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

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.