BACKGROUND:Complete coronary-artery revascularization is recommended in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, but the preferred strategy for identifying nonculprit lesions that warrant treatment remains uncertain. METHODS:In this international, randomized trial, we assigned patients with STEMI and multivessel disease in whom the culprit lesion had been successfully treated to undergo complete coronary-artery revascularization guided by functional coronary angiography (physiology-guided group) or by conventional angiography (angiography-guided group). The primary outcome was a composite of death from any cause, myocardial infarction, cerebrovascular accident (stroke or transient ischemic attack), or ischemia-driven revascularization, assessed in a time-to-event analysis. The primary safety outcome was a composite of contrast-associated acute kidney injury or major bleeding. RESULTS:A total of 1823 patients underwent randomization; 913 were assigned to the physiology-guided group and 910 assigned to the angiography-guided group. The median age of the patients was 66 years (interquartile range, 58 to 76), and 24% were women. At a median follow-up of 17.9 months, a primary-outcome event had occurred in 81 patients (8.9%) in the physiology-guided group and in 125 patients (13.7%) in the angiography-guided group (hazard ratio, 0.62; 95% confidence interval [CI], 0.47 to 0.83; P<0.001). A primary-safety-outcome event occurred in 42 patients (4.6%) in the physiology-guided group and in 65 patients (7.1%) in the angiography-guided group (hazard ratio, 0.63; 95% CI, 0.43 to 0.93; P = 0.02). CONCLUSIONS:In patients with STEMI and multivessel coronary artery disease, a strategy of complete coronary-artery revascularization guided by functional coronary angiography resulted in a lower risk of a primary-outcome event (death, myocardial infarction, cerebrovascular accident, or ischemia-driven revascularization) than a strategy guided by conventional angiography. (Funded by the Italian Health Ministry and others; AIR-STEMI ClinicalTrials.gov number, NCT05818475.).

Background Cardiovascular disease is increasingly recognized as a leading nonobstetric cause of maternal morbidity and mortality worldwide, including low- and middle-income countries. Objectives This study evaluated fetomaternal outcomes in women with and without structural heart disease (SHD). Methods From a total of 25,000 patients enrolled in the Prospective Pakistan Registry of Echocardiographic Screening in Asymptomatic Pregnant Women registry between February 2023 and April 2025, 489 pregnancies with SHD were identified and compared with 510 pregnancies without SHD. Adverse fetomaternal outcomes were evaluated in both groups as a composite endpoint, comprising fetal outcomes (preterm delivery, fetal death, or low birth weight) and maternal outcomes (maternal death and pulmonary edema). Results The SHD cohort had a higher mean maternal age (27.3 ± 5.7 vs 26.1 ± 5.2 years; P = 0.011) compared to the non-SHD cohort. Composite adverse maternal outcomes (3.7% vs 0.4%; P < 0.001), fetal outcomes (29.9% vs 13.3%; P < 0.001), and overall fetomaternal outcomes (30.7% vs 13.3%; P < 0.001) were significantly higher in the SHD compared to the non-SHD cohort. SHD was independently associated with adverse fetomaternal outcomes (adjusted OR: 2.67; 95% CI: 1.93-3.70; P < 0.001). Conclusions Prospective Pakistan Registry of Echocardiographic Screening in Asymptomatic Pregnant Women is the first global study linking subclinical echocardiographic abnormalities in asymptomatic pregnant women to adverse fetomaternal outcomes. In a large cohort of asymptomatic pregnant women, an abnormal echocardiogram was found to be associated with 2- to 4 time as many adverse fetomaternal outcomes compared to a normal echocardiogram. Future studies are needed to evaluate optimal timing of screening, cost-effectiveness, and applicability of broad antenatal screening in higher-income countries.

Myocardial bridging (MB), most commonly involving the left anterior descending artery, is an intramyocardial segment of a coronary artery traditionally regarded as a benign anatomical variant. However, in a subset of patients, MB has been implicated in anginal syndromes, myocardial infarction, and even sudden cardiac death. Most cases are asymptomatic and identified incidentally on coronary computed tomography or invasive angiography. Controversy surrounds best practices for management of this entity. This review summarizes current evidence in adult patients with isolated MB on the mechanisms producing ischemia and adverse cardiac outcomes, the value of testing modalities to diagnose ischemia, and treatment strategies based on the patient’s symptoms and clinical presentation (phenotype).

