Renal Function-Stratified Comparison of Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and Multivessel Disease
Related Experiment Video
Updated: Jan 14, 2026
Post-Myocardial Infarction Heart Failure in Closed-chest Coronary Occlusion/Reperfusion Model in Göttingen Minipigs and Landrace Pigs
Published on: April 17, 2021
Anna Cantone1, Filippo Maria Verardi1, Giuseppe Vadalà2
1Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy.
Insights
Physiology-guided complete revascularization benefits older patients with myocardial infarction (MI), regardless of kidney function. This approach is effective for patients with chronic kidney disease, offering greater clinical advantages due to their higher baseline risk.
Area of Science:
- Cardiology
- Nephrology
- Clinical Trials
Background:
- Chronic kidney disease (CKD) significantly increases cardiovascular event risk and complicates treatment decisions for myocardial infarction (MI) patients.
- Optimal revascularization strategies for elderly MI patients with CKD are not well-established.
Purpose of the Study:
- To evaluate if the benefits of physiology-guided complete revascularization are consistent across elderly MI patients with varying degrees of renal function.
- To assess the impact of renal function on the outcomes of complete versus culprit-only revascularization in older MI patients.
Main Methods:
- The FIRE trial randomized 1,445 elderly patients (≥75 years) with MI and multivessel disease to physiology-guided complete or culprit-only revascularization.
- Patients were stratified by baseline estimated glomerular filtration rate (eGFR) into eGFR ≥60 and eGFR <60 mL/min/1.73 m² groups.
- The primary outcome was a composite of death, MI, stroke, or ischemia-driven revascularization at 3 years.
Main Results:
- A significant proportion (45.8%) of patients had eGFR <60 mL/min/1.73 m².
- The primary endpoint occurred more frequently in patients with lower eGFR (33.5% vs 20.3%).
- Complete revascularization reduced the primary endpoint in both eGFR subgroups (eGFR <60: HR 0.68; eGFR ≥60: HR 0.80), with no significant interaction, indicating consistent benefit across renal function levels.
Conclusions:
- Renal function is a critical prognostic factor in elderly MI patients.
- Physiology-guided complete revascularization demonstrates efficacy irrespective of kidney function.
- The absolute clinical benefit of complete revascularization may be more pronounced in CKD patients due to their higher inherent risk.
Background:
Chronic kidney disease is a major risk factor for cardiovascular events and complicates revascularization decisions in patients with myocardial infarction (MI). However, data on optimal strategies in this population remain limited.
Objectives:
The authors sought to determine whether the benefits of physiology-guided complete revascularization are consistent across subpopulations of older MI patients stratified by renal function.
Methods:
In the FIRE (Functional Assessment in Elderly MI Patients with Multivessel Disease (FIRE) trial, 1,445 patients aged ≥75 years with MI and multivessel disease were randomized to receive physiology-guided complete or culprit-only revascularization. Patients were stratified based on baseline estimated glomerular filtration rate (eGFR) (≥60 vs <60 mL/min/1.73 m2). The primary outcome was a 3-year composite of death, MI, stroke, or ischemia-driven revascularization.
Results:
A total of 662 patients (45.8 %) had eGFR <60 mL/min/1.73 m2. The primary endpoint occurred in 222 patients (33.5%) with eGFR <60 vs 159 patients (20.3%) with eGFR ≥60 mL/min/1.73 m2. Lower eGFR was independently associated with higher risk of the primary endpoint (adjusted HR: 1.42; 95% CI: 1.15-1.76; P < 0.001). Complete revascularization reduced the primary endpoint in both subgroups (HR: 0.68; 95% CI: 0.52-0.89 for patients with eGFR <60 mL/min/1.73 m2; HR: 0.80; 95% CI: 0.59-1.10 for those with eGFR ≥60 mL/min/1.73 m2) without significant interaction (P > 0.42). HR for complete vs culprit-only revascularization remained stable across the continuous eGFR range. Contrast-associated acute kidney injury occurred in 245 patients (17%), increased progressively across Kidney Disease: Improving Global Outcomes (KDIGO) stages (P < 0.001), and was similar between treatment arms (HR: 1.11; 95% CI: 0.87-1.43).
Conclusions:
Kidney function remains a strong prognostic factor in older MI patients. Physiology-guided complete revascularization is effective regardless of renal function and may provide greater absolute clinical benefit in patients with chronic kidney disease due to their elevated baseline risk.
