The population over 75 is growing gradually, which entails an increase in acute myocardial infarction (AMI) in this group. As we all know, it is fairly common for AMI to present with multivessel disease.
It has been shown that younger patients will benefit from complete revascularization vs. a simple resolution of the culprit vessel. However, this matter has not been looked at exhaustively in older patients and we lack data from large randomized studies in this regard.
The FIRE Trial is a prospective randomized study designed to assess a physiology guided complete revascularization vs. culprit vessel revascularization in STEMI or N-STEMI patients over 75. It included a total 725 patients undergoing culprit only revascularization and 720 patients undergoing physiology guided complete revascularization (RCGF).
Primary end point was a composite of death, MI, stroke or ischemia driven revascularization within a year after randomization.
The two groups of patients had similar characteristics. Mean age was 80, and 36.5% were women. Also, 82% had hypertension, 32% diabetes, 15% prior MI, 18% prior PCI, 14% presented atrial fibrillation, 17% peripheral vascular disease, 8% stroke and 46% had some degree of kidney failure.
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65% of patients had a history of NSTEMI (non ST elevation MI), 28% had Killip-Kimball (KK) ≥2, and 49%mean ejection fraction.
The anterior descending was the most affected artery (45%), followed by the right coronary and the circumflex. The left main was seldom affected. Also, 30% of patients received two or more stents during procedure.
Hospital stay was slightly higher in the complete revascularization group, though this difference did not reach statistical significance.
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Primary end point was lower in the complete revascularization group (15.7% vs 21%; hazard ratio, 0.73; CI 95% [CI], 0.57 to 0.93; P = 0.01). The number necessary to treat to prevent new primary end point was 19 patients. There were no significant differences in terms of cardiovascular death or MI separately (8.9% vs 13.5%; hazard ratio, 0.64; CI 95%, 0.47 to 0.88). Neither were there differences in stroke, bleeding or kidney failure.
Conclusion
In conclusion, patients over 75 with MI and multivessel disease undergoing physiology guided complete revascularization were at lower risk of presenting the composite of death, MI, stroke or any revascularization within a year vs. patients receiving culprit only PCI.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Complete or Culprit-Only PCI in Older Patients with Myocardial Infarction.
Reference: S. Biscaglia, et al. N Engl J Med 2023;389:889-98.
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