Looks can be deceiving: Angiography alone misses functionally significant blockages in heart disease patients

Visual assessments of artery blockages aren't enough. A substudy of the AIR-STEMI trial, presented at TCT 2026, found that relying on angiography alone to gauge the severity of coronary artery blockages can be misleading — and potentially harmful. In patients with multivessel coronary artery disease (CAD) following a heart attack, one-third of lesions that looked severely narrowed on imaging turned out to be functionally insignificant when assessed using a physiology-guided approach.

The study enrolled 1,823 STEMI patients with multivessel disease and compared angiography-guided vs. physiology-guided treatment decisions for non-culprit lesions. Physiology-guided care — which uses blood flow estimates from angiographic images rather than a pressure wire — significantly reduced the risk of major adverse events and safety complications compared to conventional angiography-guided care.

By the Numbers:

• 33.5% of lesions with 71%–90% diameter stenosis were functionally non-significant by physiology assessment
• Physiology-guided care reduced the primary composite outcome risk (8.9% vs. 13.7%; HR = 0.62)
• Safety events were also lower (4.6% vs. 7.1%; HR = 0.63)
• Only 15.3% discordance was seen in lesions with >90% stenosis

Why it matters: These findings challenge the long-standing practice of using visual angiographic severity to decide which blockages to treat. Physiology-guided revascularization could prevent unnecessary procedures and reduce patient risk — a meaningful shift in how interventional cardiologists approach multivessel CAD.