Written by Peter Liu
Spoon Feed
Patients hospitalized with STEMI and NSTEMI should receive expedited revascularization of all significant coronary artery lesions, not just the culprit lesion implicated in the acute coronary syndrome (ACS) presentation.
Synopsis
This study (the FIRE trial) investigated whether complete revascularization improves outcomes in older patients with myocardial infarction (MI), including STEMI and NSTEMI presentations. Using a randomized trial design, 1445 patients aged ≥75 were assigned to physiology-guided complete or culprit-only percutaneous coronary intervention. At 1 year, complete revascularization significantly reduced the composite primary endpoint (death, MI, stroke, or revascularization) in NSTEMI (HR 0.71, 95%CI 0.53-0.97). Composite primary endpoint was numerically lower in STEMI (HR 0.75, 95%CI 0.50-1.13), but did not reach statistical significance. Limitations include subgroup size differences and focus on older patients. The results support complete revascularization for both MI types in this population. (AI-generated)
While you’re in there, just fix all the blockages…
For patients treated for ACS, one important decision made by the cardiac care team is whether to treat just the culprit coronary artery lesion that caused the acute MI (usually due to plaque rupture or acute thrombus formation), or whether to “go after” all significant stenotic lesions (i.e. complete revascularization).
The FIRE trial adds to a growing body of evidence that suggests the following.
- Patients have fewer cardiovascular complications if complete revascularization is achieved.
- Timely complete revascularization within days is generally superior to delayed revascularization in weeks to months.
While the relevant findings of the FIRE trial are limited to patients over 75 years old who presented with NSTEMI, several other studies allow us to generalize to younger patients presenting with NSTEMI (SMILE and BIOVASC) and patients presenting with STEMI. These findings generally prompt me to advocate for timely complete revascularization when I collaborate with cardiology teams on type 1 NSTEMI care and to look for important extenuating reasons when complete revascularization is deferred (e.g. hemodynamic instability, high contrast load and risk for contrast nephropathy, challenging anatomy, considerations for CABG rather than PCI, etc.).
Source
Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction With or Without ST-Segment Elevation. J Am Coll Cardiol. 2024 Nov 12;84(20):2014-2022. doi: 10.1016/j.jacc.2024.07.028. Epub 2024 Aug 31. PMID: 39217557
Why do we try to limit care and treat people minimally, cost cutting sometimes goes to far. I am surprised this study was done and encouraged at the same time