Functional Angiography Reduces Cardiovascular Events in AIR-STEMI Trial

Functional coronary angiography significantly reduced cardiovascular events and improved safety compared with conventional angiography in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, according to findings from the AIR-STEMI trial presented at ESC Congress 2026 and published simultaneously in the New England Journal of Medicine.

European Society of Cardiology Guidelines for STEMI and Multivessel Disease

Multivessel coronary artery disease affects nearly half of patients experiencing a STEMI. European Society of Cardiology guidelines recommend treating the culprit lesion that caused the heart attack as well as non-culprit lesions using percutaneous coronary intervention (PCI) to achieve complete revascularization, though selecting which non-culprit lesions require treatment is typically based on conventional angiography.

Associate Professor Simone Biscaglia at University Hospital of Ferrara

Associate Professor Simone Biscaglia from University Hospital of Ferrara, Italy, explained the trial’s rationale by noting that traditional coronary angiography offers a two-dimensional, subjective picture that is interpreted by the human eye, making it challenging to measure the functional importance of additional blockages during the culprit procedure. Functional coronary angiography, by contrast, uses already-acquired angiographic images to reconstruct the coronary artery in three dimensions and estimate blood flow.

AIR-STEMI Trial Across 21 Centers in Italy and Pakistan

Conducted across 21 centers in Italy and Pakistan, the AIR-STEMI trial included 1,823 patients with a median age of 66 years, of whom 24% were women. Participants had undergone successful PCI for the culprit lesion and were randomized to complete revascularization guided either by functional coronary angiography or conventional angiography. In the functional angiography group, lesions were assessed using angiography-derived fractional flow reserve (FFR), where lesions with an FFR value above 0.80 were deferred and those at or below 0.80 were treated with PCI. In the conventional group, PCI was recommended for non-culprit lesions with stenosis of at least 50%.

Physiology-Guided Strategy in the AIR-STEMI Trial

The AIR-STEMI trial demonstrated that the physiology-guided strategy resulted in fewer procedures, fewer treated vessels, shorter treated segments, and lower use of contrast agents. Specifically, 51.9% of non-culprit vessels underwent PCI in the functional angiography group compared with 94.9% in the angiography-guided group. At a median follow-up of 17.9 months, the primary endpoint—comprising all-cause death, myocardial infarction, cerebrovascular accident, or ischaemia-driven coronary revascularization—was significantly lower in the functional coronary angiography group at 8.9%, compared with 13.7% in the conventional angiography group.

Keep reading