Journal of the American College of Cardiology (JACC)Complete Revascularization in NSTEMI vs. STEMI Older Patients

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The FIRE trial’s prespecified subanalysis evaluated 1,445 older MI patients, comparing physiology-guided complete revascularization versus culprit-only strategy in both STEMI and NSTEMI populations. The study demonstrated consistent benefits of complete revascularization across both patient groups, providing the first randomized controlled trial evidence that supports similar outcomes regardless of MI type.

Key Points:

• Complete revascularization reduced primary outcomes (death, MI, stroke, or revascularization) in both groups at 1 year:
  • STEMI: 16.2% vs 21.1% (HR 0.75, 95% CI 0.50-1.13)
  • NSTEMI: 15.4% vs 20.9% (HR 0.71, 95% CI 0.53-0.97)
• No significant interaction between clinical presentation and treatment strategy (p=0.846), indicating consistent benefits across MI types
• Study population included balanced distribution:
  • STEMI: 256 culprit-only vs 253 complete revascularization
  • NSTEMI: 469 culprit-only vs 467 complete revascularization
• Secondary endpoints (cardiovascular death or MI) showed similar consistency between groups (interaction p=0.654)
• Clinical practice implications support physiology-guided complete revascularization for both STEMI and NSTEMI patients with identifiable culprit lesions

HCN Medical Memo
The FIRE trial demonstrates that age and MI type should not limit consideration for complete revascularization when guided by physiological assessment.

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