Physiology-Guided Complete Revascularization Shows Sustained 3-Year Benefit in Elderly MI Patients: JAMA
Italy: In patients aged 75 years or older with myocardial infarction and multivessel disease, physiology-guided complete revascularization continued to show superior outcomes compared with culprit-lesion–only treatment at 3-year follow-up.
The findings are from the Functional Assessment in Elderly MI Patients With Multivessel Disease (FIRE) trial, a multicenter randomized study led by Dr. Simone Biscaglia and colleagues at the Azienda Ospedaliero Universitaria di Ferrara in Italy. The results, published in JAMA Cardiology, after analysis in early 2025, provide important evidence that the advantages of complete, physiology-based revascularization in older adults are not only immediate but durable over time.
The trial enrolled 1,445 patients with myocardial infarction—either ST-segment elevation or non-ST-segment elevation—who also had multivessel coronary disease. After successful treatment of the culprit lesion, participants were randomly assigned either to receive no further intervention or to undergo physiology-guided treatment of nonculprit lesions. Patients with left main disease or uncertain culprit lesions were excluded. The median age of the study population was 80 years, and nearly two-thirds were male.
The study’s key findings were as follows:
- At 3 years, the primary composite outcome of death, recurrent heart attack, stroke, or ischemia-driven revascularization occurred less often in the physiology-guided complete revascularization group (22.9%) compared with the culprit-only group (29.8%), representing a 28% relative risk reduction (HR, 0.72).
- The combined risk of cardiovascular death or recurrent myocardial infarction was 12.8% in the complete revascularization group versus 18.2% in the culprit-only group, showing a 34% reduction (HR, 0.66).
- Hospitalizations for heart failure were also lower in the complete-treatment group (14.3%) compared with the culprit-only group (19.7%), corresponding to a hazard ratio of 0.73.
These results confirm that the initial benefit seen at one year is not only preserved but continues to grow in importance over longer follow-up. Importantly, the trial addresses previous concerns raised by other studies that questioned whether older adults truly sustain the same benefits from complete revascularization as younger populations.
The implications are clinically significant. Older patients with myocardial infarction often present with multiple coexisting health issues and are sometimes managed more conservatively due to concerns about procedural risk. However, the FIRE trial demonstrates that with physiology-guided decision-making, comprehensive treatment of coronary blockages leads to meaningful improvements in survival and long-term cardiovascular outcomes—even in this higher-risk group.
“In elderly patients with multivessel disease, adopting a physiology-based complete revascularization strategy provides lasting protection against recurrent cardiovascular events and hospitalizations,” the authors concluded.
"Overall, the trial highlights that age alone should not be a barrier to comprehensive, physiology-guided coronary intervention in patients with myocardial infarction and multivessel disease," they wrote.
Reference:
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. Published online August 29, 2025. doi:10.1001/jamacardio.2025.3099
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