Dear Editor,

I would like to comment on the article entitled “Finding the balance: Advancing strategies for managing severely calcified coronary lesions” by Mila et al., published in Cardiovascular Revascularization Medicine, which explores a stratified approach to deferred stenting (DS) in ST-elevation myocardial infarction (STEMI) patients. The authors propose an individualized reperfusion strategy using multimodal assessments to select patients who may avoid stent implantation. While the study offers a hypothesis-generating perspective, we identified several concerns warranting discussion.

The study reports a significantly lower stent implantation rate in the DS group (10.5 % vs. 97.7 % in the control group, p < 0.001), attributing this to careful patient selection guided by coronary angiography, intravascular imaging, and physiological assessments. However, the criteria for assigning patients to the DS group appear inconsistently applied. The authors state that patients failing to meet reperfusion criteria (e.g., TIMI 3 flow, >70 % ST-segment resolution) were allocated to the control group, yet Fig. 3 indicates that 51.1 % of control group patients underwent immediate stenting due to suboptimal angiographic results. This raises questions about how DS patients with similar characteristics were selected. Could the authors clarify the specific clinical or imaging parameters that consistently distinguished DS candidates from controls?