IVUS-guided PCI beats angiography in patients with acute coronary syndrome

In patients with acute coronary syndrome (ACS), intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) reduced target vessel failure at 1 year compared with angiography-guided PCI in the IVUS-ACS trial. This benefit was driven by reductions in target vessel myocardial infarction (MI) and target vessel revascularisation.

“So far, there were no dedicated randomised-controlled trials of IVUS-guided PCI versus angiography-guided PCI in patients with ACS,” Prof. Shao-Liang Chen (Nanjing Medical University, China) explained the rationale for the IVUS-ACS trial (NCT03971500) [1]. Until recently, only 3 small randomised-controlled trials of intravascular imaging-guided versus angiography-guided PCI have been performed in patients with ACS. Therefore, Prof. Chen and his team set up the international, investigator-initiated IVUS-ACS trial to investigate whether IVUS guidance compared with angiography guidance for implantation of second-generation drug-eluting stents improves the outcomes of PCI in these patients [1,2].

All participants presented with ACS within 30 days before randomisation. The analysis included 3,505 participants from 58 centres in China (over 2,000 of the participants), Italy, Pakistan, and the UK, who were randomised to IVUS-guided PCI (n=1,753) or angiography-guided PCI (n=1,752). In the IVUS group, 39.9% had unstable angina, 32.5% had a non-ST elevation myocardial infarction (non-STEMI), and 27.6% had a STEMI. The percentages in the angiography-guided group were similar: 41.4% had unstable angina, 30.7% non-STEMI, and 27.9% STEMI.

The primary study endpoint was target vessel failure, a composite of cardiac death, target vessel MI, or clinically driven target vessel revascularisation 1 year after randomisation. At this time, 4.0% in the IVUS-guided PCI group compared with 7.3% of participants in the angiography-guided PCI group reached this endpoint, a highly significant difference driven by reductions in target vessel MI and target vessel revascularisation (HR 0.55; 95% CI 0.41–0.74; P<0.0001; see Figure). The safety outcomes were similar between the 2 groups.

Figure: Primary endpoint of the IVUS-ACS trial: target vessel failure [1]



CI, confidence interval; IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention; TVF, target vessel failure.

Prof. Chen pointed out that all subgroups (including participants with diabetes, multivessel disease, or those receiving antiplatelet therapy) benefitted from the IVUS-guided stent implantation independent of whether they had unstable angina, STEMI, or non-STEMI.

1. Chen SL, et al. Intravascular Ultrasound-guided Versus Angiography-guided Percutaneous Coronary Intervention in Acute Coronary Syndromes: The Multicenter, Randomized, Blinded, IVUS-ACS Trial. Featured Clinical Research 3, Session 413, ACC 2024 Scientific Session, 6–8 April, Atlanta, USA.
2. Li X, et al. Lancet 2024;Apr 8. DOI: 10.1016/S0140-6736(24)00282-4.

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Posted on 16 May 202413 June 2024