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FIRE Trial: The benefits of complete revascularization in older MI patients

Simone Biscaglia, M.D., Vincenzo Guiducci, M.D., Javier Escaned, M.D., Raul Moreno, M.D., Valerio Lanzilotti, M.D., Andrea Santarelli, M.D., Enrico Cerrato, M.D., Giorgio Sacchetta, M.D., Alfonso Jurado-Roman, M.D., Alberto Menozzi, M.D., Ignacio Amat Santos, M.D., José Luis Díez Gil, M.D., et al., for the FIRE Trial Investigators† (2023)

In this multicenter, randomized trial, elderly patients with myocardial infarction (MI) and multivessel coronary disease who were undergoing percutaneous coronary intervention (PCI) for the culprit lesion, were enrolled. These patients were randomly assigned to one of two groups: either receiving physiology-guided complete revascularization of nonculprit lesions or undergoing no further revascularization. Functionally significant nonculprit lesions were identified using either pressure wire measurements or angiography. The primary endpoint was a composite outcome, which included death, myocardial infarction, stroke, or any revascularization within one year. Additionally, a key secondary endpoint was evaluated, a composite of cardiovascular death or myocardial infarction. Safety considerations were based on a composite assessment involving contrast-associated acute kidney injury, stroke, or bleeding.

The study encompassed 1445 patients who underwent randomization, with 720 assigned to receive complete revascularization and 725 to receive revascularization limited to the culprit lesion. The median age of the patients was 80 years. Of these, 528 patients (36.5%) were women, and 509 (35.2%) were admitted for ST-segment elevation myocardial infarction. Primary-outcome events occurred in 113 patients (15.7%) in the complete-revascularization group, and 152 patients (21.0%) in the culprit-only group, resulting in a hazard ratio of 0.73 (95% confidence interval [CI], 0.57 to 0.93; P=0.01). For the key secondary endpoint, cardiovascular death or myocardial infarction, 64 patients (8.9%) in the complete-revascularization group experienced the outcome compared to 98 patients (13.5%) in the culprit-only group, with a hazard ratio of 0.64 (95% CI, 0.47 to 0.88). Safety assessments did not reveal significant differences between the groups, with event rates of 22.5% and 20.4% for complete revascularization and culprit-only groups, respectively (P=0.37).

In summary, among patients aged 75 years or older with myocardial infarction and multivessel coronary disease, those who underwent physiology-guided complete revascularization exhibited a reduced risk of a composite outcome encompassing death, myocardial infarction, stroke, or ischemia-driven revascularization at one year compared to those who underwent PCI limited to the culprit lesion. These findings suggest the potential benefits of comprehensive revascularization in this specific patient population.

It’s important to note that this study contributes significantly to the evolving field of interventional cardiology, providing evidence that supports the potential advantages of a more comprehensive approach to coronary intervention in specific patient populations. The study offers a promising step toward improved care for older MI patients.

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