FIRE: Physiology-Guided Complete Revascularization vs. Culprit-Only Strategy in Older Patients With MI

Physiology-guided complete revascularization reduced ischemic events compared with culprit-only revascularization in patients aged 75 years or older with myocardial infarction and multivessel disease, based on findings from the FIRE trial presented at ESC Congress 2023 and simultaneously published in the New England Journal of Medicine.

The trial enrolled 1,445 patients from 34 sites in Italy, Spain and Poland who were over 75 years of age, had been admitted to hospital with STEMI or NSTEMI, had undergone successful PCI of the culprit lesion, and had multivessel disease with at least one lesion in a non-culprit coronary artery with a minimum vessel diameter of 2.5 mm and a visually estimated diameter stenosis of 50-99%.

After successful treatment of the culprit lesion, researchers randomized patients to receive either culprit-only treatment or physiology-guided complete revascularization. Those patients in the physiology-guided complete revascularization group underwent a physiological assessment using wire-based and angiography-based measurements, as well as PCI of all functionally significant non-culprit lesions. Patients in the culprit-only revascularization group did not receive any physiological assessment or revascularization of non-culprit lesions.

The primary outcome was a composite of death, MI, stroke, or ischemia-driven coronary revascularization occurring within one year of randomization. The primary outcome occurred in 113 patients (15.7%) in the physiology-guided complete revascularization group and 152 patients (21.0%) in the culprit-only group. The number needed to treat to prevent the occurrence of one primary outcome event was 19 patients.

Researchers also assessed one-year composite endpoint of cardiovascular death or MI, which appeared to be lower in the physiology-guided complete revascularization group compared with the culprit-only group. Additionally, with the exception of stroke, each component of the primary outcome appeared to be lower in the physiology-guided complete revascularization group as well. No apparent difference between the two groups was observed in terms of the incidence of a composite of contrast-associated acute kidney injury, stroke, or bleeding within one year of randomization.

"The FIRE trial provides much needed data on the safety and efficacy of physiology-guided complete revascularization in older MI patients with multivessel disease," said Simone Biscaglia, MD, of University Hospital Santa Anna, Ferrara, Italy. "The reduction of the primary endpoint with physiology-guided complete revascularization was mainly driven by hard endpoints such as death and MI. The results suggest that in older MI patients with multivessel disease, complete revascularization guided by physiology should be routinely pursued."

In a related editorial comment, Shamir R. Mehta, MD, FACC, notes that "the FIRE trial confirms the benefit of complete revascularization that has been observed in previous trials and provides additional evidence for this approach in older patients." Mehta adds that findings from the ongoing COMPLETE-2 trial may further help to determine the most appropriate revascularization strategy. Additionally, Mehta cautions not to overlook the value of shared decision-making when discussing strategy options with this vulnerable patient population.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS

Keywords: ESC Congress, ESC23, ACC International, Acute Coronary Syndrome, Percutaneous Coronary Intervention

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