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Complete Revascularization in NSTEMI vs. STEMI Older Patients
Quick Takes
- In older MI patients, the use of physiology-guided complete revascularization compared with culprit-only strategy provided consistent benefits across the entire spectrum of MI.
- The clinical implications of this finding are important, as it provides the first evidence from a randomized controlled trial supporting that the benefit of complete revascularization did not differ between STEMI and NSTEMI patients.
- These data suggest that in the presence of a clearly identifiable culprit lesion, physiology-guided complete revascularization is reasonable in both older STEMI and NSTEMI patients.
Study Questions:
What is the impact of complete revascularization versus culprit-only revascularization on outcomes in older patients with ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation myocardial infarction (NSTEMI)?
Methods:
The investigators analyzed 1,445 older patients with myocardial infarction (MI) from the FIRE (Functional Assessment in Elderly MI Patients with Multivessel Disease) trial, who were randomized to culprit-only or physiology-guided complete revascularization, stratified by STEMI (n = 256 culprit-only vs. n = 253 complete) and NSTEMI (n = 469 culprit-only vs. n = 467 complete). This was a prespecified subanalysis. The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. The key secondary outcome was a composite of cardiovascular death or MI at 1 year. Time-to-event data were evaluated with the use of Kaplan–Meier estimates and Cox proportional hazards models, dividing the study population according to clinical presentation and/or randomization arm.
Results:
In the overall study population, physiology-guided complete revascularization reduced both primary and key secondary outcomes. The primary outcome occurred in 54 (21.1%) STEMI patients randomized to culprit-only versus 41 (16.2%) STEMI patients of the complete group (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.50-1.13) and in 98 (20.9%) NSTEMI patients randomized to culprit-only versus 72 (15.4%) NSTEMI patients of the complete group (HR, 0.71; 95% CI, 0.53-0.97), with negative interaction testing ( for interaction = 0.846). Similarly, no signal of heterogeneity with respect to the initial clinical presentation was observed for the key secondary endpoint (p for interaction = 0.654).
Conclusions:
The authors report that a physiology-guided complete revascularization, compared with culprit-only revascularization, provided consistent benefit across the whole spectrum of patients with MI.
Perspective:
The results of this prespecified subanalysis of the FIRE trial show that in older MI patients, the use of physiology-guided complete revascularization compared with culprit-only strategy provided consistent benefits across the entire spectrum of MI, without evidence that type of clinical presentation affected the results of the random allocation. The clinical implications of this finding are important, as it provides the first evidence from a randomized controlled trial supporting that the benefit of complete revascularization did not differ between STEMI and NSTEMI patients. These data suggest that in the presence of a clearly identifiable culprit lesion, physiology-guided complete revascularization is reasonable in both older STEMI and NSTEMI patients.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, Myocardial Revascularization, Non-ST Elevated Myocardial Infarction, ST Elevation Myocardial Infarction
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