In patients with STEMI and multivessel coronary artery disease, a strategy of complete coronary-artery revascularization guided by functional coronary angiography resulted in a lower risk of death, myocardial infarction, cerebrovascular accident, or ischemia-driven revascularization than a strategy guided by conventional angiography.
Key Findings
Results
Physiology-guided complete revascularization significantly reduced the composite primary outcome compared to angiography-guided revascularization in STEMI patients with multivessel disease.
Primary outcome events occurred in 81 patients (8.9%) in the physiology-guided group versus 125 patients (13.7%) in the angiography-guided group.
Hazard ratio of 0.62 (95% CI, 0.47 to 0.83; P<0.001) favoring the physiology-guided strategy.
The primary outcome was a composite of death from any cause, myocardial infarction, cerebrovascular accident (stroke or transient ischemic attack), or ischemia-driven revascularization.
Median follow-up was 17.9 months.
1823 patients were randomized: 913 to the physiology-guided group and 910 to the angiography-guided group.
Results
Physiology-guided revascularization was also associated with improved safety outcomes compared to angiography-guided revascularization.
Primary safety outcome events occurred in 42 patients (4.6%) in the physiology-guided group versus 65 patients (7.1%) in the angiography-guided group.
Hazard ratio of 0.63 (95% CI, 0.43 to 0.93; P=0.02) favoring the physiology-guided strategy.
The primary safety outcome was a composite of contrast-associated acute kidney injury or major bleeding.
The safety benefit suggests physiology-guided strategy may reduce unnecessary interventions and associated procedural risks.
Methods
The trial enrolled a broadly representative STEMI population with multivessel disease across international sites.
The median age of patients was 66 years (interquartile range, 58 to 76).
24% of enrolled patients were women.
The study was an international, randomized trial (AIR-STEMI, NCT05818475).
Patients were eligible after successful treatment of the culprit lesion.
The trial was funded by the Italian Health Ministry and others.
Background
Complete revascularization guided by functional coronary angiography (physiology-guided) was compared to conventional angiography-guided complete revascularization for nonculprit lesion identification in STEMI.
The preferred strategy for identifying nonculprit lesions that warrant treatment in STEMI with multivessel disease had remained uncertain prior to this trial.
Complete coronary-artery revascularization is recommended in patients with STEMI and multivessel disease per existing guidelines.
Functional coronary angiography was used to guide decisions about which nonculprit lesions to treat in the physiology-guided group.
Conventional angiography alone guided nonculprit lesion treatment decisions in the control group.
What This Means
This research addresses a common clinical challenge: when someone has a heart attack (STEMI), they often have blockages in multiple heart arteries, not just the one that caused the heart attack. Doctors agree that treating these additional blockages (called nonculprit lesions) is beneficial, but it was unclear whether standard visual assessment of the arteries using X-ray imaging (angiography) or a more sophisticated physiological measurement of blood flow through those arteries was the better approach for deciding which blockages to treat. This large international trial randomly assigned 1,823 heart attack patients to have their additional blockages treated based on either physiological flow measurements (functional coronary angiography) or conventional visual imaging alone.
The study found that patients whose treatment decisions were guided by physiological measurements had substantially better outcomes. About 9% of patients in the physiology-guided group experienced a major adverse event (death, another heart attack, stroke, or need for repeat revascularization) compared to nearly 14% in the conventional angiography group — a 38% relative reduction in risk. Importantly, the physiology-guided approach was also safer, with fewer cases of kidney injury from contrast dye and major bleeding (4.6% vs. 7.1%), suggesting that this approach may help avoid unnecessary procedures while still treating the blockages that truly matter.
This research suggests that using functional physiological measurements, rather than visual appearance alone, to decide which additional coronary blockages to treat after a heart attack leads to meaningfully better patient outcomes over roughly 18 months of follow-up. The findings have the potential to change clinical practice by supporting a more precise, measurement-driven approach to complete revascularization in heart attack patients with multiple diseased arteries.
Biscaglia S, Erriquez A, Colaiori I, Hakeem A, Mantovani F, Menozzi M, et al.. (2026). Complete Revascularization Guided by Functional Coronary Angiography in STEMI.. The New England journal of medicine. https://doi.org/10.1056/NEJMoa2605373