Physiology-guided complete revascularisation in STEMI, transcatheter tricuspid repair in heart failure, and a randomised test of anticoagulation at intermediate AF risk

The edition in brief

AIR-STEMI randomised 1,823 patients with STEMI and multivessel disease to complete revascularisation guided by functional coronary angiography or by conventional angiography; the primary composite occurred in 8.9% vs 13.7% (HR 0.62, 95% CI 0.47 to 0.83) at a median 17.9 months. TRIC-I-HF randomised 360 patients, mean age 80, with symptomatic severe tricuspid regurgitation to transcatheter repair plus medical therapy or medical therapy alone; the win ratio at 1 year was 2.42 (1.76 to 3.33) and freedom from death or heart-failure hospitalisation at 3 years was 52.4% vs 21.0% (HR 0.40). A pooled patient-level analysis of heart-failure cohorts found that the association of mineralocorticoid receptor antagonist use with outcomes depended on baseline aldosterone, favourable when high (HR 0.63) and unfavourable when low (HR 1.66); the authors call this hypothesis-generating. A prespecified BRIGHT-4 analysis found the benefit of bivalirudin over heparin in primary PCI for STEMI was clearest in low-bleeding-risk patients, with no clear difference in higher-risk patients. SINGLE-AF, an open-label trial of 1,803 Korean patients with atrial fibrillation at intermediate stroke risk, found fewer composite events with a DOAC than with no anticoagulation (0.5% vs 1.5% at 24 months; HR 0.31, 0.10 to 0.94), on very small event numbers. The edition closes with a pearl on interpreting trials with few events.