PCI among older heart attack patients: Complete revascularization outperforms culprit-only approach
When treating older patients with a history of myocardial infarction and multivessel disease with percutaneous coronary intervention (PCI), physiology-guided complete revascularization is associated with better outcomes than only targeting culprit lesions. That was the key takeaway from new research presented at ESC Congress 2023, the annual meeting of the European Society of Cardiology (ESC), and simultaneously published in The New England Journal of Medicine.[1]
The FIRE clinical trial included data from nearly 1,500 patients 75 years old or older. All patients were treated at one of 34 sites in Italy, Spain or Poland.
Each patient presented with a history of myocardial infarction, multivessel disease and a visually estimated diameter stenosis of 50-99%. Studies were excluded if a culprit lesion could not be clearly identified, nonculprit lesions resided in the left main coronary artery or the patient’s life expectancy was less than one year.
While all patients underwent PCI of the culprit lesion, patients were randomized to either undergo physiology-guided complete revascularization or no additional revascularization. The median age was 80 years old.
The study’s primary outcome—a composite of death, myocardial infarction, stroke or revascularization after one year—was seen in 15.7% of patients in the complete revascularization group and 21% in the culprit lesion-only group. The secondary outcome—a composite of cardiovascular death or repeat myocardial infarction after one year—was seen in 8.9% of patients in the complete revascularization group and 13.5% of patients in the culprit lesion-only group.
Safety, meanwhile, was examined by focusing on a composite outcome of contrast-associated acute kidney injury, stroke or bleeding events. For this outcome, there was not a significant outcome between the two patient groups.
“The FIRE trial provides much needed data on the safety and efficacy of physiology-guided complete revascularization in older MI patients with multivessel disease,” principal investigator Simone Biscaglia, MD, PhD, an interventional cardiologist with University Hospital Santa Anna in Italy, said in a prepared statement. “The reduction of the primary endpoint with physiology-guided complete revascularization was mainly driven by hard endpoints such as death and myocardial infarction. The results suggest that in older MI patients with multivessel disease, complete revascularization guided by physiology should be routinely pursued.”
Steen Dalby Kristensen, an interventional cardiologist with Aarhus University Hospital in Denmark and former ESC vice president, spoke with Cardiovascular Business at ESC Congress 2023 about the conference’s many late-breaking studies. Kristensen highlighted the importance of the FIRE trial, saying it helped prove to cardiologists that physiology-guided complete revascularization was the best plan of action.
Read the full study here.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.