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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 , 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 . International guidelines do not currently recommend IVUS-guided PCI in patients with acute coronary syndromes.

In an , 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 , 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.