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.
Renal Function-Stratified Comparison of Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and Multivessel Disease
Cantone, Anna;Verardi, Filippo Maria;Casella, Gianni;Cavazza, Caterina;Serenelli, Matteo;Cocco, Marta;Marchini, Federico;Pavasini, Rita;Caglioni, Serena;Lanzilotti, Valerio;Erriquez, Andrea;Campo, Gianluca;Biscaglia, Simone
2025
Abstract
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.I documenti in SFERA sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
