Complete Revascularization in Older Adults with Myocardial Infarction: Does Lesion Complexity Matter?

In contemporary practice, there remains uncertainty around whether complete revascularization offers consistent benefit in older adults with complex coronary anatomy. The FIRE trial (Functional Assessment in Elderly Myocardial Infarction Patients With Multivessel Disease) offers new evidence to address this gap.

This prespecified analysis of the FIRE trial included 1,445 patients aged 75 years or older with myocardial infarction and multivessel coronary disease, randomized to either culprit-only percutaneous coronary intervention or physiology-guided complete revascularization.

Nonculprit lesions were classified as complex if they had any of the following features: heavy calcification, ostial location, true bifurcation with side branches greater than 2.5 mm, in-stent restenosis, or lesion length requiring a stent longer than 28 mm. These criteria are widely used in randomized trials studying complex high-risk PCI and have clinical applicability.

Key findings from this subgroup analysis:

• Forty-four percent of patients had at least one complex nonculprit lesion. These patients were at significantly higher risk of adverse cardiovascular events over three years, including myocardial infarction (hazard ratio 2.35), cardiovascular death or myocardial infarction (hazard ratio 1.31), and ischemia-driven revascularization (hazard ratio 2.25), even after adjustment for clinical and angiographic confounders.
• Complete revascularization reduced the primary outcome—a composite of death, myocardial infarction, stroke, or repeat revascularization—in both patients with complex lesions (hazard ratio 0.75) and those without (hazard ratio 0.71). There was no statistical interaction by lesion complexity (P for interaction 0.625).
• There were no significant differences in safety outcomes, including contrast-associated acute kidney injury, stroke, or major bleeding, between complex and noncomplex groups, regardless of the revascularization strategy. This suggests that complete revascularization did not increase procedural risk, even in the anatomically complex subgroup.
• The treatment strategy was physiology-guided, using either wire-based or angiography-based assessments. Only ischemia-producing nonculprit lesions were treated. The use of intracoronary imaging was low (<10 percent), reflecting real-world practice in many centers.
• Lesion complexity was not a modifier of treatment effect for any clinical outcome, including cardiovascular death, myocardial infarction, or repeat revascularization. The benefit of complete revascularization appeared consistent across subgroups, regardless of baseline clinical or anatomical risk.
• The benefit was observed despite higher lesion complexity. Among complex cases, 57 percent underwent PCI compared with 32 percent in the noncomplex group. The most common features were long lesions (44 percent), heavy calcification (25 percent), and bifurcations (23 percent).

These findings support the role of physiology-guided complete revascularization in older adults with myocardial infarction and multivessel disease, irrespective of nonculprit lesion complexity. Lesion anatomy alone should not preclude consideration of a complete revascularization strategy in appropriately selected patients.

This study provides actionable evidence to inform revascularization decisions in older populations—a group frequently underrepresented in prior trials. It reinforces the value of personalized, physiology-driven strategies and supports broader application of complete revascularization in older patients with complex anatomy.

Citation: Sarti A, Erriquez A, Dal Passo B, et al. Complete Revascularization in Older Patients With Myocardial Infarction With or Without Complex Nonculprit Lesions. Circulation: Cardiovascular Interventions. Published online 2025. doi:10.1161/CIRCINTERVENTIONS.125.015902