J Med"}],"container-title":["European Heart Journal - 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