Benefits of physiology-guided complete revascularization of non-culprit lesions in elderly patients with myocardial infarction across the spectrum of GRACE score: insights from the FIRE trial

Background The GRACE score is a well-established tool for predicting mortality outcomes in patients with myocardial infarction (MI) (1). However, its interaction with revascularization strategies in older patients with MI remains unclear. The FIRE trial demonstrated the benefits of complete physiology-guided revascularization in this clinical setting (2). Purpose This study aimed to assess whether the GRACE score was predictive of adverse events in the FIRE trial cohort and whether the benefits of complete revascularization were independent of GRACE score tertiles. Methods The FIRE trial randomized 1,445 patients aged 75 years or older with MI and multivessel coronary artery disease to receive either culprit-only or complete revascularization. In this sub-analysis, patients were stratified according to GRACE score tertiles: the first tertile (GRACE 92.6–128.0), the second tertile (GRACE 128.1–146.5), and the third tertile (GRACE 146.6–236.0). The primary endpoint was all-cause mortality at one-year. Secondary endpoints included cardiovascular (CV) death and a composite of CV death or MI at one-year. Outcomes at one-month were also evaluated. Interaction analyses were conducted to evaluate whether the GRACE score modified the benefits of complete coronary revascularization. Results According to GRACE score tertiles, 487 patients were in the first tertile (33.7%), 477 in the second tertile (33.0%), and 481 in the third tertile (33.3%). Patients in the third tertile were more compromised in terms of cardiovascular risk factors and comorbidities. At one-year, all-cause mortality was significantly higher in the third tertile (p < 0.0001), as well as CV death (p < 0.0001) and the composite of CV death or MI (p < 0.0001). However, the effect of physiology-guided revascularization did not differ across GRACE score tertiles (p for interaction > 0.05 for all the outcomes of interest). The same effect was observed at one-month (all p for interaction > 0.05). Survival analysis showed that the GRACE score was significantly associated with increased all-cause mortality (HR 1.027, 95% CI 1.021–1.033, p < 0.001), CV death (HR 1.031, 95% CI 1.023–1.039, p < 0.001), and the composite of CV death or MI (HR 1.020, 95% CI 1.013–1.026, p < 0.001). Again, no interaction was found between revascularization strategy and GRACE score classes (all p for interaction > 0.05). Physiology-guided revascularization was protective for all the outcomes of interest (all HRs < 1, all p < 0.05). Conclusions The GRACE score was confirmed to be predictive of mortality outcomes in the FIRE cohort. However, the benefits of physiology-guided complete revascularization were maintained across the entire spectrum of GRACE score. Older patients with MI and multivessel disease should receive complete physiology-guided revascularization, regardless of the severity of their GRACE score.