Complete or Culprit-Only PCI in Older Patients with Myocardial Infarction

The FIRE trial a multicenter, randomized study compared physiology-guided complete revascularization versus culprit-lesion-only PCI in 1445 patients aged ≥75 with STEMI or NSTEMI and multivessel coronary disease. Functionally significant nonculprit lesions were assessed via pressure wire or quantitative flow ratio imaging. At 1-year follow-up, complete revascularization reduced the primary composite endpoint (death, MI, stroke, or ischemia-driven revascularization) from 21.0% to 15.7% (HR 0.73; P=0.01). Cardiovascular death or MI occurred in 8.9% vs. 13.5% (HR 0.64), with all-cause mortality lower in the complete-revascularization group (9.2% vs. 12.8%; HR 0.70). Safety events (acute kidney injury, major bleeding, or stroke) were similar (22.5% vs. 20.4%). Physiology-guided PCI enabled selective stenting, avoiding unnecessary interventions in ~51% of nonculprit vessels. Benefits accrued steadily over 12 months across subgroups (e.g., STEMI/NSTEMI, EF, renal function). The trial supports physiology-based complete revascularization for older MI patients with multivessel disease.

The FIRE trial a multicenter, randomized study compared physiology-guided complete revascularization versus culprit-lesion-only PCI in 1445 patients aged ≥75 with STEMI or NSTEMI and multivessel coronary disease. Functionally significant nonculprit lesions were assessed via pressure wire or quantitative flow ratio imaging. At 1-year follow-up, complete revascularization reduced the primary composite endpoint (death, MI, stroke, or ischemia-driven revascularization) from 21.0% to 15.7% (HR 0.73; P=0.01). Cardiovascular death or MI occurred in 8.9% vs. 13.5% (HR 0.64), with all-cause mortality lower in the complete-revascularization group (9.2% vs. 12.8%; HR 0.70). Safety events (acute kidney injury, major bleeding, or stroke) were similar (22.5% vs. 20.4%). Physiology-guided PCI enabled selective stenting, avoiding unnecessary interventions in ~51% of nonculprit vessels. Benefits accrued steadily over 12 months across subgroups (e.g., STEMI/NSTEMI, EF, renal function). The trial supports physiology-based complete revascularization for older MI patients with multivessel disease.