BACKGROUND:Post-dilatation with a noncompliant (NC) balloon is generally associated with better expansion and apposition of stent struts, leading to improved immediate angiographic results and clinical outcomes. However, some studies have raised uncertainty about its utility, suggesting a potential aggravation of microvascular obstruction and vessel wall injury. Therefore, this study aimed to investigate the impact of post-dilatation on the incidence of complications in STEMI (ST elevation myocardial infarction) patients undergoing primary percutaneous coronary intervention (PCI). METHODS:In this retrospective cohort study, we included consecutive adult STEMI patients (age ≥ 18 years) who underwent primary PCI between October 2022 and December 2024. Patients were categorized into two groups based on post-dilatation status after stent deployment. The post-dilatation and non-post-dilatation groups were compared for complications and immediate outcomes, including mortality, cardiac arrest, cardiogenic shock, heart failure, stroke, and stent thrombosis. RESULTS:The study sample consisted of 12,608 STEMI patients who underwent primary PCI, of whom 10,081 (80%) were male. The mean age was 55.8 ± 10.8 years. Post-dilatation with an NC balloon was documented in 7935 (62.9%) patients. The analysis of matched cohorts revealed, a 4.3% lower risk of cardiac arrest (risk ratio [RR]; 0.957 [95% CI: 0.945-0.97; p < 0.001]), 1.3% lower risk of cardiogenic shock (RR; 0.987 [95% CI: 0.979-0.996; p = 0.003]), 0.9% lower risk of heart failure (RR; 0.991 [95% CI: 0.984-0.997; p = 0.005]), and 4.8% lower risk of in-hospital mortality (RR; 0.952 [95% CI: 0.939-0.966; p < 0.001]) among post-dilatation as compared to non-post-dilatation cohorts. CONCLUSIONS:Post-dilatation with an NC balloon after stent deployment in patients undergoing primary PCI is associated with improved clinical outcomes and lower rates of post-procedure complications and in-hospital adverse outcomes.

BACKGROUND:Incomplete microvascular reperfusion during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) remains a major challenge. OBJECTIVES:This study sought to determine whether the pressure optimization protocol (POP) improves reperfusion outcomes compared with conventional rapid inflation-deflation stenting in patients undergoing primary PCI for STEMI. METHODS:In this multicenter randomized trial with blinded endpoint assessment, patients undergoing primary PCI were assigned 1:1 to POP (stent inflation to ≥14 atm maintained until pressure stability, defined as no pressure drop ≥0.3 atm over 30 seconds) or conventional rapid inflation-deflation stenting. The primary endpoint was hierarchical reperfusion success, analyzed using the Finkelstein-Schoenfeld unmatched WIN ratio: ST-segment resolution ≥70% at 90 minutes, final TIMI grade 3, and absence of slow-flow/no-reflow. RESULTS:Between September 30, 2024, and November 11, 2025, 607 patients underwent randomization (POP arm, n = 307; conventional arm, n = 300). POP improved the primary hierarchical reperfusion endpoint (WIN ratio: 1.42; 95% CI: 1.11-1.79; P = 0.004). The net WIN difference was +12.64% (95% CI: 3.69-20.98), driven mainly by the first 2 hierarchical components, ST-segment resolution ≥70% (+5.70%; 95% CI: -1.89 to 12.56) and final TIMI grade 3 flow (+5.95%; 95% CI: 1.80-10.00). Postdilation was less frequent with POP (213 of 326 stents [65.3%] vs 294 of 323 [91.0%]; P < 0.001). At median follow-up of 30 days (IQR: 29-32), major adverse cardiovascular events (death, myocardial infarction, stent thrombosis, or stroke) occurred in 6 of 307 vs 12 of 300 patients; Kaplan-Meier estimated event rates were 2.0% (95% CI: 0.4-3.5) and 4.1% (95% CI: 1.8-6.3), respectively (HR: 0.49; 95% CI: 0.18-1.31; P = 0.15). CONCLUSIONS:Among patients with STEMI undergoing primary PCI, pressure-optimized stent inflation resulted in significantly higher rates of successful reperfusion than conventional stenting and reduced need for post dilation. A trend toward fewer 30-day major adverse cardiovascular events was observed. Larger trials are warranted to assess effects on longer-term clinical outcomes. (RAPID-POP: A Randomized Controlled Trial; NCT06430892).

