Complete Revascularization in Older Patients with Myocardial Infarction

This editorial evaluates the FIRE trial, which randomized 1445 patients (≥75 years old; median age 80) with acute myocardial infarction and multivessel coronary disease to receive complete revascularization versus culprit-lesion-only PCI. Most patients had NSTEMI. At 1 year, complete revascularization reduced the composite of death, MI, stroke, or repeat revascularization (15.7% vs. 21.0%; HR 0.73; P=0.01), with significant reductions in cardiovascular death or MI (8.9% vs. 13.5%; HR 0.64) and all-cause mortality (9.2% vs. 12.8%; HR 0.70). No major safety concerns were noted. The editorial highlights the consistency of benefit regardless of ST-segment elevation status, the need to consider physiologic vs. angiographic guidance, and the future role of intracoronary imaging and shared decision-making tailored to older adults’ values and comorbidities. It underscores COMPLETE-2 as a key ongoing trial to clarify optimal lesion-selection strategy.

This editorial evaluates the FIRE trial, which randomized 1445 patients (≥75 years old; median age 80) with acute myocardial infarction and multivessel coronary disease to receive complete revascularization versus culprit-lesion-only PCI. Most patients had NSTEMI. At 1 year, complete revascularization reduced the composite of death, MI, stroke, or repeat revascularization (15.7% vs. 21.0%; HR 0.73; P=0.01), with significant reductions in cardiovascular death or MI (8.9% vs. 13.5%; HR 0.64) and all-cause mortality (9.2% vs. 12.8%; HR 0.70). No major safety concerns were noted. The editorial highlights the consistency of benefit regardless of ST-segment elevation status, the need to consider physiologic vs. angiographic guidance, and the future role of intracoronary imaging and shared decision-making tailored to older adults’ values and comorbidities. It underscores COMPLETE-2 as a key ongoing trial to clarify optimal lesion-selection strategy.