IVUS guidance bests angiography guidance in PCI for acute coronary syndrome
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Key takeaways:
- IVUS-guided PCI reduced risk for target vessel failure for patients with ACS vs. angiography-guided PCI.
- Lower risk was only observed for lesions meeting the target criteria for optimal IVUS-guided PCI.
ATLANTA — Intravascular ultrasound-guided PCI lowered risk for target vessel failure vs. an angiography-guided approach for patients with acute coronary syndrome, a speaker reported.
The results of the multicenter, international, randomized IVUS-ACS trial were presented at the American College of Cardiology Scientific Session and simultaneously published in The Lancet.
“Before the conduction of this trial, there were only three small dedicated randomized clinical trials using OCT- compared with angiography-guided PCI in patients with acute coronary syndrome. But the results were inconclusive,” Shao-Liang Chen, MD, PhD, interventional cardiologist at Nanjing Medical University and Nanjing First Hospital in Nanjing, China, said during a presentation. “So far, there was no dedicated randomized study using IVUS-guided PCI compared with angiography-guided PCI in patients with acute coronary syndrome.”
The IVUS-ACS trial included 3,505 patients with ACS referred for PCI using a second-generation drug-eluting stent. Participants were randomly assigned to either IVUS- or angiography-guided PCI.
The mean age of participants was 62 years in the IVUS group and 63 years in the angiography group, and nearly three-quarters were men.
The primary endpoint was a composite of 1-year target vessel failure (TVF), including cardiac death, target vessel MI, or clinically driven target vessel revascularization (TVR). Secondary endpoints included TVF without procedural MI, stent thrombosis and individual components of the primary endpoint.
had no major ischemic or bleeding events after 1 month of post-procedure dual antiplatelet therapy underwent a second randomization for ULTIMATE-DAPT.
At 1 year, Chen and colleagues observed that risk for the primary composite outcome was lower among patients assigned to IVUS compared with those assigned angiography (4% vs. 7.3%; HR = 0.55; 95% CI, 0.41-0.74; P = .0001).
This finding was consistent across all subgroups, including for patients who presented with non-STEMI/STEMI or unstable angina (P for interaction = .26), according to the presentation.
Lower risk for the primary composite endpoint at 1 year was mainly driven by lower risk for:
- spontaneous target-vessel MI (HR = 0.41; 95% CI, 0.2-0.84; P = .0143)
- clinically driven TVR (HR = 0.44; 95% CI, 0.27-0.72; P = .001); and
- clinically driven target lesion revascularization (HR = 0.52; 95% CI, 0.31-0.88; P = .0141).
Risk for the secondary endpoint of TVF without procedural MI was also lower in the IVUS-guided PCI arm compared with angiography (HR = 0.45; 95% CI, 0.3-0.66; P < .0001).
Chen noted that the lower risk for TVF was only observed for patients with prespecified optimal IVUS criteria, which consisted of nearly 80% of the IVUS arm of the study. Suboptimal IVUS-guided PCI conferred similar 1-year TVF risk compared with angiography. Please see the study for full details on the target criteria for optimal IVUS-guided PCI.
“In patients with acute coronary syndrome, IVUS-guided implantation of contemporary drug-eluting stents reduced the 1-year rate of the composite of target vessel failure, including cardiac death, target-vessel myocardial infarction or clinically driven TVR compared with angiography guidance alone,” Chen said during the presentation.
Reference:
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Chen SL. Featured clinical research III. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
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