Functional Revascularization Outperforms Culprit-Only Strategy in Older Adults With Multivessel Disease

Aug 31, 2023

Complete revascularization improved outcomes in patients older than 75 with myocardial infarction and multivessel disease compared with culprit-only approach.

In the FIRE trial, physiology-guided complete revascularization was superior to a culprit-only revascularization strategy in older patients with myocardial infarction (MI) and multivessel disease.

At ESC Congress 2023, Simone Biscaglia, MD, emphasized that patients older than 75 years are poorly represented in trials evaluating revascularization strategies. “Importantly, the risk of periprocedural complications is higher and prognostically impactful in this population, and the benefit of complete revascularization has been questioned in older patients with MI.” Therefore, the randomized controlled FIRE trial compared a physiology-guided complete revascularization with a culprit-only revascularization strategy in patients older than 75 with MI and multivessel disease. The included patients (N=1,445) were randomly assigned 1:1 to one of the treatment arms and the primary endpoint was a composite of death, MI, stroke, or ischemia-driven revascularization.

At 3 years of follow-up, the data showed that participants in the complete revascularization arm had a reduced risk for a primary endpoint event compared with those in the culprit-only arm (15.7% vs 21.0%; HR, 0.73; 95% CI, 0.57–0.93; P=0.01). Similar results were observed for the key secondary endpoint of cardiovascular death or MI (8.9% vs 13.5%; HR, 0.64; 95% CI, 0.47–0.88; P=0.005). Finally, the composite safety endpoint of contrast-associated acute kidney injury, stroke, or BARC type 3, 4, or 5 bleeding did not show a significant increase in these events in participants in the complete revascularization arm compared with those who were randomly assigned to the culprit only arm (22.5% vs 20.4%; HR, 1.11; 95% CI, 0.89-1.37; P=0.37).