The use of physiology-guided complete revascularization is superior to a culprit-only strategy for older patients with either STEMI or NSTEMI, according to a prespecified substudy of the FIRE trial presented at ESC Congress 2024 in London and simultaneously published in JACC.

Across centers in Italy, Spain and Poland between 2019 and 2021, the FIRE trial randomized 1,445 patients ≥75 years with an MI and multivessel disease to either physiology-guided complete revascularization or culprit-only revascularization. Patients were only eligible if they had a clearly identified culprit lesion successfully treated by PCI and a nonculprit coronary artery lesion with a minimum diameter of 2.5 mm and a diameter stenosis of 50% to 99%.

Among the participants, those with STEMI tended to have a worse Killip class at hospital admission and a lower left ventricle ejection fraction at hospital discharge. Patients with an NSTEMI, on the other hand, had culprit lesions more frequently located in the left main and left anterior descending coronary artery and a higher burden of comorbidities.

Results showed that, at one-year follow-up, the benefit of complete revascularization was consistent in patients with either STEMI or NSTEMI. Among patients with STEMI, the composite primary outcome, consisting of death, MI, stroke or ischemia-driven coronary revascularization, occurred in 16.2% in the complete revascularization arm and 21.1% in the culprit-only arm (hazard ratio [HR], 0.75; 95% CI, 0.50-1.13). Similarly, in patients with NSTEMI, the outcome occurred in 15.4% and 20.9% of the two arms, respectively (HR, 0.71; 95% CI, 0.53-0.97; pint<0.846). Results were similar for the key secondary outcome, a one-year composite endpoint of cardiovascular death or MI (pint<0.658).

Study authors Marta Cocco, MD, et al., write, "The clinical implication of this finding is important, as it provides the first evidence from an RCT [randomized clinical trial] supporting that the benefit of complete revascularization did not differ between STEMI and NSTEMI patients." They note that in patients with NSTEMI where identifying culprit lesions can be challenging, this can be of particular benefit.

In an accompanying editorial comment, Yousif Ahmad, MD, PhD, FACC; Rohin K. Reddy, MBBS; and Shamir R. Mehta, MD, FACC, caution that, because the data are based on a secondary analysis, conclusions should be categorized as "hypothesis-generating" for now, but they "welcome both this study and other RCTs in progress that will attempt to use high-quality randomized data to answer some of the ongoing questions regarding acute MI and multivessel [coronary artery disease]."