iMODERN Compares iFR and MRI to Guide Revascularization of Nonculprit Lesions in STEMI

November 24, 2025—Three-year data from the iMODERN trial demonstrated that instantaneous wave-free ratio (iFR)-guided revascularization performed during an initial revascularization procedure is not superior to deferred cardiac magnetic resonance (CMR)-guided management of nonculprit lesions for patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease.

The findings were presented at the TCT 2025 scientific symposium and simultaneously published by Robin Nijveldt, MD, et al in The New England Journal of Medicine. According to TCT, the iMODERN trial was composed of 1,146 patients at 41 international sites. It included patients who were treated with successful primary percutaneous coronary intervention (PCI) and had one or more nonculprit lesions.

The patients were randomly assigned to either complete revascularization during the index event of every noninfarct coronary lesion > 50% with iFR ≤ 0.89 (n = 558) or deferred revascularization based on stress perfusion CMR performed within 6 weeks after the index procedure (n = 588). A total of 237 of 556 (42.6%) patients in the iFR group and 110 of 587 (18.7%) patients in the CMR group underwent nonculprit-lesion coronary artery PCI in the intention-to-treat analysis.

The primary endpoint was a composite of all-cause death, recurrent myocardial infarction, and hospitalization for heart failure at 3-year follow-up. The endpoint occurred in 9.3% of the iFR group compared to 9.8% in the CMR group (hazard ratio [HR], 0.95; 95% CI, 0.65-1.40; P = .81). Hospitalizations for heart failure were lower with iFR compared with deferred CMR group (0.6% vs 2.3%; HR, 0.24; 95% CI, 0.07-0.84), but the other components of the composite endpoint did not differ significantly between groups.

Additionally, secondary outcomes at 3 years were similar for iFR compared to CMR as follows: cardiac death (1.9% vs 2%), target lesion failure (10.2% vs 10.5%), unplanned coronary angiography (12.2% vs 14.2%), unstable angina (3.3% vs 3.9%), and major bleeding (1.9% vs 1.1%). Finally, stroke or transient ischemic attack occurred in 1.3% vs 3.7% (HR, 0.36; 95% CI, 0.15-0.86) and stent thrombosis in 1.7% vs 0.6% (HR, 3.11; 95% CI, 0.84-11.49).