The optimal timing for treating nonculprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease remains a topic of clinical debate. The iMODERN trial sought to clarify this by comparing outcomes between an immediate, physiology-guided percutaneous coronary intervention (PCI) strategy and a deferred, imaging-guided approach.¹˒²
Methodology
The international, investigator-initiated, open-label, randomised controlled iMODERN trial enrolled 1,146 patients with STEMI who had undergone successful primary PCI and had at least one nonculprit lesion. Participants were assigned in a 1:1 ratio to one of two treatment strategies.
The immediate intervention group (n=558) received PCI guided by instantaneous wave-free ratio (iFR) for any nonculprit lesion with over 50% stenosis and an iFR of ≤0.89. The deferred group (n=588) underwent cardiac stress magnetic resonance imaging (MRI) within six weeks, with PCI performed based on the imaging results.
The primary endpoint was a composite of death from any cause, recurrent myocardial infarction, or hospitalisation for heart failure at a three-year follow-up.
Results
The mean age of the participants was 63 years, and 78% were men. A significantly higher proportion of patients in the immediate iFR-guided group underwent nonculprit-lesion PCI compared to the deferred MRI-guided group (42.6% vs 18.7%, respectively).
After three years, the primary endpoint occurred in 50 patients (9.3%) in the immediate iFR group and 55 patients (9.8%) in the deferred MRI group (hazard ratio, 0.95; 95% confidence interval, 0.65 to 1.40; P=0.81). There was no statistically significant difference between the two strategies.
Regarding safety, serious adverse events were reported in 145 patients in the immediate intervention group and 181 patients in the deferred group.
Interpretation
The findings from the iMODERN trial indicate that a strategy of immediate iFR-guided PCI for nonculprit lesions in STEMI patients does not offer superior outcomes compared to a deferred approach guided by cardiac stress MRI. The iMODERN Investigators concluded, "Among patients with STEMI who have undergone successful primary PCI, immediate iFR-guided PCI was not superior to deferred cardiac stress MRI–guided PCI of nonculprit coronary-artery lesions with respect to death from any cause, recurrent myocardial infarction, or hospitalization for heart failure at 3 years."¹
This study was funded by Philips Volcano, Biotronik Scientific, and the Dutch Ministry of Economic Affairs.
References
1. Nijveldt R, Maeng M, Beijnink CWH, et al. Immediate or Deferred Nonculprit-Lesion PCI in Myocardial Infarction. N Engl J Med 2026;394:958-968. https://doi.org/10.1056/NEJMoa2512918
2. Fearon WF. Assessing Nonculprit Coronary-Artery Lesions in STEMI. N Engl J Med 2026;394:1021-1022. https://doi.org/10.1056/NEJMe2517834
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