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. 2025 Oct 25:S1936-8798(25)02464-1.
doi: 10.1016/j.jcin.2025.09.019. Online ahead of print.

Renal Function-Stratified Comparison of Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and Multivessel Disease

Anna Cantone  1 , Filippo Maria Verardi  1 , Giuseppe Vadalà  2 , Vincenzo Guiducci  3 , Gianni Casella  4 , Caterina Cavazza  5 , Enrico Cerrato  6 , Giorgio Sacchetta  7 , Raul Moreno  8 , Matteo Serenelli  1 , Ignacio Amat Santos  9 , José Luis Díez Gil  10 , Roberto Scarsini  11 , Andrea Picchi  12 , Marta Cocco  1 , Iginio Colaiori  13 , Marco Barbierato  14 , Manfredi Arioti  15 , Federico Marchini  1 , Rita Pavasini  1 , Serena Caglioni  1 , Valerio Lanzilotti  4 , Mila Menozzi  5 , Andrea Erriquez  1 , Gianluca Campo  16 , Simone Biscaglia  17
Affiliations

Renal Function-Stratified Comparison of Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction and Multivessel Disease

Anna Cantone et al. JACC Cardiovasc Interv. .

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.

Keywords: coronary physiology; myocardial infarction; older patients; renal function.

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Conflict of interest statement

Funding Support and Author Disclosures Sahajanand Medical Technologies Ltd. (SMT), Medis Medical Imaging Systems, Eukon S.r.l., Siemens Healthineers, General Electric (GE) Healthcare, and Insight Lifetech provided unrestricted funding to the study sponsor for the conduction of the trial. These companies had no involvement in the trial design, data collection, analysis, interpretation, or writing of the manuscript. Dr Biscaglia received funding from the Italian Health Minister (Ricerca Finalizzata 2021, GR-2021-12372516) for the conduction of the Functional Coronary Angiography Guided Revascularization in STEMI trial. Dr Moreno has received speaker/consulting fees from Abbott Vascular, AMGEN, AstraZeneca, Biosensors, Biotronik, Boston Scientific, Daiichi Sankyo, Edwards Lifesciences, Medtronic, and Philips, outside the submitted work. Dr Campo has received research grants and personal fees from Abbott Vascular, GADA, Menarini, Amgen, Daiichi Sankyo, and Sanofi, outside the submitted work. Dr Biscaglia has received personal fees from Abbott Vascular and Siemens Healthcare, outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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