Diabetes does not attenuate the benefit of physiology-guided complete revascularization in older patients with myocardial infarction

In patients with myocardial infarction (MI) and multivessel disease, diabetes mellitus is associated with more diffuse coronary atherosclerosis and worse clinical outcomes, often influencing revascularization decisions. The Functional Assessment in Elderly MI Patients with Multivessel Disease (FIRE) trial demonstrated the superiority of physiology-guided complete revascularization in older patients with MI. Whether this benefit is preserved in patients with diabetes remains uncertain. In FIRE, 1445 patients aged ≥ 75 years with MI and multivessel disease were randomized to culprit-only or physiology-guided complete revascularization. In this prespecified analysis, outcomes were assessed according to diabetes status. The primary endpoint was a composite of death, MI, stroke, or revascularization at 3 years. The key secondary endpoint was cardiovascular death or MI. The safety endpoint included contrast-associated acute kidney injury, stroke, or Bleeding Academic Research Consortium type 3–5 bleeding. Among 1445 patients, 463 (32%) had diabetes. After adjustment for baseline characteristics, diabetes was independently associated with a higher risk of the primary endpoint (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.02–1.56) and heart failure (HR 1.35, 95% CI 1.01–1.83) at 3 years. Physiology-guided complete revascularization reduced the primary outcome in both patients with diabetes (HR 0.70, 95% CI 0.50–0.97) and without diabetes (HR 0.75, 95% CI 0.58–0.97), with no evidence of effect modification by diabetes status (p for interaction = 0.712). Similar consistency was observed for the key secondary and safety endpoints. In older patients with MI and multivessel disease, physiology-guided complete revascularization reduces ischemic events irrespective of diabetes status, supporting its use in elderly diabetic patients. Trial registration ClinicalTrials.gov Identifier NCT03772743.

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Journal
Cardiovascular Diabetology
Published
2026-04-14
DOI
https://doi.org/10.1186/s12933-026-03165-5
Primary Topic
Coronary Interventions and Diagnostics
Type
article
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article

Diabetes does not attenuate the benefit of physiology-guided complete revascularization in older patients with myocardial infarction

Marco Ruozzi, Caterina Cavazza, Giuseppe Vadalà, Filippo Maria Verardi et al.
Cardiovascular Diabetology
Coronary Interventions and Diagnostics
article

Diabetes does not attenuate the benefit of physiology-guided complete revascularization in older patients with myocardial infarction

Marco Ruozzi, Caterina Cavazza, Giuseppe Vadalà, Filippo Maria Verardi, Simone Biscaglia, Federico Marchini, Roberto Scarsini, Andréa Picchi, Jacopo Farina, Andrea Erriquez, Marco Barbierato, Matteo Tebaldi, Alberto Menozzi, Serena Caglioni, José Luis Díez Gil, Alberto Sarti, Ignacio Amat Santos, Alessandro Capecchi, E Cerrato, Francesco Gallo, Javier Escaned, Marta Cocco, Vincenzo Guiducci, Rita Pavasini, Gianni Casella, Raul Moreno, Gianluca Campo
article en

Abstract

In patients with myocardial infarction (MI) and multivessel disease, diabetes mellitus is associated with more diffuse coronary atherosclerosis and worse clinical outcomes, often influencing revascularization decisions. The Functional Assessment in Elderly MI Patients with Multivessel Disease (FIRE) trial demonstrated the superiority of physiology-guided complete revascularization in older patients with MI. Whether this benefit is preserved in patients with diabetes remains uncertain. In FIRE, 1445 patients aged ≥ 75 years with MI and multivessel disease were randomized to culprit-only or physiology-guided complete revascularization. In this prespecified analysis, outcomes were assessed according to diabetes status. The primary endpoint was a composite of death, MI, stroke, or revascularization at 3 years. The key secondary endpoint was cardiovascular death or MI. The safety endpoint included contrast-associated acute kidney injury, stroke, or Bleeding Academic Research Consortium type 3–5 bleeding. Among 1445 patients, 463 (32%) had diabetes. After adjustment for baseline characteristics, diabetes was independently associated with a higher risk of the primary endpoint (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.02–1.56) and heart failure (HR 1.35, 95% CI 1.01–1.83) at 3 years. Physiology-guided complete revascularization reduced the primary outcome in both patients with diabetes (HR 0.70, 95% CI 0.50–0.97) and without diabetes (HR 0.75, 95% CI 0.58–0.97), with no evidence of effect modification by diabetes status (p for interaction = 0.712). Similar consistency was observed for the key secondary and safety endpoints. In older patients with MI and multivessel disease, physiology-guided complete revascularization reduces ischemic events irrespective of diabetes status, supporting its use in elderly diabetic patients. Trial registration ClinicalTrials.gov Identifier NCT03772743.

Cardiovascular Diabetology
NATO Centre for Maritime Research and Experimentation (IT), Santa Maria Nuova Hospital (IT), Hospital Universitario La Paz (ES), Hospital Clínico San Carlos (ES), Ospedale Maggiore (IT), Azienda Unita' Sanitaria Locale Di Modena (IT), Azienda Sanitaria Unità Locale di Reggio Emilia (IT), Azienda Ospedaliera Universitaria Integrata Verona (IT), Centro de Investigación en Red en Enfermedades Cardiovasculares (ES), Ospedale Maggiore Carlo Alberto Pizzardi (IT), Azienda Unità Sanitaria Locale di Ferrara (IT), Santa Maria Nuova Hospital (IT), Hospital La Paz Institute for Health Research (ES), Centro de Investigación Biomédica en Red (ES), Ospedale per gli Infermi (IT), Arcispedale Sant'Anna (IT), Ospedale Infermi di Rimini (IT), Ospedale Misericordia - Grosseto (IT), Ospedale dell' Angelo (IT), Azienda Ospedaliera Universitaria Policlinico "Paolo Giaccone" di Palermo (IT), Ospedale San Luigi Gonzaga (IT), National Operating Committee on Standards for Athletic Equipment (US), Union des Industries Ferroviaires Européennes (BE)
Good health and well-being
Openalex Percentile: Top 26%
Coronary Interventions and Diagnostics
DOIOpen Access PDFOpenAlex
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