Physiology beats the picture in STEMI revascularisation

The edition in brief

AIR-STEMI randomised 1,823 patients with STEMI and multivessel disease to complete revascularisation guided by coronary physiology or by angiography alone. The physiology-guided strategy cut the composite of death, myocardial infarction, stroke and ischaemia-driven revascularisation to 8.9% from 13.7% (hazard ratio 0.62, 95% CI 0.47–0.83), with fewer contrast-related and bleeding events. SINGLE-AF, an open-label Korean trial of 1,803 patients with atrial fibrillation at intermediate stroke risk (CHA2DS2-VASc 1 in men, 2 in women), found a DOAC lowered a composite of stroke, embolism, major bleeding or cardiovascular death to 0.5% from 1.5% at two years (hazard ratio 0.31, 95% CI 0.10–0.94) — a 1-percentage-point absolute gain against very low event rates. ULYSSES randomised 986 patients to ultrasound-guided or palpation-guided femoral venous puncture for AF ablation; access-site complications fell to 0.6% from 3.3% (risk ratio 0.19), with far fewer arterial punctures and failed attempts, and it stopped early for efficacy. A clinic pearl: start the full secondary-prevention bundle during the ACS admission, because therapy not begun in hospital often never starts. Finally, the COMBINE AF patient-level analysis (10,212 Asian and 61,471 non-Asian patients) found standard-dose DOACs reduced stroke, major bleeding and the net clinical outcome more in Asian than non-Asian patients, without the excess gastrointestinal bleeding seen in non-Asians, while lower-dose DOACs raised stroke risk (hazard ratio 1.57) — so standard-dose DOACs, not reflexive dose reduction, are preferred in Asian patients who meet no reduction criterion.