Physiology-guided revascularization improves heart attack outcomes

In selected patients with major heart attack and multivessel disease, physiology-guided complete revascularization reduced clinical events and safety complications.
*Randomized controlled trial; Level 2 (OCEBM).

Citation

Biscaglia S, Erriquez A, Colaiori I, et al. Complete Revascularization Guided by Functional Coronary Angiography in STEMI. New England Journal of Medicine. Published August 29, 2026. doi:10.1056/NEJMoa2605373

Background

Complete treatment of blocked heart arteries is recommended after a major heart attack when several arteries are diseased. It has been unclear whether additional artery blockages should be treated based on angiogram appearance alone or on a blood-flow assessment derived from angiogram images.

Patients

Adults hospitalized with ST-segment elevation myocardial infarction, successful treatment of the culprit blockage, and at least one untreated 50% to 99% narrowing in another artery. Key exclusions included unclear culprit lesion, left main artery nonculprit disease, planned or previous bypass surgery, or life expectancy under 1 year.

Intervention

Complete revascularization guided by functional coronary angiography; blockages with a blood-flow value of 0.80 or lower were treated, with planning aided by pullback analysis.

Control

Complete revascularization guided by conventional angiography; all nonculprit blockages of 50% or greater were treated.

Outcome

Primary outcome: death, myocardial infarction, stroke or transient ischemic attack, or ischemia-driven revascularization. Safety outcome: contrast-related acute kidney injury or major bleeding.

Follow-up Period

Median 17.9 months.

Results

Outcome Physiology-guided Angiography-guided Effect
Primary composite 81/913 (8.9%) 125/910 (13.7%) HR 0.62 (95% CI 0.47 to 0.83); NNT 21
Cardiovascular death or myocardial infarction 52/913 (5.7%) 96/910 (10.5%) HR 0.52 (95% CI 0.37 to 0.73); NNT 21
Myocardial infarction 35/913 (3.8%) 73/910 (8.0%) HR 0.47 (95% CI 0.31 to 0.70); NNT 24
Safety composite 42/913 (4.6%) 65/910 (7.1%) HR 0.63 (95% CI 0.43 to 0.93); NNT 40

HR: hazard ratio; CI: confidence interval; NNT: number needed to treat.

Analyses were intention-to-treat. Secondary outcomes were not adjusted for multiple comparisons. Conventional angiography-guided complete revascularization reflects widely used current care.

Limitations

The trial was open-label, and repeat revascularization was part of the primary outcome, which may introduce bias. The approach combined lesion selection and procedure planning, so their separate effects are unknown. Central laboratory analysis, selected anatomy, and adequate image quality may limit routine generalizability.

Funding

Italian Health Ministry; unrestricted industry funding/software, without sponsor trial role.

Clinical Application

For eligible patients, consider physiology-guided complete revascularization when available; evidence supports fewer events than angiography-guided treatment but depends on expertise and software.