Karthikeyan, Ganesan (57188672173)Ganesan (57188672173)KarthikeyanPeix, Amalia (55899478200)Amalia (55899478200)PeixDevasenapathy, Niveditha (23033698100)Niveditha (23033698100)DevasenapathyJimenez-Heffernan, Amelia (55897520300)Amelia (55897520300)Jimenez-HeffernanHaque, Saif-ul (57218168830)Saif-ul (57218168830)HaqueRodella, Carlo (31067520000)Carlo (31067520000)RodellaGiubbini, Raffaele (7004319496)Raffaele (7004319496)GiubbiniRosas, Erick Alexanderson (57205709570)Erick Alexanderson (57205709570)RosasOzkan, Elgin (7007024961)Elgin (7007024961)OzkanKeng, Yung Jih Felix (57942745400)Yung Jih Felix (57942745400)KengVitola, João (6602072314)João (6602072314)VitolaSobic-Saranovic, Dragana (57202567582)Dragana (57202567582)Sobic-SaranovicSoni, Manoj (57942104600)Manoj (57942104600)SoniLópez, Leonardo (57941442200)Leonardo (57941442200)LópezCabrera, Lázaro O. (14061659500)Lázaro O. (14061659500)CabreraCamacho-Freire, Santiago (55515266200)Santiago (55515266200)Camacho-FreireManovel-Sanchez, Ana (14520375700)Ana (14520375700)Manovel-SanchezNaeem, Hesham (57224600165)Hesham (57224600165)NaeemFatima, Shazia (8331748200)Shazia (8331748200)FatimaRinaldi, Roberto (57217700985)Roberto (57217700985)RinaldiCarvajal-Juarez, Isabel (57203129644)Isabel (57203129644)Carvajal-JuarezEsenboga, Kerim (55965196800)Kerim (55965196800)EsenbogaDondi, Maurizio (56789705600)Maurizio (56789705600)DondiPaez, Diana (54785022800)Diana (54785022800)Paez2025-06-122025-06-122023https://doi.org/10.1007/s12350-022-03108-zhttps://www.scopus.com/inward/record.uri?eid=2-s2.0-85140609422&doi=10.1007%2fs12350-022-03108-z&partnerID=40&md5=db01b0e24d2c548d3f643504ae2e26behttps://remedy.med.bg.ac.rs/handle/123456789/2729Background: In patients with multi-vessel disease presenting with ST elevation myocardial infarction (STEMI), the efficacy and safety of ischemia-guided, vs routine non-culprit vessel angioplasty has not been adequately studied. Methods: We conducted an international, randomized, non-inferiority trial comparing ischemia-guided non-culprit vessel angioplasty to routine non-culprit vessel angioplasty, following primary PCI for STEMI. The primary outcome was the between-group difference in percent ischemic myocardium at follow-up stress MPI. All MPI images were processed and analyzed at a central core lab, blinded to treatment allocation. Results: In all, 109 patients were enrolled from nine countries. In the ischemia-guided arm, 25/48 (47%) patients underwent non-culprit vessel PCI following stress MPI. In the routine non-culprit PCI arm, 43/56 (77%) patients underwent angioplasty (86% within 6 weeks of randomization). The median percentage of ischemic myocardium on follow-up imaging (mean 16.5 months) was low, and identical (2.9%) in both arms (difference 0.13%, 95%CI − 1.3%–1.6%, P <.0001; non-inferiority margin 5%). Conclusion: A strategy of ischemia-guided non-culprit PCI resulted in low ischemia burden, and was non-inferior to a strategy of routine non-culprit vessel PCI in reducing ischemia burden. Selective non-culprit PCI following STEMI offers the potential for cost-savings, and may be particularly relevant to low-resource settings. (CTRI/2018/08/015384). © 2022, The Author(s).MPIMyocardial ischemia and infarctionSPECT