The edition · Cardiology
Physiology, not the picture: guiding complete revascularisation in STEMI cut events by a third
AIR-STEMI randomised 1823 patients and found fewer events and less harm when non-culprit lesions were selected by function rather than by eye. Plus a lifetime risk model for HFpEF, and what a cyclone does to door-to-balloon time.
The edition in brief
The cardiology desk today is built around AIR-STEMI, an international randomised trial of 1823 patients with ST-elevation myocardial infarction and multivessel disease whose culprit lesion had already been treated. Choosing which non-culprit lesions to treat by functional coronary angiography rather than by the angiographic appearance reduced the composite of death, myocardial infarction, stroke or transient ischaemic attack and ischaemia-driven revascularisation from 13.7% to 8.9% over a median 17.9 months, a hazard ratio of 0.62 (95% CI 0.47-0.83). Unusually for a strategy that adds a step in the catheter laboratory, the safety composite of contrast-associated acute kidney injury or major bleeding also fell, from 7.1% to 4.6%. The LIFE-Preserved model offers individual short-term and lifetime risk of heart failure hospitalisation or cardiovascular death in heart failure with preserved ejection fraction, derived in 20,332 Swedish registry patients and externally validated in 28,062 more. Discrimination was modest - pooled C-statistic 0.714 in trials and 0.658 in registries - which is honest performance for a heterogeneous syndrome, and calibration held. A Chinese nationwide case-crossover study of 2,563,780 acute coronary syndrome presentations found a 14% higher risk of acute coronary syndrome in the 0-3 days after tropical cyclone exposure, alongside longer self-referral delay and longer admission-to-catheterisation time. An ongoing Class II recall covers a ready-to-use intravenous amiodarone presentation for manufacturing deviations. A state-of-the-art review of myocardial infarction management completes the edition.
A lifetime risk model for HFpEF, and an honest C-statistic
Use LIFE-Preserved to frame the prognosis conversation in HFpEF, not to decide who gets preventive therapy.
Cyclones raise acute coronary syndrome risk and lengthen the time to the catheter laboratory
Plan the reperfusion fallback and patient messaging before cyclone season, because presentations rise at the moment transport and catheter laboratory access get worse.
A state-of-the-art review of infarct management, with MINOCA given its own place
Make the 120-minute primary PCI threshold an explicit transport decision, and give MINOCA a defined workup rather than a label.
Ongoing Class II recall of ready-to-use intravenous amiodarone
Check your premixed amiodarone stock against the recall, and write down the dilution if you have to fall back to preparing it yourself.
If you cannot measure physiology in the non-culprit vessel, say so in the report
Document explicitly which non-culprit lesions were assessed by physiology and which by eye, so the staged operator is not guessing.
AIR-STEMI: fewer events and less harm when function picks the non-culprit lesion
In STEMI with multivessel disease and the culprit already treated, select non-culprit lesions by physiology rather than by the angiogram.
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