Key Points:
- The IVUS-ACS trial assessed whether the use of intravascular ultrasound guidance, as compared with angiography guidance, improves the outcomes of percutaneous coronary intervention with contemporary drug-eluting stents in patients presenting with an acute coronary syndrome.
- The study showed that IVUS-guided implantation of contemporary DES resulted in a lower 1-year rate of the composite outcome of cardiac death, target vessel myocardial infarction, or clinically driven revascularization compared with angiography guidance alone.
During the ACC 2024 scientific session, researchers unveiled the results of the Intravascular Ultrasound-guided Versus Angiography-guided Percutaneous Coronary Intervention in Acute Coronary Syndromes (IVUS-ACS) Trial. Led by S. Chen, SR, and G. W. Stone, this multicenter, randomized, blinded trial sheds new light on optimizing treatment strategies for ACS patients.
The IVUS-ACS trial addresses a critical gap in knowledge regarding the efficacy of IVUS-guided PCI compared to angiography-guided PCI in ACS cases. With limited prior data on this subject, the study’s findings carry significant implications for clinical practice. In this two-stage, multicentre, randomized trial, patients aged 18 years or older and presenting with an acute coronary syndrome at 58 centers in China, Italy, Pakistan, and the UK were randomly assigned to IVUS-guided percutaneous coronary intervention or angiography-guided PCI. Patients, follow-up health-care providers, and assessors were masked to random assignment; The primary endpoint was target vessel failure, a composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization at 1 year after randomization. Secondary endpoints included stent thrombosis and all-cause death at 1 year, providing a comprehensive evaluation of the two PCI approaches’ effectiveness. Secondary endpoints included stent thrombosis and all-cause death at 1 year, providing a comprehensive evaluation of the two PCI approaches’ effectiveness.
A total of 3505 patients with an ACS were randomly assigned to IVUS-guided percutaneous coronary intervention (n=1753) or angiography-guided percutaneous coronary intervention (n=1752). The trial included a diverse cohort, with a mean patient age of 61.4 years and a predominance of male participants. Clinical syndromes ranged from unstable angina to ST-segment elevation myocardial infarction. Notably, the trial encompassed patients with high-risk features, including long lesions, true bifurcations, heavily calcified lesions, and left main lesions.The primary endpoint occurred in 70 patients in the intravascular ultrasound group and 128 patients in the angiography group (Kaplan-Meier rate 4-0% vs 7-3%; hazard ratio 0-55 [95% CI 0-41-0-74]; p=0-0001), driven by reductions in target vessel myocardial infarction or target vessel revascularization. There were no significant differences in ali-cause death or stent thrombosis between groups. Safety endpoints were also similar in the two groups.
In individuals experiencing acute coronary syndromes, utilizing IVUS guidance during the placement of modern drug-eluting stents led to a decreased one-year occurrence of the combined events of cardiac death, target-vessel myocardial infarction, or clinically-driven target-vessel revascularization in contrast to relying solely on angiography guidance. After one year of clinical follow-up, the trial’s results offer crucial insights into the efficacy and safety of IVUS-guided PCI in ACS patients, compared to angiography-guided PCI.
The IVUS-ACS trial represents a landmark effort in advancing personalized treatment approaches for ACS patients. By rigorously evaluating the benefits of IVUS guidance in PCI procedures, the study paves the way for optimized therapeutic strategies and improved patient outcomes in this high-risk population.
