Functional Assessment in Elderly MI Patients With Multivessel Disease - FIRE

Jun 25, 2024
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Kim A. Eagle, MD, MACC
Trial Sponsor:
Consorzio Futuro in Ricerca
Date Presented:
08/26/2023
Date Published:
05/14/2024
Date Updated:
06/25/2024
Original Posted Date:
08/26/2023
References

Contribution To Literature:

Highlighted text has been updated as of June 25, 2024.

The FIRE trial showed that physiology-guided complete revascularization reduces major adverse cardiac events compared with culprit-only revascularization.

Description:

The goal of the trial was to evaluate multivessel revascularization guided by coronary physiology compared with culprit-only revascularization among elderly patients with acute myocardial infarction (MI) and multivessel coronary artery disease (CAD).

Study Design

  • Randomized
  • Parallel
  • Open-label

Patients with acute MI and multivessel CAD were randomized to multivessel revascularization guided by coronary physiology (n = 720) vs. culprit-only revascularization (n = 725).

  • Total number of enrollees: 1,445
  • Duration of follow-up: 12 months
  • Mean patient age: 80 years
  • Percentage female: 37%
  • Percentage with diabetes: 32%

Inclusion criteria:

  • ≥75 years of age
  • ST-segment elevation myocardial infarction (STEMI) or NSTEMI
  • Successful percutaneous coronary intervention (PCI) of culprit lesion

Exclusion criteria:

  • Unclear culprit lesion
  • Life expectancy <1 year
  • Prior coronary artery bypass grafting (CABG)

Principal Findings:

The primary outcome, death, MI, stroke, or ischemia-driven revascularization at 12 months, was 15.7% in the physiology-guided complete revascularization group vs. 21.0% in the culprit-lesion only group (p < 0.05).

Secondary outcomes:

  • Death or MI: 8.9% in the physiology-guided complete revascularization group vs. 13.5% in the culprit-lesion only group (p < 0.05)
  • Acute kidney injury, stroke, or major bleeding: 22.5% in the physiology-guided complete revascularization group vs. 20.4% in the culprit-lesion only group (p = not significant)

Outcomes according to high bleeding risk status:

  • Primary outcome (death, MI, stroke, or ischemia-driven revascularization at 12 months) among those with high bleeding risk (n = 1,025): 19% among those with physiology-guided complete revascularization vs. 24% among those with culprit-lesion only revascularization
  • Primary outcome (death, MI, stroke, or ischemia-driven revascularization at 12 months) among those with non–high bleeding risk (n = 420): 8.5% among those with physiology-guided complete revascularization vs. 14% among those with culprit-lesion only revascularization (p for interaction = 0.55)
  • Major bleeding (Bleeding Academic Research Consortium [BARC] 3, 4, or 5) among those with high bleeding risk (n = 1,025): 6% among those with physiology-guided complete revascularization vs. 6.5% among those with culprit-lesion only revascularization
  • Major bleeding (BARC 3, 4, or 5) among those with non–high bleeding risk (n = 420): 2% among those with physiology-guided complete revascularization vs. 1% among those with culprit-lesion only revascularization (p for interaction = 0.08)

Quantitative flow ratio (QFR):

QFR is an angiography-based modality (without use of wire) for functional assessment of coronary stenoses.

In the physiology-guided complete revascularization group, endpoints were compared between nonculprit vessels investigated with QFR vs. wire-based physiology. QFR was used to determine physiology in 35.2% of cases. There was no difference in vessel-oriented composite endpoints for QFR vs. wire-based physiology (hazard ratio 0.57, 95% confidence interval 0.28-1.15).

In the culprit-lesion only group, QFR was measured for nonculprit lesions and associated with outcomes. There were 40.5% of nonculprit vessels with a QFR value ≤0.8. Low QFR values were associated with increased vessel-oriented composite endpoints (22.1%) vs. normal QFR values (7.1%) (p < 0.001).

Interpretation:

Among elderly patients with acute MI, physiology-guided complete revascularization improves outcomes compared with culprit-lesion only revascularization. Outcomes were the same among those with high bleeding risk. The incidence of acute kidney injury, stroke, or major bleeding was similar between the treatment groups. Multiple trials now support a strategy of complete revascularization among patients with acute coronary syndrome and multivessel CAD. QFR is a novel, wire-free method, which appears to be feasible in determining coronary physiology.

References:

Erriquez A, Campo G, Guiducci V, et al. QFR for the Revascularization of Nonculprit Vessels in MI Patients: Insights From the FIRE Trial. JACC Cardiovasc Interv 2024;17:1425-36.

Editorial Comment: Complete Revascularization in AMI: Igniting Insights Beyond the Flames of FIRE. JACC Cardiovasc Interv 2024;17:1437-9.

Erriquez A, Campo G, Guiducci V, et al. Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and High Bleeding Risk: A Randomized Clinical Trial. JAMA Cardiol 2024;9:565-73.

Biscaglia S, Guiducci V, Escaned J, et al., on behalf of the FIRE Trial Investigators. Complete or Culprit-Only PCI in Older Patients With Myocardial Infarction. N Engl J Med 2023;389:889-98.

Editorial: Mehta SR. Complete Revascularization in Older Patients With Myocardial Infarction. N Engl J Med 2023;389:951-2.

Presented by Dr. Simone Biscaglia at the European Society of Cardiology Congress, Amsterdam, Netherlands, August 26, 2023.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS

Keywords: Acute Coronary Syndrome, ESC Congress, ESC23, Geriatrics, Myocardial Revascularization


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