Despite its high prevalence, Acute rheumatic fever (ARF) and Rheumatic heart disease (RHD) is underrepresented in Pakistan's national and federal health plans. To address this gap, we gathered multi-geographic and specialty perspectives from frontline clinicians in Pakistan'. Major challenges in RHD diagnosis and care include regional healthcare disparities, diagnostic limitations, scarcity of Benzathine Penicillin G (BPG) for prophylaxis, and lack of multidisciplinary RHD teams.Our practitioner-informed recommendations emphasize community outreach, targeted screening, and surveillance, and comprehensive training for healthcare providers in the diagnosis and management of GAS infections and ARF. Strengthening multidisciplinary care and ensuring stable BPG supplies are essential, as is integrating RHD care into Universal Health Coverage (UHC) models currently being implemented to reduce patient financial burdens. Improving RHD management requires systemic changes to healthcare infrastructure, practitioner training, and coordinated policy efforts. Crucially, these proposals align with WHO's latest RHD guidelines on primary (treating GAS infections) and secondary prevention (antibiotic prophylaxis and screening). By translating local clinical wisdom into actionable policies, this viewpoint yields practical interventions tailored to Pakistan that are also adaptable to similar LMIC settings.

BACKGROUND:Vitamin K antagonists, such as warfarin, are the standard treatment for left ventricular thrombus (LVT). However, direct oral anticoagulants, such as rivaroxaban, are increasingly being considered due to their fixed dosing and lack of routine monitoring requirements. OBJECTIVES:This study aimed to compare the effectiveness of rivaroxaban vs warfarin in treating post-myocardial infarction (MI) acute LVT at 12 weeks. METHODS:We conducted an open-label, noninferiority, randomized controlled trial involving patients with acute LVT diagnosed during initial MI hospitalization. Participants were randomized 2:1 to receive either rivaroxaban (20 mg daily) or warfarin (target international normalized ratio 2-3) for 12 weeks. The primary endpoint, LVT resolution, was assessed by echocardiography at 4 and 12 weeks. RESULTS:A total of 261 patients were randomized, with 171 in the rivaroxaban group and 90 in the warfarin group. The groups were similar in sex, age, and MI subtype, with most having ST-segment elevation MI and severe LV dysfunction. At 4 weeks, LVT resolution was higher in the rivaroxaban group (20% vs 8%; P = 0.017), with similar resolution at 12 weeks (95.8% vs 96.6%; P = 0.759). The cumulative all-cause mortality was comparable (3.5% vs 3.3%; P = 0.921). Major bleeding occurred in 2.3% of rivaroxaban patients vs 1.1% of the warfarin group (P = 0.491). CONCLUSIONS:Rivaroxaban demonstrated similar efficacy to warfarin in treating post-MI LVT, with >95% resolution in both groups. Future multicenter trials with longer follow-up are needed to validate these findings (Rivaroxaban in Left Ventricular Thrombus; NCT04970576).

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis, yet the majority of TAVR devices are optimized for Caucasian and Latin American aortic root anatomies. Unfortunately, data specific to the South Asian (SA) population is limited. This study sought to evaluate and compare aortic root dimensions in Pakistani patients undergoing TAVR with those of other racial groups. This study included consecutive patients undergoing TAVR workup at 2 tertiary care centers in Karachi, Pakistan. A comprehensive assessment of aortic root anatomy and dimensions was performed via cardiac computed tomography angiography. Data for 90 patients from a Japanese cohort and 181 patients from a European cohort were obtained from the published literature. In a sample of 494 patients, 58.1% (287) were male, and the mean age was 71.2 ± 9.7 years. The mean annular area was 427.33 ± 122.49 mm 2 , and the mean perimeter was 73.96 ± 10.17 mm. In comparison, the sinus of Valsalva (SOV) was <28 mm in 22.8% (113) versus 66.7% (60) versus 14% (17); left main height was <10.7 mm in 18.7% (90) versus 13.3% (12) versus 3.9% (7); and right coronary artery height was <12.7 mm in 14% (69) versus 7.8% (7) versus 2.2% (4) among the Pakistani, Japanese, and European cohorts, respectively. The Pakistani population exhibited a higher incidence of smaller SOV dimensions compared to the European cohort and a higher incidence of shorter coronary artery heights. These findings highlight the need for tailored TAVR device designs and procedural strategies to accommodate the unique anatomical characteristics of the SA population, ensuring optimal outcomes in this demographic.

