Key result
Functional angiography-guided complete revascularization reduces major events ~38% compared to conventional angiography.
Why the trial?
Complete revascularisation benefits STEMI patients with multivessel disease, but how best to select non-culprit lesions is unsettled. AIR-STEMI asked whether functional coronary angiography (angiography-derived FFR) guides complete revascularisation better than conventional angiographic assessment.
Does complete coronary-artery revascularization guided by functional coronary angiography reduce the composite of death, MI, stroke, or ischemia-driven revascularization in patients with STEMI and multivessel disease compared to conventional angiography guidance?
Population
1,823 patients with STEMI + multivessel disease after successful culprit-lesion PCI
Comparison
Functional angiography-guided vs conventional angiography-guided complete revasc.
Design
International multicenter randomized trial; blinding not described
Follow-up
Median 17.9 months
Authors
Congrats to the investigators! AIR-STEMI shows angio-FFR with virtual PCI cuts MACE (HR 0.62) and AKI/bleeding (HR 0.63) vs visual angiography in STEMI. Only 20–23% of non-culprit lesions were intermediate (50–69%), yet physiology safely halved PCIs (52% vs 95%) even in angiographically severe disease. Caveats include offline core-lab reliance, top-center volume leverage, bundled deferral/planning, excluded complex anatomies (LM, CTOs), low female representation (24%).
Experts broadly read AIR-STEMI as a strong signal that physiology-guided complete revascularisation should replace eyeball angiography in STEMI with multivessel disease, though some question whether the benefit comes from smarter stenting or simply fewer stents.
Most clinicians welcome the result and see it as evidence that functional assessment of non-culprit lesions after STEMI should become standard practice. A smaller but notable thread questions the mechanism: some argue the benefit may owe more to avoiding unnecessary stents than to identifying ischaemia. Open questions remain about hard endpoints like mortality alone, procedural cost, and whether the early curve separation reflects spontaneous MI or another driver.
Multiple clinicians agree the trial supports moving from conventional angiography to physiology-guided decision-making for non-culprit lesions in STEMI with multivessel disease.
What they’re arguing about
supportiveneutralcautiouscritical
Counts are expert takes we classified by axis. Tap a row to see the takes behind its count.
Several experts want to see whether the benefit holds for hard endpoints such as death and MI alone, and what the cost and procedural-time implications are. One expert flags that the early separation of the event curves raises questions about when spontaneous MIs occurred and whether the mechanism is truly physiology-guided selection or simply fewer stents and fewer stent-related complications.
Calls the result important and says it supports moving beyond eyeballing lesions in the acute setting. Flags that cost, procedural time, and hard endpoints need further scrutiny before full adoption.
Argues AIR-STEMI is very interesting but perhaps not for the reason suggested by its title. Frames the takeaway as reducing unnecessary intervention rather than simply layering on a new tool.
Heerajnarain BulluckInterventional / Structural Cardiology · Leeds General Infirmary, Leeds Teaching Hospitals NHS TrustContextAug 30Frames the clinical problem clearly: once the culprit artery has been opened in STEMI, deciding which remaining blockages actually need a stent is the critical question AIR-STEMI set out to answer.
Physiology-guided complete revascularization improves outcomes in STEMI with multivessel disease; extends prior recommendations by favoring functional over conventional angiography.
| Outcome | FCA-guided | Angio-guided |
|---|---|---|
| Death, MI, stroke/TIA, or ischemia-driven revascularization | 81/913 (8.9%) | 125/910 (13.7%) |
| HR 0.62 (95% CI 0.47-0.83; P<0.001) · individual components not reported in the record | ||
Safety
Contrast-associated AKI or major bleeding (primary safety outcome) 42/913 (4.6%) vs 65/910 (7.1%); HR 0.63 (95% CI 0.43-0.93; P=0.02).
Statistical certainty
component-level results of the primary composite are not reported in the record, so what drove the benefit is unclear.
Design limitations
ischemia-driven revascularization, a composite component, is susceptible to bias since blinding is not described, and median follow-up of 17.9 months is relatively short.
Does complete coronary-artery revascularization guided by functional coronary angiography reduce the composite of death, MI, stroke, or ischemia-driven revascularization in patients with STEMI and multivessel disease compared to conventional angiography guidance?
Hazard Ratio: 0.62 (95% CI 0.47–0.83)
Absolute Event Rate: 8.9% vs 13.7%
p-value: p=<0.001
In STEMI patients with multivessel disease, guiding complete revascularization with functional coronary angiography significantly reduces the composite risk of death, MI, stroke, or ischemia-driven revascularization compared to conventional angiography.
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Biscaglia et al. (2026) conducted an RCT in STEMI and multivessel disease (n=1,823). Functional coronary angiography-guided complete revascularization vs. Conventional angiography-guided complete revascularization was evaluated on composite of death from any cause, myocardial infarction, cerebrovascular accident (stroke or transient ischemic attack), or ischemia-driven revascularization (HR 0.62, 95% CI 0.47-0.83, p=<0.001). Functional angiography-guided complete revascularization reduced death, MI, stroke, or ischemia-driven revascularization compared to conventional angiography (HR 0.62; 95% CI 0.47-0.83; P<0.001).
