Guiding non-culprit PCI by functional angiography cut major events after STEMI

Design

International, randomised controlled trial (AIR-STEMI)

Population

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

Primary outcome

Death, MI, stroke or TIA, or ischaemia-driven revascularisation

Effect

8.9% vs 13.7%; HR 0.62 (95% CI 0.47–0.83), median 17.9 months

AIR-STEMI randomised 1,823 patients with STEMI and multivessel disease, after successful culprit-lesion treatment, to complete revascularisation guided by functional coronary angiography (a physiology estimate derived from the angiogram, with no pressure wire) or by conventional angiography alone. Median age was 66.

At a median 17.9 months, death, MI, stroke or TIA, or ischaemia-driven revascularisation occurred in 8.9% with physiology guidance and 13.7% with angiography guidance (HR 0.62, 95% CI 0.47 to 0.83). Contrast kidney injury or major bleeding was also lower (4.6% vs 7.1%, HR 0.63, 0.43 to 0.93).

Complete revascularisation after STEMI is already standard; the question was how to choose which non-culprit lesions to treat. Functional angiography needs no wire and no extra drug, so it may be feasible in centres that rarely use pressure wires. Cardiologists will act on this; everyone else will see its effect on who gets stented after a heart attack.

• After STEMI with multivessel disease, selecting non-culprit lesions by angiography-derived physiology (functional coronary angiography) reduced major events compared with visual assessment.
• Functional coronary angiography is computed from the angiogram and needs no pressure wire.
• Safety was better too: fewer contrast kidney injuries and major bleeds.
• Patients after STEMI should be told whether further stenting is planned and why.

Why it matters

It replaces the operator's eye with a measurement for one of the commonest decisions after a heart attack.

Don't overread it

The composite includes repeat revascularisation; the abstract does not report death or MI separately. The comparator was conventional angiography, not pressure-wire assessment, so the result does not extend to wire-based physiology.

The statistics, in plain English

A hazard ratio of 0.62 means about 38% fewer events. In absolute terms, 4.8 fewer patients in 100 had an event over about 18 months, so about 21 patients needed physiology guidance to prevent one event. The composite includes repeat revascularisation, which is softer than death or MI.

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