Background: Gestational diabetes mellitus (GDM) is a frequent metabolic complication of pregnancy and is strongly linked to adverse fetal outcomes, including structural and functional cardiac alterations. While the impact of maternal hyperglycemia on fetal cardiac development has been extensively documented, the additional role of genetic predisposition through a positive family history of diabetes (FHD) has received limited attention. Investigating this interaction is particularly important in high-risk populations such as Pakistan, where diabetes prevalence is alarmingly high. Objective: The objective of this study was to evaluate fetal echocardiographic parameters, including interventricular septal (IVS) thickness, left ventricular end-diastolic diameter (LVDd), ejection fraction (EF), and fractional shortening (FS), and to determine their association with family history of diabetes in women with GDM. Methods: A prospective cross-sectional study was carried out in the Echocardiography Department of The Children’s Hospital, Lahore, over a two-month period. A total of 89 pregnant women aged 20–45 years with singleton pregnancies between 18–36 weeks of gestation were recruited using purposive sampling. Fetal echocardiography was performed using a 3–5 MHz transducer, with standard cardiac views and Doppler assessment to measure IVS thickness, LVDd, EF, and FS. Maternal demographic data and family history of diabetes were systematically recorded. Statistical analysis was conducted using SPSS version 30, applying descriptive statistics and Chi-square tests, with significance set at p < 0.05. Results: Among the 89 participants, 77 (86.5%) reported a positive FHD and 12 (13.5%) had no such history. Septal hypertrophy was identified in 74 women (83.15%) with FHD compared to 9 (10.11%) without, demonstrating a significant association (p = 0.007). LVDd values showed similar significance (p = 0.006), with 50 (56.18%) of women with FHD exhibiting reduced dimensions compared to 5 (5.62%) without. In contrast, EF and FS were preserved across both groups, showing no statistical association with family history (p = 0.691). Conclusion: The study concluded that GDM in combination with a positive family history of diabetes significantly influenced fetal cardiac morphology, particularly septal hypertrophy and reduced LVDd, while systolic parameters such as EF and FS remained unaffected. These findings highlight the importance of enhanced prenatal surveillance and targeted echocardiographic screening in high-risk pregnancies.

BACKGROUND:Ticagrelor has been proven superior to clopidogrel in reducing adverse cardiovascular events in patients with acute coronary syndrome (ACS), yet economic factors often favor clopidogrel in real-world clinical practice. Although double dose clopidogrel has shown potential benefits over once-daily regimens, its direct comparison with ticagrelor in ST-elevation myocardial infarction (STEMI) patients remains unexplored. METHODS AND DESIGN:Twice a Day Clopidogrel vs. Ticagrelor in Reducing Major Cardiac Events in Patients with Acute STEMI Undergoing Primary PCI (TADCLOT) trial is a double-blind, randomized controlled trial conducted at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. It is designed as a superiority trial to evaluate the efficacy and safety of ticagrelor over twice-daily clopidogrel in reducing major adverse cardiac events (MACE) in STEMI patients undergoing primary percutaneous coronary intervention (PCI). Following successful PCI for STEMI, and when the patient is deemed suitable for discharge, patients are randomized 1:1 to receive either ticagrelor (180 mg loading dose followed by 90 mg BID for 30 days) or clopidogrel (600 mg loading dose followed by 75 mg BID for 30 days). The primary endpoint is the rate of major adverse cardiac events (MACE), a composite of death, myocardial infarction, stent thrombosis, target lesion revascularization, or stroke at 30 days following randomization. Secondary endpoints include the individual components of MACE, bleeding complications, and drug discontinuation due to adverse events. Enrollment has reached 88%, with 2,200 patients planned to complete the trial. IMPLICATIONS:The TADCLOT trial will provide crucial insights into the comparative efficacy of ticagrelor versus twice-daily clopidogrel in reducing early stent thrombosis and improving outcomes in STEMI patients undergoing primary PCI. The trial will particularly contribute valuable insights for post-PCI care, considering both the economic and genetic context of the high risk South Asian population. TRIAL REGISTRATION:ClinicalTrials.gov NCT06318481.

