Physiology-Guided Revascularization Strategies in Older Myocardial Infarction Patients: Clinical Insights

A recent trial found that physiology-guided complete revascularization reduces major events at three years in older MI patients, shifting how clinicians weigh revascularization strategies.

The trial reframes practice for older adults with myocardial infarction (MI) and multivessel disease: instead of routine culprit-only PCI for frail or comorbid patients, lesion-level physiology testing identifies ischemia-producing nonculprit lesions and concentrates benefit while avoiding indiscriminate multivessel stenting.

The randomized study enrolled 1,445 older adults with MI and multivessel disease and compared culprit-only treatment with physiology-guided complete revascularization, following patients to three years. The primary composite of death, MI, stroke, or ischemia‑driven revascularization occurred less often with physiology-guided complete revascularization (22.9% vs 29.8%; HR, 0.72; 95% CI, 0.58–0.88; P = .002). The key secondary outcome of cardiovascular death or MI and rates of heart‑failure hospitalization were also reduced. Fewer recurrent MIs and fewer ischemia‑driven revascularizations drove the composite benefit, supporting a durable event reduction with physiology-guided strategies in older patients.

Procedure-related safety signals were favorable or balanced for physiology-guided complete revascularization, with no excess renal harm reported. Assessments of contrast use and renal events showed no increase in renal injury in the trial cohort. In practice, limiting contrast volume, staging procedures for frail patients, and peri‑procedural hydration and monitoring remain key steps to implement physiology-guided strategies safely.

Looking ahead, the trial supports integrating physiology assessment into revascularization planning to refine benefit‑to‑risk decisions for eligible older MI patients with multivessel disease.