The long-term durability of complete revascularization in older patients with myocardial infarction (MI) and multivessel disease has been a subject of recent debate. New 3-year follow-up data from the Functional Assessment in Elderly MI Patients With Multivessel Disease (FIRE) trial show that the clinical benefits of a physiology-guided complete revascularization strategy are sustained over time compared with a culprit-only approach.¹
The FIRE trial was an investigator-initiated, multicentre, prospective, randomised superiority trial conducted across 34 centres in three countries. The study enrolled 1,445 patients aged 75 years or older who were hospitalised with MI (either ST-elevation MI or non-ST-elevation MI) and multivessel disease, following successful percutaneous coronary intervention (PCI) of the culprit lesion.²
Participants were randomised to either physiology-guided complete revascularization of all functionally significant nonculprit lesions (n=720) or a culprit-only treatment strategy (n=725). The primary outcome was a patient-oriented composite endpoint of death, MI, stroke, or ischaemia-driven revascularization. A key secondary endpoint was the composite of cardiovascular (CV) death or MI.
At the 3-year follow-up, the primary outcome occurred in significantly fewer patients in the complete revascularization group than in the culprit-only group (165 patients [22.9%] versus 216 patients [29.8%]; hazard ratio [HR] 0.72; 95% CI 0.58–0.88; p=0.002).
The key secondary outcome of CV death or MI was also lower in the complete revascularization arm (92 patients [12.8%] versus 132 patients [18.2%]; HR 0.66; 95% CI 0.50–0.88; p=0.004). Furthermore, hospitalisations for heart failure were less frequent in the complete revascularization group compared with the culprit-only group (103 [14.3%] versus 143 [19.7%]; HR 0.73; 95% CI 0.54–0.97; p=0.03).
These findings demonstrate that for older patients with MI and multivessel disease, the benefits of physiology-guided complete revascularization extend beyond the first year, providing a durable prognostic advantage. A landmark analysis showed that the benefits observed in the first year were maintained over the subsequent two years, with a continued reduction in heart failure hospitalisations.
“Among patients 75 years or older with MI and multivessel disease, physiology-guided complete revascularization was associated with a sustained reduction in the composite end point of death, MI, stroke, or ischemia-driven revascularization over a 3-year follow-up, compared with a culprit-only strategy,” the authors concluded.¹
The study had an open-label design and did not directly compare physiology-guided revascularization with an angiography-guided approach. The ongoing COMPLETE-2 and NCT05818475 trials are expected to provide further insights into this comparison in patients with acute coronary syndrome.
References
1. Biscaglia S, Erriquez A, Guiducci V, et al. Physiology-Guided Complete Revascularization in Older Patients With Myocardial Infarction: Three-Year Outcomes of a Randomized Clinical Trial. JAMA Cardiol. 2025. https://doi.org/10.1001/jamacardio.2025.3099
2. Biscaglia S, Guiducci V, Escaned J, et al. Complete or Culprit-Only PCI in Older Patients with Myocardial Infarction. N Engl J Med. 2023;389(10):889-898. https://doi.org/10.1056/NEJMoa2300468
This study was funded by the nonprofit organization Consorzio Futuro in Ricerca, with unrestricted funding from Sahajanand Medical Technologies, Medis Medical Imaging Systems, Eukon, Siemens Healthineers, GE Healthcare, and Insight Lifetech.
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