For PCI, Intravascular Ultrasound Guidance Bests Angiography Guidance

ATLANTA — The use of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients with acute coronary syndromes resulted in better outcomes compared with angiography-guided therapy, a randomized trial showed.

Target vessel failure — a composite of cardiac death, target vessel myocardial infarction, and clinically driven target vessel revascularization — at 1 year occurred among 4% of patients who had IVUS-guided PCI compared with 7.3% of those who underwent angiography-guided PCI (HR 0.55, 95% CI 0.41-0.74, P=0.0001), reported Shao-Liang Chen, MD, of Nanjing Medical University and Nanjing First Hospital in China, during the American College of Cardiology annual meeting.

As detailed in The Lancet, a breakdown of the composite endpoint was as follows:

• Target vessel myocardial infarction occurred in 2.5% of the IVUS-guided group versus 3.8% of the angiography-guided group (HR 0.63, 95% CI 0.43-0.92, P=0.018)
• Clinically driven target vessel revascularization was required by 1.4% and 3.2%, respectively (HR 0.44, 95% CI 0.27-0.72, P=0.0010)
• Cardiac death occurred in 0.5% and 1.1% (HR 0.56, 95% CI 0.24-1.29, P=0.17)

There were no significant differences in all-cause death or stent thrombosis between the groups.

The study included patients who were mostly Chinese. In the non-Chinese-population — 3% of the more than 3,500 people in the study — there was no significant difference favoring one imaging methodology over the other. A similar non-significant outcome was seen in women, who made up about 25% of the study population.

Chen noted that previous registry studies have suggested that major adverse cardiac events in patients with acute coronary syndromes could be reduced by implanting contemporary drug-eluting stents guided by IVUS, but only three small randomized trials have compared IVUS-guided PCI with angiography-guided PCI and all had inconclusive results. International guidelines do not currently recommend IVUS-guided PCI in patients with acute coronary syndromes.

In an accompanying commentary, Wijnand den Dekker, MD, of University Medical Center Rotterdam in the Netherlands, noted that “the IVUS-ACS study is the first large randomized study to show the beneficial effect of intravascular ultrasound in patients with acute coronary syndromes.”

“It seems that intravascular imaging guidance might get a class 1 recommendation soon with some more trials to come in both patients with ST-elevation myocardial infarction and patients undergoing complex coronary intervention,” he wrote. “Until then, operators would benefit from getting familiar with intravascular imaging-guided percutaneous coronary intervention.”

For this study, Chen and colleagues enrolled patients who presented with acute coronary syndrome at 58 centers in China, Italy, Pakistan, and the U.K. from August 2019 through October 2022. About 40% of the patients had unstable angina, 31-33% had non-STEMI, and roughly 28% had STEMI.

All patients had been referred for treatment with second-generation drug-eluting stents. The researchers randomly assigned 1,753 patients to receive IVUS-guided PCI (mean age 62, 73.3% men, 88.4% Chinese), and 1,752 to angiography-guided PCI (mean age 63, 74.1% men, 88.2% Chinese). Across both groups, 62% of patients had a history of hypertension, 31% had diabetes, 68-70% had dyslipidemia, and 6% had been diagnosed with heart failure.

Almost all of the procedures — 96.4% in both cohorts — were performed using transradial access. Resolute stents were employed in 42% of patients, Firehawk stents were used in 52% of patients, and a mixture of stents were implanted in about 6% of patients.

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