Functional revascularisation outperforms culprit-only strategy in older MI patients

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

Dr Simone Biscaglia (Ferrara University Hospital, Italy) emphasised that patients older than 75 years of age are poorly represented in trials evaluating revascularisation strategies. “Importantly, the risk of periprocedural complications is higher and prognostically impactful in this population, and the benefit of complete revascularisation has been questioned in older patients with MI” [1,2].

Therefore, the randomised-controlled FIRE trial (NCT03772743) compared a physiology-guided complete revascularisation with a culprit-only revascularisation strategy in patients older than 75 years of age with MI and multivessel disease [3,4]. The included participants (n=1,445) were randomised 1:1 to one of the treatment arms and the primary endpoint was a composite of death, MI, stroke, or ischaemia-driven revascularisation.

At 1 year follow-up, the data showed that participants in the complete-revascularisation arm had a reduced risk of experiencing 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; see Figure). 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-revascularisation arm compared with those who were randomised to the culprit-only arm (22.5% vs 20.4%; HR 1.11; 95% CI 0.89-1.37; P=0.37).

Figure: Primary endpoint of all-cause death, any MI, stroke, or ischaemia-driven revascularisation [3]



“The results of the FIRE trial demonstrated that physiology-guided complete revascularisation reduces adverse cardiovascular outcomes,” said Prof. Vijay Kunadian (Newcastle University, UK), discussant of this trial. “These results may, however, not be generalisable to all older patients. We should be careful with frail patients, those with many co-morbidities, cognitive impairment, prior coronary artery bypass grafting, or left main disease in particular. Furthermore, we need to await the long-term results of this study and it should be investigated whether angiography-guided percutaneous coronary intervention would result in similar outcomes.”

1. 
   
   1. Biscaglia S, et al. Am Heart J. 2020;229;100–109.
   2. Joshi FR, et al. Catheter Cardiovasc Interv. 2021;97:e467-e474.
   3. Biscaglia S, et al. Functional versus culprit-only revascularization in elderly patients with myocardial infarction and multivessel disease. Hot Line Session 3, ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.
   4. Biscaglia S, et al. N Engl J Med 2023; Sept 7. DOI: 10.1056/NEJMoa2300468.

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Posted on 30 October, 202330 October, 2023