BACKGROUND:The first month postprimary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is the highest risk period for major adverse cardiovascular events (MACEs), including stent thrombosis. Ticagrelor and double-dose clopidogrel are effective antiplatelet therapies, but no head-to-head comparison exists in this setting. OBJECTIVES:The authors sought to evaluate the efficacy of ticagrelor over twice-daily clopidogrel in reducing MACE events within the first 1 month postprimary PCI. METHODS:TADCLOT (Twice-A-Day CLOpidogrel vs Ticagrelor), a double-blind, randomized superiority trial at the National Institute of Cardiovascular Diseases, Karachi, Pakistan (February 19, 2024 to January 30, 2025), randomized 2,201 patients with STEMI within 24 hours of primary PCI 1:1 to ticagrelor (180-mg loading dose, 90 mg twice a day) or twice-daily clopidogrel (600-mg loading dose, 75 mg twice a day) for 1 month. The primary endpoint was MACEs (death, myocardial infarction, stent thrombosis, stroke, or target lesion revascularization) at 1 month, analyzed by intention to treat. Secondary endpoints were individual MACE components and clinically significant bleeding (Bleeding Academic Research Consortium [BARC] type 2, 3, or 5). RESULTS:Among 2,201 randomized patients, MACEs occurred in 24 (2.2%) ticagrelor patients vs 32 (2.9%) in twice-daily clopidogrel patients (HR: 0.75; 95% CI: 0.44-1.27; P = 0.28; absolute risk difference: -0.7%; 95% CI: -2.05 to 0.60). Cardiovascular death or definite stent thrombosis occurred in 21 (1.9%) vs 27 (2.5%) patients (HR: 0.77; 95% CI: 0.44-1.37). Clinically significant bleeding (BARC type 2, 3, or 5) occurred in 6 patients (0.5%) with ticagrelor vs 4 (0.4%) with clopidogrel (HR: 1.50; 95% CI: 0.42-5.31). Major bleeding (BARC type 3 or 5) was infrequent and similar between the groups: 3 patients (0.3%) in the ticagrelor arm and 2 (0.2%) in the clopidogrel arm (HR: 1.50; 95% CI: 0.25-8.97). At both 7 (HR: 0.15; 95% CI: 0.04-0.5; P = 0.002) and 14 days (HR: 0.46; 95% CI: 0.23-0.91; P = 0.02), MACEs were significantly lower with ticagrelor compared with twice-daily clopidogrel, although these differences were no longer statistically significant at 30 days. CONCLUSIONS:Ticagrelor was not superior to twice-daily clopidogrel in reducing MACEs at 1 month after primary PCI, and bleeding rates were similar. However, event rates were lower than anticipated, and ticagrelor significantly reduced MACEs within the first 2 weeks compared with twice-daily clopidogrel. (TADCLOT-a Double Blind Randomized Controlled Trial [TADCLOT]; NCT06318481).

Aims:The Prospective Pakistan Registry of Echocardiographic Screening in Asymptomatic Pregnant Women (PRESAP) is a registry designed for the echocardiographic screening of structural heart disease (SHD). It offers a unique opportunity to compare the effectiveness of point-of-care ultrasound (POCUS) vs. routine transthoracic echocardiography (TTE) in this population. This sub-study of the PRESAP registry aimed to compare the detection of SHD in asymptomatic pregnant women using POCUS vs. routine TTE. Methods and results:Between February 2023 and March 2024, pregnant women without known heart disease were enrolled in the PRESAP registry. Participants underwent a limited echocardiogram, using either POCUS or TTE. The primary outcome was the detection of abnormal findings, including left ventricular systolic dysfunction (LVSD), valvular heart disease (VHD), and congenital heart disease (CHD). Matching cohorts were created using propensity score matching, based on demographic factors, comorbid conditions, and gestational history. Among 18 401 patients, 9681 (52.6%) underwent POCUS. The 1:1 propensity-matched cohort included 4177 patients in each arm. Abnormal echocardiographic findings were detected in 4.4% (185) of the TTE group and 3% (124) of the POCUS group (P < 0.001). VHD (1.3% vs. 1.1%; P = 0.416) and CHD (0.4% vs. 0.6%; P = 0.093) were detected at similar rates by both methods, while LVSD was more frequently identified by TTE compared with POCUS (2.8% vs. 1.5%; P < 0.001). Conclusion:POCUS may be considered as an alternative to TTE for screening for SHD in asymptomatic pregnant women, particularly in resource-limited settings. TTE was superior for LVSD, and POCUS was equally effective in identifying valvular and congenital heart disease.

