Functional Coronary Angiography-Guided Complete Revascularization Reduces Major Events in STEMI: NEJM
Italy: A recent study published in the New England Journal of Medicine reports that among patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease, complete revascularization guided by functional coronary angiography significantly reduced major cardiovascular events compared with a conventional angiography-guided strategy.
The AIR-STEMI trial findings suggest that incorporating functional assessment of coronary lesions may help optimize revascularization decisions and improve clinical outcomes in this high-risk patient population.
The study, led by Simone Biscaglia of the Cardiovascular Institute, Azienda Ospedaliero Universitaria di Ferrara, Cona, Italy, and colleagues, addressed uncertainty about how best to identify nonculprit coronary lesions that require treatment after successful treatment of the culprit artery in STEMI.
The international randomized trial included 1,823 patients with STEMI and multivessel disease whose culprit lesion had been successfully treated. Participants were randomly assigned to undergo complete coronary revascularization based either on functional coronary angiography or conventional angiographic assessment. The median patient age was 66 years, with women accounting for 24% of the study population.
In the physiology-guided strategy, functional assessment was used to determine which additional coronary lesions warranted revascularization, whereas the angiography-guided approach relied on conventional visual assessment of the coronary arteries.
The primary efficacy outcome was a composite of death from any cause, myocardial infarction, stroke or transient ischemic attack, and ischemia-driven revascularization. The primary safety outcome included contrast-associated acute kidney injury or major bleeding.
The trial led to the following findings:
- After a median follow-up of 17.9 months, major cardiovascular events occurred in 8.9% of patients receiving physiology-guided revascularization versus 13.7% receiving conventional angiography-guided treatment (HR, 0.62).
- The physiology-guided strategy was associated with a 38% lower risk of the primary cardiovascular outcome compared with conventional angiography.
- The primary safety outcome occurred in 4.6% of patients in the physiology-guided group compared with 7.1% in the angiography-guided group (HR, 0.63).
- Overall, functional coronary angiography was associated with lower risks of both major cardiovascular events and the composite safety outcome.
The findings indicate that using functional information to guide treatment of nonculprit lesions may offer advantages over relying solely on angiographic appearance when performing complete revascularization in patients with STEMI and multivessel coronary disease.
The researchers concluded that functional coronary angiography-guided complete revascularization significantly lowered the risk of death, myocardial infarction, cerebrovascular events, or ischemia-driven revascularization compared with conventional angiography-guided treatment. The strategy also reduced the risk of the composite safety outcome, supporting further consideration of physiology-guided decision-making during complete revascularization in STEMI.
Reference:
DOI: 10.1056/NEJMoa2605373
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