FIRE trial supports complete revascularization for older MI patients

medwireNews: Physiology-guided complete revascularization can be considered for older patients with myocardial infarction (MI) and multivessel disease, suggest the results of the FIRE trial. The approach was associated with a significant 27% reduction in the risk for a composite of death, MI, stroke, or ischemia-driven revascularization at 1 year versus culprit-only revascularization, reported Simone Biscaglia (Azienda Ospedaliero Universitaria di Ferrara, Italy) at the ESC Congress 2023 in Amsterdam, the Netherlands. He added that there was no significant difference between the approaches with respect to the safety outcome, and therefore Biscaglia expects the management of older patients with MI and multivessel disease to change from a conservative to a complete approach as a result of these findings. The study enrolled 1445 patients aged 75 years or older with MI – with (35.2%) or without (64.8%) ST-segment elevation – and multivessel disease who had undergone successful percutaneous coronary intervention of the culprit lesion. Participants were randomly allocated to either undergo physiology-guided complete revascularization of nonculprit lesions or no further revascularization. During a year of follow-up, the primary outcome event occurred in 15.7% of the 720 patients in the complete vascularization group and 21.0% of the 725 in the culprit-only revascularization group, a significant difference equating to a hazard ratio (HR) of 0.73. “The benefit was driven by a reduction in each individual component of the composite outcome, with the exception of stroke,” write the researchers in an accompanying publication in The New England Journal of Medicine. The incidence of a key secondary outcome, a composite of cardiovascular death or MI, at 1 year was also significantly lower in the complete than culprit-only revascularization arm, at 8.9% versus 13.5%, and an HR of 0.64. The safety outcome was a composite of contrast-associated acute kidney injury, stroke, or major bleeding at 1 year, and this occurred in a numerically greater proportion of patients who underwent complete rather than culprit-only revascularization, at 22.5% versus 20.4%, but the between-group difference was not statistically significant. Writing in a related editorial, Shamir Mehta (McMaster University and Hamilton Health Sciences, Ontario, Canada) says 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.” He continues: “The reduction in mortality with complete revascularization at 1 year is particularly notable and reinforces the finding that complete revascularization should be considered in all patients presenting with acute myocardial infarction, regardless of age.” The editorialist notes, however, that “uncertainty remains as to whether to perform complete revascularization with a physiology-guided strategy, in which only functionally significant lesions are revascularized, or with an angiography-guided strategy, in which revascularization is based on stenosis severity.” medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2023 Springer Healthcare Ltd, part of the Springer Nature Group ESC Congress 2023; Amsterdam, the Netherlands: 25–28 August N Engl J Med 2023; doi:10.1056/NEJMoa2300468 N Engl J Med 2023; doi:10.1056/NEJMe2307941

ERS International Congress 2023

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FIRE trial supports complete revascularization for older MI patients

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ERS International Congress 2023

Springer Medicine

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