[Myocardial infarction of the elderly : After FIRE trial, complete coronary revascularization for all ?]

Myocardial infarction (MI) is the leading cause of death worldwide, particularly affecting the elderly, a growing population. Yet, their management remains under-researched, especially in cases of multivessel coronary artery disease. These patients are at higher risk for post-procedural complications, but evidence - especially from the FIRE study (2023 - suggests that complete revascularization guided by coronary physiology (FFR or QFR) significantly reduces cardiovascular events in patients over 75, without a significant increase in complications. However, other studies like FLOWER-MI and SENIOR-RITA offer more nuanced perspectives. FLOWER-MI did not show a benefit of FFR guidance in younger patients, while SENIOR-RITA (2024) found that an invasive strategy after a non ST elevation acute coronary syndrome did not improve survival over medical therapy in very comorbid elderly patients, though it did reduce the rate of recurrent MIs. In conclusion, complete physiology-guided revascularization appears beneficial and safe for robust or mildly comorbid elderly patients, whereas a conservative approach may be preferable for more frail individuals. Treatment decisions should be individualized, considering overall health, comorbidities, life expectancy, patient preferences, and ideally discussed within a cardiogeriatric team. There's a growing need for practical tools to assess patient frailty and support clinical decision-making.