The optimal timing for treating nonculprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease remains a key clinical question. The iMODERN trial investigated whether an immediate intervention strategy was superior to a deferred approach in this patient population.¹
The international, investigator-initiated, open-label iMODERN (Immediate or Deferred Non-culprit Lesion Percutaneous Coronary Intervention in Myocardial Infarction) trial randomised patients with STEMI who had undergone successful primary percutaneous coronary intervention (PCI) and had at least one nonculprit lesion. A total of 1,146 patients were assigned in a 1:1 ratio to one of two treatment strategies.
The immediate group (n=558) received PCI guided by instantaneous wave-free ratio (iFR) for nonculprit lesions with over 50% stenosis and an iFR of ≤0.89. The deferred group (n=588) underwent PCI guided by cardiac stress magnetic resonance imaging (MRI) within six weeks of randomisation.
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.
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. The results showed no significant difference between the two strategies (hazard ratio, 0.95; 95% confidence interval, 0.65 to 1.40; P=0.81). Serious adverse events were reported in 145 patients in the immediate group and 181 in the deferred group.
The findings from the iMODERN trial indicate that an immediate iFR-guided PCI strategy for nonculprit lesions is not superior to a deferred strategy guided by cardiac stress MRI. The iMODERN Investigators concluded that, “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.”
This study was funded by Philips Volcano and others.
References
1. Nijveldt R, Maeng M, Beijnink CWH, et al. Immediate or Deferred Nonculprit-Lesion PCI in Myocardial Infarction. N Engl J Med 2025. https://doi.org/10.1056/NEJMoa2512918.
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