August 2023: Complete or Culprit-Only PCI in Older Patients with Myocardial Infarction
The issue
For heart‑attack patients ≥ 75 with multivessel coronary disease, cardiologists have debated whether to stent only the blocked “culprit” artery or go on to treat additional narrowings. In the FIRE trial, physiology‑guided complete revascularization lowered the 1‑year risk of death, new heart attack, stroke, or repeat procedures to 15.7 % versus 21.0 % with culprit‑only stenting (hazard ratio 0.73; number‑needed‑to‑treat 19).
What do I need to know?
The study enrolled 1,445 adults (median age 80; one‑third women) who first underwent successful stenting of the culprit lesion and were then randomized. Complete revascularization, guided by pressure‑wire or angiographic flow measurements, also cut the composite of cardiovascular death or recurrent heart attack to 8.9 % vs 13.5 % (HR 0.64). Serious safety events—acute kidney injury, stroke, or major bleeding—were similar between strategies (22.5 % vs 20.4 %). These benefits came without a penalty in complications, supporting a more proactive stenting approach when additional lesions are physiologically significant.
Potential risk of future cardiac events
The older adult has had the culprit artery opened but still has other narrowings of unclear significance.
Recommended Actions
Ask the cardiologist whether those lesions have been assessed with pressure‑wire or quantitative flow ratio.
Keep guideline‑directed medical therapy (dual antiplatelet, statin, β‑blocker, ACE‑inhibitor/ARB) optimized while evaluation is pending.
Schedule cardiac rehabilitation to restore fitness and monitor symptoms.
Imminent risk of future cardiac events
Physiology testing shows at least one non‑culprit lesion is flow‑limiting, but no additional stent has been placed yet.
Recommended Actions
Discuss completing revascularization during the same hospitalization or soon after, given the proven 1‑year benefit.
Review kidney function and bleeding history to plan contrast volume and antiplatelet strategy.
Confirm follow‑up within three months to track recovery and medication tolerance.
Confirmed high‑risk anatomy
Recurrent angina, ischemia on imaging, or severe non‑culprit stenosis after the initial PCI.
Recommended Actions
Proceed with physiology‑guided stenting of all significant lesions, using radial access and ultrathin drug‑eluting stents when possible.
Continue dual antiplatelet therapy for at least 12 months (longer if bleeding risk is low).
Monitor renal function and hemoglobin after the procedure; adjust medications promptly if adverse effects emerge.
What can I do?
Ask the heart team, “Am I at potential, imminent, or confirmed risk from untreated blockages, and what is our step‑by‑step plan?” Bring hospitalization records, current medication list, and any new chest‑pain diary to each visit. After additional stenting, maintain cardiac‑rehab attendance, report shortness of breath or bleeding right away, and ensure regular lab checks so you get the full survival benefit without added harm.
