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Hot Line: How to treat older MI patients with multivessel disease? Results from the FIRE trial

27 Aug 2023

Doctor Simone Biscaglia (University Hospital Santa Anna - Ferrara, Italy) presented important new data to address a knowledge gap regarding the benefits of physiology-guided complete revascularisation versus culprit-only revascularisation in older patients with a myocardial infarction (MI) and multivessel disease (MVD).

With longer life expectancy, increasing numbers of older patients are experiencing MI and these patients are at higher risk of both ischaemic and bleeding complications than younger patients.1 The prognosis of elderly patients is equally impaired with ST-elevation (STE) or non-STE (NSTE) MI and markedly worsened by the common presence of MVD.1 Limited evidence is available for elderly patients with MI and MVD, and there are no specific recommendations on the type of revascularisation as it has not yet been established whether, as for younger patients, a complete revascularisation strategy is preferable in older patients. ESC guidelines state that routine revascularisation of non-culprit lesions should be considered in STEMI patients with MVD before hospital discharge.2,3 For NSTEMI, ESC guidelines recommend applying the same interventional strategies in older patients as for younger patients.4

As presented in a Hot Line session yesterday, the FIRE trial examined whether complete revascularisation based on coronary physiology is superior to a culprit-only strategy in 1,445 older patients with MI and MVD. Patients were eligible if they were at least 75 years old, had been admitted to hospital with STEMI or NSTEMI, had undergone successful percutaneous coronary intervention (PCI) of the culprit lesion, and had MVD with at least one lesion in a non-culprit coronary artery with a minimum vessel diameter of 2.5 mm and a visually estimated diameter stenosis of 50–99%. Patients who were randomised to the physiology-guided complete revascularisation group received physiological assessment using wire-based and angiography-based measurements plus PCI of all functionally significant non-culprit lesions. Both physiological assessment and PCI of non-culprit lesions were allowed during either the index intervention or in a staged procedure within the index hospitalisation. Patients randomised to culprit-only revascularisation did not undergo any physiological assessment or revascularisation of non-culprit lesions. The primary outcome was a patient-oriented composite endpoint of death, MI, stroke or ischaemia-driven coronary revascularisation occurring at 1 year. Patients from Italy, Spain and Poland participated and their median age was 80 years (36.5% were women).

The primary outcome occurred in 15.7% in the physiology-guided complete revascularisation group and 21.0% of patients in the culprit-only group (hazard ratio [HR] 0.73; 95% CI 0.57 to 0.93; p=0.01).

The number needed to treat (NNT) to prevent the occurrence of one primary outcome event was 19. The key secondary outcome of CV death or MI appeared to be lower in the physiology-guided complete revascularisation group (HR 0.64; 95% CI 0.47 to 0.88) and the NNT was 22. With the exception of stroke, each component of the primary outcome appeared to be lower in the physiology-guided complete revascularisation group, including death (HR 0.70; 95% CI 0.51 to 0.96) where the NNT to prevent one death was 27.

The safety outcome was a composite of contrast-associated acute kidney injury, stroke or bleeding (Bleeding Academic Research Consortium type 3 or 5) within 1 year. No apparent difference was observed between the two groups for the safety outcome, with an HR of 1.11 for physiology-guided complete revascularisation versus culprit-only revascularisation (95% CI 0.89 to 1.37; p=0.37).

“The FIRE trial provides much needed data on the safety and efficacy of physiology-guided complete revascularisation in older MI patients with MVD,” comments Dr. Biscaglia. “The reduction of the primary endpoint with physiology-guided complete revascularisation was mainly driven by hard endpoints such as death and MI. The results suggest that in older MI patients with MVD, complete revascularisation guided by physiology should be routinely pursued.”


  1. Biscaglia S, et al. Am Heart J. 2020;229:100–109.
  2. Ibanez B, et al. Eur Heart J. 2018;39:119–177.
  3. Neumann FJ, et al. Eur Heart J. 2019;40:87–165.
  4. Collet JP, et al. Eur Heart J. 2021;42:1289–1367.