iMODERN: No Difference Between Immediate and Deferred Heart Attack Treatment

Immediate instantaneous wave-free ratio (iFR)-guided percutaneous coronary intervention (PCI) showed no major difference compared to deferred cardiac stress magnetic resonance imaging (MRI)-guided PCI of nonculprit lesions in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease who were undergoing primary PCI, according to data from the iMODERN trial.1

Announced by parent company Royal Philips at the Transcatheter Cardiovascular Therapeutics (TCT) 2025 conference, these data showcase that patients can safely have additional arteries treated during the initial procedure rather than requiring a second intervention later. This allows clinicians to complete treatment in 1 session without compromising long-term outcomes.1

“These results address one of the longest-standing questions in interventional cardiology,” Niels van Royen, MD, PhD, co-principal investigator and Chief of Cardiology at Radboud University Medical Center, said in a statement. “Measuring and eventually treating additional arteries can be performed during the first procedure or during a staged procedure. That means cardiologists can feel confident offering patients a complete solution in one sitting when it’s appropriate.”1

iMODERN was an international, open-label, randomized, controlled trial. Royen and colleagues included patients who were ≥18 years of age, had undergone successful primary PCI within 12 hours after symptom onset, and had ≥1 nonculprit lesion in a non-infarct-related artery with a stenosis diameter >50% and which were amenable to PCI. Patients with a history of STEMI, chronic total occlusion, complex nonculprit lesions, or >50% stenosis of the left main stem were excluded.2

The trial’s primary endpoint was a composite of all-cause mortality, recurrent myocardial infarction, or hospitalization for heart failure at 3 years. Secondary endpoints included the individual components of the composite at 6 and 12 months, as well as cardiac death, stroke, transient ischemic attack, major bleeding, unstable angina, unplanned coronary angiography, unplanned revascularization, and stent thrombosis at 3 years.2

A total of 1146 patients with STEMI were initially enrolled in the trial. Patients were randomly assigned in a 1:1 ratio to undergo immediate iFR-guided nonculprit-lesion PCI or deferred cardiac stress MRI-guided nonculprit-lesion PCI: 556 were assigned to the iFR group and 587 were assigned to the MRI group. Follow-up was performed in person at 6 and 12 months and by phone at 3 months and 3 years.2

Among the iFR group, iFR was successfully measured in 541 patients, and 6 underwent PCI without iFR assessment of a nonculprit lesion. Collectively, ≥1 coronary-artery lesions with a positive iFR indicating ischemia were found in 243 of the 541 patients, and nonculprit coronary-artery PCI was performed in 237 of all 556 patients and in 281 of all 739 lesions in the iFR group.2

The MRI group saw 476 patients undergo cardiac MRI at a median of 27 days (interquartile range, 15-37) after index. A total of 65 patients did not have a cardiac MRI and underwent an iFR-guided bailout procedure. Of the 476 who underwent cardiac MRI, 96 had a positive cardiac stress MRI result showing ischemia, and 32 of the 65 bailout patients had a coronary-artery lesion with a positive iFR.2

At the 3-year follow-up, the composite primary endpoint occurred in 50 of 536 patients with available data in the iFR group and in 55 of 562 patients in the MRI group (hazard ratio [HR], 0.95; 95% CI, 0.65-1.4; P = .81). All-cause mortality occurred in 22 patients in the iFR group and 22 patients in the MRI group (HR, 1.04; 95% CI, 0.58-1.88), recurrent myocardial infarction occurred in 29 patients in the iFR group and 31 patients in the MRI group (HR, 0.99; 95% CI, 0.59-1.64), and hospitalization for heart failure occurred in 3 patients in the iFR group and 13 patients in the MRI group (HR, 0.24; 95% CI, 0.07-0.84).2

Ultimately, investigators determined these data showed no significant difference between immediate iFR-guided PCI and deferred cardiac stress MRI-guided PCI.2

“These results complement current international guideline recommendations (Class I recommendation, Level A evidence) for complete revascularization in STEMI,” Darshan Doshi, head of medical & clinical at Philips Image-Guided Therapy Devices, said in a statement. “By integrating physiological assessment, iMODERN’s evidence demonstrates that cardiologists can follow these findings for full revascularization while also tailoring treatment to each vessel’s true ischemic relevance.”1

References

1. BioSpace. Late-breaking iMODERN findings presented at TCT 2025 and published in the New England Journal of Medicine highlight new evidence to guide treatment choices for heart attack patients. October 29, 2025. Accessed October 29, 2025. https://www.biospace.com/press-releases/late-breaking-imodern-findings-presented-at-tct-2025-and-published-in-the-new-england-journal-of-medicine-highlight-new-evidence-to-guide-treatment-choices-for-heart-attack-patients

2. Nijveldt R, Maeng M, Beijnink CWH, et al. Immediate or deferred nonculprit-lesion PCI in myocardial infarction. NEJM. Published online October 28, 2025. doi:10.1056/nejmoa2512918