Cardiovascular disease (CVD) is understudied, underdiagnosed, and undertreated in women due to a lack of knowledge and understanding, particularly in the context of low-middle incomes countries (LMICs). Over a 20-month period from October 2022 to June 2024, we included 2003 patients from our valve registry, 11,894 patients from the Cath-PCI registry, and 542 patients from the structural intervention registry in Pakistan’s largest tertiary-care cardiac hospital. We discovered that females are more likely than males to suffer from valvular heart disease (VHD) and present at a considerably younger age. Females had a higher likelihood of mitral valve disease than males, who were more likely to have aortic valve disease. Rheumatic heart disease was the leading cause of all left-sided VHD. Amongst the acute coronary syndrome cohort, females had a significantly higher prevalence of diabetes and hypertension and significantly higher rate of death, longer door to balloon time and total ischemic time.

INTRODUCTION:Functionally optimizing percutaneous coronary intervention (PCI) with post-PCI fractional flow reserve (FFR) measurement has been associated with improved outcomes in native vessels. However, its role in in-stent restenosis (ISR) PCI is not well understood. METHODS:Consecutive patients undergoing PCI for stable angina or stabilized acute coronary syndrome enrolled in a PCI registry were included. FFR was measured pre- and post-PCI with the goal of further optimization of the PCI result based on post-PCI FFR. Target vessel revascularization (TVR) was evaluated in those with optimized FFR (≥0.86) in the ISR and native vessel lesions. RESULTS:There were 675 lesions in 574 patients who underwent pre- and post-PCI FFR with 101 lesions with ISR. ISR group was more likely to present with acute coronary syndrome and to have hypertension and chronic kidney disease. Both groups had long to diffuse disease. Median pre-PCI stenosis (70 %, IQR 60-80 %) and pre-PCI FFR (0.69 vs 0.70) were similar in native and ISR groups. There was similar and modest correlation between angiographic severity and pre-PCI FFR in native and ISR lesions (-0.57[-0.62 to -0.51] and -0.54 [-0.67 to -0.38], both p < 0.0001). Similar proportions of stenosis were functionally optimized to a post-PCI FFR ≥0.86 (66 % vs 71 %, p = 0.7). Despite functional optimization, TVR was significantly higher in ISR compared to native lesions [HR 0.71, 95 % CI 0.08-0.38 Log rank P < 0.001] even when ISR was treated with a drug-eluting stent. CONCLUSION:Despite functional optimization by post-PCI FFR, TVR is significantly higher after ISR PCI.

Background Complete revascularization has been shown to be superior to culprit-only treatment in patients with ST- segment elevation myocardial infarction (STEMI) and multivessel disease. However, it remains unclear whether complete revascularization should be guided by coronary physiology or conventional angiography. Angiography-derived physiology may allow functional assessment and procedural guidance using angiograms from primary percutaneous coronary intervention (PCI), potentially maximizing the benefits of a physiology-guided approach. We present the design of a dedicated study that will address this research gap. Methods and Design The Functional Coronary Angiography to Indicate and Guide Revascularization in STEMI Patients with Multivessel Disease (AIR-STEMI) trial is a prospective, randomized, international, multicenter, open-label study with blinded adjudicated evaluation of outcomes. After successful treatment of the culprit lesion, patients will be randomized to receive PCI of the nonculprit lesions guided by conventional angiography or by angiography-derived fractional flow reserve (FFR). The primary endpoint is the composite endpoint of all-cause death, any myocardial infarction (MI), any cerebrovascular accident, or any revascularization. It will be censored once the last enrolled patient reaches 1-year follow-up. The secondary endpoint will be the composite of cardiovascular death or MI and each single component of the primary endpoint. All endpoints will be tested also at 3 and 5 years. The sample size for the study is a minimum of 1,800 patients. Implications The AIR-STEMI trial will provide novel evidence on whether a specific complete revascularization strategy should be applied to patients with STEMI and multivessel disease to improve their clinical outcomes. Trial Registration ClinicalTrials.gov NCT05818475. (Am HeartJ 2025;284:71-80.)