Late-breaking science presented at TCT 2025 addressed immediate PCI guided by instantaneous wave-free ratio (iFR) vs. deferred PCI of nonculprit lesions in acute STEMI patients, as well as management of patients with myocardial infarction with nonobstructive coronary arteries (MINOCA).

In the iMODERN trial, simultaneously published in NEJM, three-year outcomes showed immediate PCI guided by iFR was not superior to deferred PCI guided by cardiac stress MRI of nonculprit coronary-artery lesions in patients with acute STEMI.

Researchers randomly assigned 1,146 patients with STEMI and at least one nonculprit lesion who had undergone successful primary PCI to receive immediate iFR-guided PCI (n=558) or deferred cardiac stress MRI-guided PCI (n=588) within six weeks of randomization. The primary endpoint was a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure at three years. The mean age of participants awas 63 years and 78% were men.

Overall results showed a primary endpoint event occurred in 50 patients (9.3%) in the iFR group and in 55 patients (9.8%) in the MRI group. In addition, serious adverse events occurred in 145 patients in the iFR group and in 181 in the MRI group. The secondary endpoints of cardiac death, target-lesion failure, major bleeding and unstable angina at three years occurred in a similar number of patients across both treatment groups, according to Robin Nijveldt, MD, PhD, FACC, who presented the findings.

In the PROMISE trial, simultaneous published in EHJ, researchers found that a stratified treatment of patients with MINOCA significantly improved angina status at 12 months (the primary endpoint) and was also feasible and safe, compared with standard care.

Researchers randomly assigned participants 1:1 to either stratified therapy or standard care. Stratified therapy involved an advanced diagnostic work-up to uncover the mechanism of MINOCA, coupled with tailored therapy targeting the specific mechanism of MINOCA, while standard care included only coronary angiography and standard therapy for acute coronary syndrome.

"PROMISE is the first randomized trial evaluating the management of MINOCA patients," said Rocco A. Montone, MD, PhD, in presenting the findings. In addition to improved angina benefits, Montone noted there were no adverse events related to the advanced diagnostic workup, as well as proven diagnostic utility, with reclassification of initial suspected diagnosis occurring in 75.5% of cases.

The trial did have limitations, with Montone noting early termination due to no definite conclusions of heard endpoints and its open label design. However, he closed with a Latin quote from Seneca: "If one does not know to which port one is sailing, no wind is favorable."

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Transcatheter Cardiovascular Therapeutics, TCT25, Angiography, Acute Coronary Syndrome