AIR-STEMI: physiology-guided complete revascularisation beat angiography-guided

Design

International randomised trial, physiology-guided vs angiography-guided complete revascularisation

Population

1,823 patients with STEMI and multivessel disease after successful culprit treatment

Primary outcome

Death, myocardial infarction, stroke or TIA, or ischaemia-driven revascularisation

Effect

8.9% vs 13.7%; HR 0.62 (95% CI 0.47 to 0.83), median follow-up 17.9 months

In this international randomised trial, 1,823 patients with STEMI and multivessel disease, whose culprit lesion had been treated successfully, were assigned to complete revascularisation guided by functional coronary angiography (913) or by conventional angiography (910). Median age was 66 years and 24% were women.

At a median follow-up of 17.9 months, the primary composite of death, myocardial infarction, stroke or transient ischaemic attack, or ischaemia-driven revascularisation occurred in 81 patients (8.9%) with physiology guidance and 125 (13.7%) with angiography guidance (HR 0.62, 95% CI 0.47 to 0.83). The safety composite of contrast-associated acute kidney injury or major bleeding was also lower: 4.6% vs 7.1% (HR 0.63, 0.43 to 0.93).

Complete revascularisation is already recommended in this setting; the trial addresses how to choose which non-culprit lesions to treat. Whether the finding generalises depends on access to functional angiography, which is not widely available, and on how the composite was driven. The abstract does not break the composite into its components.

• In STEMI with multivessel disease, how non-culprit lesions are chosen may matter as much as whether they are treated.
• Functional coronary angiography guidance lowered the composite of death, MI, stroke/TIA or ischaemia-driven revascularisation.
• The safety composite of contrast-associated AKI or major bleeding was also lower with physiology guidance.
• Check local availability: this technique is not routine in many Indian cath labs, so the practical step is discussion with your interventional team.

Why it matters

It shifts the question in complete revascularisation from whether to treat other vessels to how to choose them.

Don't overread it

The abstract gives no component breakdown, and the composite includes softer endpoints such as ischaemia-driven revascularisation.

The statistics, in plain English

A hazard ratio of 0.62 with an interval of 0.47 to 0.83 means the physiology-guided group had roughly a third fewer composite events across follow-up, and the interval excludes no difference. The composite mixes outcomes of different weight, such as death and repeat revascularisation, so the headline does not tell you which component moved.

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