Physiology-Guided Complete Revascularization in Elderly Adults with Complex Disease

Complete revascularization in patients with acute myocardial infarction (AMI) and multivessel coronary artery disease has consistently shown clinical benefits in reducing major ischemic events. However, the applicability of this strategy in elderly patients with non-culprit lesions of high anatomical complexity is still subject to controversy. Clinical decisions in this group are often influenced by the perception of high risk, both due to age and to the presence of challenging angiographic characteristics such as severe calcification, true bifurcations, or extensive lesions.

In this context, Sarti et al. conducted a subanalysis of the FIRE study, in which they assessed the clinical impact of a physiology-guided complete revascularization strategy in patients aged ≥75 years with AMI, according to the anatomical complexity of non-culprit lesions, comparing it with culprit-lesion revascularization only.

Complexity was angiographically defined by the presence of severe calcification, ostial lesions, true bifurcations (>2.5 mm), in-stent restenosis, or long lesions (>28 mm). Researchers included a total of 1445 patients aged ≥75 years hospitalized for AMI (with or without ST-segment elevation) and with at least one functionally assessable non-culprit lesion.

The population was divided into two subgroups: patients with at least one complex non-culprit lesion (44%) and those without complex lesions (56%). At three years, patients with complex lesions had a higher incidence of MACE (major adverse cardiovascular events: death, AMI, stroke, or ischemia-driven revascularization), as well as of individual events such as AMI (9.4% vs. 6.5%) and need for repeat revascularization (9.8% vs. 6.1%), compared with those without complex lesions. 

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Nevertheless, this higher baseline risk did not negate the benefits of the complete revascularization strategy: in both subgroups, this approach was associated with a significant reduction in the primary event (in the complex lesion group, adjusted hazars ratio [HR] 0.75 [95% confidence interval (CI): 0.56–0.99], and in the non-complex lesion group, adjusted HR 0.71 [95% CI: 0.53–0.95]).

This finding underscores the relevance of physiology: even in technically high-risk anatomies, physiology-guided complete revascularization maintains its efficacy without increasing safety events such as bleeding, stroke, or acute kidney injury.

Conclusions

This study challenges the conservative clinical approach often adopted in elderly or complex coronary anatomy patients. The evidence highlights that advanced age and anatomical complexity should not be barriers to offering optimal treatment. Therapeutic decisions should be guided more by coronary functionality than by anatomy in itself.

Original Title: Complete Revascularization in Older Patients With Myocardial Infarction With or Without Complex Nonculprit Lesions.

Reference: Sarti A, Erriquez A, Dal Passo B, Casella G, Guiducci V, Moreno R, Escaned J, Marchini F, Cocco M, Verardi FM, Clò S, Caglioni S, Farina J, Barbato E, Vadalà G, Cavazza C, Capecchi A, Gallo F, Campo G, Biscaglia S. Complete Revascularization in Older Patients With Myocardial Infarction With or Without Complex Nonculprit Lesions. Circ Cardiovasc Interv. 2025 Oct 3:e015902. doi: 10.1161/CIRCINTERVENTIONS.125.015902. Epub ahead of print. PMID: 41039960.