近日，荷兰拉德福德大学医学中心Robin Nijveldt团队比较了心肌梗死即刻或延迟非罪犯病变PCI的患者预后。2025年10月28日出版的《新英格兰医学杂志》发表了这项成果。

ST段抬高型心肌梗死（STEMI）患者非罪犯病变的首选治疗时间仍不确定。比较基于瞬时无波间期比值（iFR）指导下的即时经皮冠状动脉介入治疗（PCI）和心脏应激磁共振成像（MRI）指导下的延迟PCI对STEMI和多血管疾病患者的影响是必要的。

在这项由研究者发起、开放标签、随机对照的国际试验中，STEMI患者和至少一个非罪犯病变已成功行首次PCI的患者在随机分组后6周内按1:1的比例随机分配到立即iFR引导的PCI（在狭窄50%且iFR≤0.89[正常值>0.89]的病变中）或延迟心脏应激MRI引导的PCI。主要终点是3年随访期间全因死亡、复发性心肌梗死或因心力衰竭住院的复合终点。

该试验纳入1146例患者（iFR组558例，MRI组588例），平均（±SD）年龄为63±11岁；78%是男性。iFR组556例患者中有237例（42.6%），MRI组587例患者中有110例（18.7%）行非罪犯病变冠状动脉PCI。iFR组中有50例患者（9.3%）发生了主要终点事件，MRI组中有55例患者（9.8%）发生了主要终点事件（风险比为0.95；95%可信区间为0.65 ~ 1.40；P=0.81）。iFR组145例发生严重不良事件，MRI组181例发生严重不良事件。

研究结果表明，在STEMI患者中，成功接受了首次PCI治疗，在全因死亡、复发性心肌梗死或3年心力衰竭住院方面，iFR引导下的即时PCI并不优于延迟心脏应激MRI引导下的非罪犯冠状动脉病变的PCI。

附：英文原文

Title: Immediate or Deferred Nonculprit-Lesion PCI in Myocardial Infarction

Author: Robin Nijveldt, Michael Maeng, Casper W.H. Beijnink, Jan J. Piek, Rasha K. Al-Lamee, Luís Raposo, Sergio Bravo Baptista, Javier Escaned, Justin Davies, Igor Klem, Bahram Yosofi, Robert-Jan M. van Geuns, Christian A. Frederiksen, Lars Jakobsen, Abdelilah El Barzouhi, Dirk J. van der Heijden, Mustafa Ilhan, Saman Rasoul, Stijn Brinckman, Colette Saraber, Daniel A. Jones, Steffen E. Petersen, Toma Podlesnikar, Matja Bunc, Marcel A.M. Beijk, Lieuwe H. Piers, Johannes B. van Rees, Henry Seligman, Graham Cole, Juan F. Iglesias, Sophie Degrauwe, Arnoud W.J. van ’t Hof, Erik Lipsic, Gabija Pundziute-do Prado, Pairoj Chattranukulchai, José F. Rodríguez-Palomares, Johannes Rigger, Martijn Meuwissen, Lennaert Kleijn, Bruno Pereira, Lorenzo Monti, René J. van der Schaaf, Juan Sanchis, Guido Belli, Jan G.P. Tijssen, Troels Thim, Niels van Royen

Issue&Volume: 2025-10-28

Abstract:

BACKGROUND

The preferred timing of treatment of nonculprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) remains uncertain. A comparison of immediate percutaneous coronary intervention (PCI) guided by instantaneous wave-free ratio (iFR) and deferred PCI guided by cardiac stress magnetic resonance imaging (MRI) in patients with STEMI and multivessel disease is warranted.

METHODS

In this international, investigator-initiated, open-label, randomized, controlled trial, patients with STEMI and at least one nonculprit lesion who had undergone successful primary PCI were randomly assigned in a 1:1 ratio to immediate iFR-guided PCI (in lesions with >50% stenosis and an iFR of ≤0.89 [normal value, >0.89]) or deferred cardiac stress MRI–guided PCI within 6 weeks after randomization. The primary end point was a composite of death from any cause, recurrent myocardial infarction, or hospitalization for heart failure at 3-year follow-up.

RESULTS

The trial included 1146 patients (558 in the iFR group and 588 in the MRI group) with a mean (±SD) age of 63±11 years; 78% were men. A total of 237 of 556 patients (42.6%) in the iFR group and 110 of 587 patients (18.7%) in the MRI group underwent nonculprit-lesion coronary-artery PCI. A primary-end-point event occurred in 50 patients (9.3%) in the iFR group and in 55 patients (9.8%) in the MRI group (hazard ratio, 0.95; 95% confidence interval, 0.65 to 1.40; P=0.81). Serious adverse events occurred in 145 patients in the iFR group and in 181 in the MRI group.

CONCLUSIONS

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.

DOI: NJ202510280000007

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2512918