Article Impact Level: HIGH Data Quality: STRONG Summary of New England Journal of Medicine https://doi.org/10.1056/NEJMoa2512918 Dr. Robin Nijveldt et al.
Points
- An acute heart attack requires immediate stenting of the blocked coronary artery to prevent heart muscle damage.
- A study with 1,146 participants found that delaying treatment of other narrowed coronary arteries for up to six weeks is safe.
- Deferring treatment led to half as many additional stent procedures compared to immediate intervention, without affecting outcomes.
- Cardiologists used MRI scans in the deferred group to assess overall blood flow, determining if additional stenting was truly necessary.
- Current guidelines recommending immediate full treatment for multivessel disease in STEMI patients may require revision based on these findings.
Summary
This international, investigator-initiated, open-label, randomized, controlled trial (iMODERN, NCT03298659) investigated the optimal timing for treating nonculprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease following successful primary percutaneous coronary intervention (PCI). A total of 1146 patients (mean age 63±11 years; 78% men) were randomized 1:1 to either immediate instantaneous wave-free ratio (iFR)-guided PCI (for lesions >50% stenosis with iFR ≤0.89) or deferred cardiac stress magnetic resonance imaging (MRI)-guided PCI within 6 weeks.
The primary endpoint was a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure at 3-year follow-up. The results indicated no significant difference between the groups, with primary endpoint events occurring in 50 patients (9.3%) in the iFR group and 55 patients (9.8%) in the MRI group (hazard ratio, 0.95; 95% confidence interval, 0.65 to 1.40; P=0.81). Notably, 237 of 556 patients (42.6%) in the iFR group underwent nonculprit-lesion PCI, compared to only 110 of 587 patients (18.7%) in the MRI group.
Serious adverse events were reported in 145 patients in the iFR group and 181 in the MRI group. The findings demonstrate that immediate iFR-guided PCI is not superior to deferred cardiac stress MRI-guided PCI for nonculprit coronary-artery lesions in terms of long-term clinical outcomes. This suggests that a deferred approach, potentially guided by non-invasive imaging, can significantly reduce the number of stent procedures without compromising patient safety, offering crucial evidence for re-evaluating current STEMI treatment guidelines.
Link to the article: https://www.nejm.org/doi/10.1056/NEJMoa2512918
References
Nijveldt, R., Maeng, M., Beijnink, C. W. H., Piek, J. J., Al-Lamee, R. K., Raposo, L., Baptista, S. B., Escaned, J., Davies, J., Klem, I., Yosofi, B., Van Geuns, R.-J. M., Frederiksen, C. A., Jakobsen, L., El Barzouhi, A., Van Der Heijden, D. J., Ilhan, M., Rasoul, S., Brinckman, S., … Van Royen, N. (2025). Immediate or deferred nonculprit-lesion pci in myocardial infarction. New England Journal of Medicine, NEJMoa2512918. https://doi.org/10.1056/NEJMoa2512918
