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Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and High Bleeding Risk: A
Andrea Erriquez1, Gianluca Campo1, Vincenzo Guiducci2
1Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy.
Insights
For older patients with myocardial infarction (MI) and high bleeding risk (HBR), physiology-guided complete revascularization significantly reduces adverse events compared to a culprit-only strategy.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- High bleeding risk (HBR) is associated with poor prognosis in myocardial infarction (MI) patients.
- The benefit of complete revascularization in HBR patients post-MI remains unclear.
Purpose of the Study:
- To compare physiology-guided complete revascularization versus a culprit-only strategy in patients with HBR, MI, and multivessel disease.
Main Methods:
- Prespecified analysis of the FIRE randomized clinical trial data.
- Inclusion of patients aged 75+ with MI and multivessel disease.
- Randomization to physiology-guided complete revascularization or culprit-only strategy.
Main Results:
- 71% of 1445 patients met HBR criteria and faced higher risks of adverse events.
- Physiology-guided complete revascularization significantly reduced the primary endpoint (death, MI, stroke, revascularization) in HBR patients (HR, 0.73; 95% CI, 0.55-0.96).
- No interaction between revascularization strategy and HBR status for primary/secondary endpoints.
Conclusions:
- HBR is common in older MI patients and increases adverse event likelihood.
- Physiology-guided complete revascularization is effective in reducing ischemic events in HBR patients compared to culprit-only strategy.
Importance:
Patients with high bleeding risk (HBR) have a poor prognosis, and it is not known if they may benefit from complete revascularization after myocardial infarction (MI).
Objective:
To investigate the benefit of physiology-guided complete revascularization vs a culprit-only strategy in patients with HBR, MI, and multivessel disease.
Design, Setting, And Participants:
This was a prespecified analysis of the Functional Assessment in Elderly MI Patients With Multivessel Disease (FIRE) randomized clinical trial data. FIRE was an investigator-initiated, open-label, multicenter trial. Patients 75 years or older with MI and multivessel disease were enrolled at 34 European centers from July 2019 through October 2021. Physiology treatment was performed either by angiography- or wire-based assessment. Patients were divided into HBR or non-HBR categories in accordance with the Academic Research Consortium HBR document.
Interventions:
Patients were randomized to either physiology-guided complete revascularization or culprit-only strategy.
Main Outcomes And Measures:
The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. Secondary outcomes included a composite of cardiovascular death or MI and Bleeding Academic Research Consortium (BARC) types 3 to 5.
Results:
Among 1445 patients (mean [SD] age, 81 [5] years; 917 male [63%]), 1025 (71%) met HBR criteria. Patients with HBR were at higher risk for the primary end point (hazard ratio [HR], 2.01; 95% CI, 1.47-2.76), cardiovascular death or MI (HR, 1.89; 95% CI, 1.26-2.83), and BARC types 3 to 5 (HR, 3.28; 95% CI, 1.40-7.64). The primary end point was significantly reduced with physiology-guided complete revascularization as compared with culprit-only strategy in patients with HBR (HR, 0.73; 95% CI, 0.55-0.96). No indication of interaction was noted between revascularization strategy and HBR status for primary and secondary end points.
Conclusions And Relevance:
HBR status is prevalent among older patients with MI, significantly increasing the likelihood of adverse events. Physiology-guided complete revascularization emerges as an effective strategy, in comparison with culprit-only revascularization, for mitigating ischemic adverse events, including cardiovascular death and MI.
Trial Registration:
ClinicalTrials.gov Identifier: NCT03772743.
