Thank you so much, Roxana. This was an excellent summary. It's really, I think we're all confused. I mean, to be honest with you, so many permutations, so many time variables. So what do you do in practice? Well, I think what I do, and I think what I tell everybody is that we still have to be clinicians and think about that risk of the patient in terms of their bleeding and ischemic risk. And I usually show this four quadrants, where do they all belong? There is high bleeding risk and high ischemic risk. That's where it's the most difficult, where you really, really have to think about some of these novel strategies and maybe guided de-escalation. But it's a lot easier if they're at low risk for bleeding, high risk for thrombosis, where you really should not be rationing dual antiplatelet therapies and even thinking about escalating or even prolonging dual antiplatelet therapy in some of those patients. And those who are at high bleeding risk, less is more. We're seeing that over and over again, short duration, as short as one month. The MasterDAP study showed that where you really can stop after a month. And I think that really is where we're going. And in those patients who are at both low bleeding and low ischemic risk, I think you just follow the guidelines and think about it as you can. But those patients are rare. Most of our patients now are either at high bleeding risk or high ischemic risk or both. And so we still have to do a lot of thinking. And I think this area really opens up a great place for artificial intelligence, machine learning, and precision medicine. And this is one of the projects I'm working on right now, where we are constantly feeding into the machine what's going on with the decisions we're making and its consequences, whether we are following guidelines or not. And at the moment, the guidelines are very much associated with the clinical trials that are in front of us. And that is the way we write the guidelines, based on what's there and what evidence is there, and a little bit of a consensus amongst the people who are part of that. But there is no question that not one size fits all. And we have to still have our thinking cap on and thinking about these patients to see what we should do. Just today, I received a phone call from a very, very good private practitioner who said, I have a patient who's three years post CABG, and I've been doing CTAs, and his left main is getting very, very tight. And I said, well, isn't he bypassed? And he says, well, no, I have him on DAPT. I'm very worried about him. And I was thinking that maybe I can go to a single antiplatelet therapy. Can I just go to clopidogrel? And I said, well, you know, the data shows it, but you don't really have guidelines. The guidelines say aspirin indefinitely, but I probably would choose clopidogrel if you're really worried about his multiple ischemic findings, and maybe even keep him on DAPT if he's done well. So, you know, there is a lot of ways that you could evaluate this. I don't really have clear answers for anyone because I think it is confusing. Thank you, Roxana. Tom, can you unmute yourself? So any questions? No, that's terrific. I mean, I think that I agree with everything Roxana said, you know, one of the most important innovations of this guideline, and indeed, like much of the recent thinking about this is, as you point out, Mauricio, there's a nearly infinite set of permutations of drug and time and combinations. And so, you know, in that context, we could test every possible combination of drug and time, or we could sort of apply some first principles, which is to say that, you know, in the old days, it was pretty binary, you got a you got PCI, and you got a certain duration of therapy. And I think now the onus is really on all of us as clinicians to at the patient level assess ischemic risk and bleeding risk. And, you know, I've heard someone say it's as close to a natural law as possible, where, you know, you can't reduce ischemic risk without increasing bleeding risk, and vice versa, right? So you're always going to weigh that balance. And so the key is to get it right at the patient level. I think time is your friend, you know, we have the luxury often of time in the clinic to follow up our patients and see if they're tolerating therapy or not. And the only other nuance I throw into the mix is that some factors, not all of them, but some both bleeding and ischemic risk factors are dynamic and reversible. So, you know, if they had an ulcer, and they treated it, maybe they were high bleeding risk, but they are no longer, you know, vice versa, maybe they had risk factors well controlled, and now they're out of control. So it adds another layer of complexity to it. But the sentiment is the same, which is to say, whereas before it was more binary go or no go for therapy, now we have many, many options, which means that we have to have really nuanced decision making the patient level. And, you know, I guess also, it takes a team, doesn't it? It takes the cardiologist, the interventionalist, the surgeon, the patient, the primary care doc, all these folks are working together to make these decisions. But right, it's super complex. But the paradigm is really nice, right? So bleeding risk, ischemic risk, and you have to wait those in some in some. Okay, perfect. So one questions for Selena. So Selena, can you unmute yourself? So what do you think? Do you think we should do everybody with imaging at this? With all we know, do you think that, you know, we did a radial push a few years ago with Sunil and company to transform everybody to go radial? Do you think that we now have to push everybody to go imaging? I don't think we have to do imaging in every single PCI. I think it's particularly useful when we're doing left main, proxy LAD, complex lesions, anything that we, especially some of our patients are, there's very difficult imaging in terms of just angiographic visualization. But it adds some time to it a little bit of complexity sometimes. And so I think it's most useful when these are the highest risk lesions that we were treating. And I think we need to combine our understanding of functional assessment in combination with our procedural optimization with imaging. So do you think that then the next guidelines imaging will be a 1A patient? You know, there've been so many studies, so many studies, and we haven't seen a convincing signal for mortality improvement anyway. And that really drove our decision to call it improvement in ischemic events. I'm not sure it's going to change, but there's tremendous advancements as we speak with the imaging itself. And I think we're constantly getting better at the way we use it. So I think it will continue to be a great tool for our complex PCI.

pharmaceutical therapy

bleeding

ischemic events

personalized approach

artificial intelligence