Metanalysis: OCT or IVUS is associated with improved outcomes compared to angiography alone

By Lucas Marinacci on

Key Points

  • This metanalysis integrating data from ILUMIEN IV and OCTOBER Trials with 18 prior randomized trials found that intravascular imaging (IVI) with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was associated with a 31% reduction in target lesion failure (TLF) compared to angiography alone.
  • In addition, there were statistically significant reductions in all-cause death, all myocardial infarction (MI), and target vessel revascularization (TVR), a novel finding.
  • OCT and IVUS performed similarly compared against angiography and one another.
  • These data indicate that IVI with either OCT or IVUS is associated with better long-term clinical outcomes compared to angiography alone. The authors plan to update the analysis with data from the OCTIVUS trial, also presented the same day at ESC.

There have been multiple trials comparing intravascular imaging to conventional angiography, the majority of which have studied IVUS, as OCT is a relatively new technology.  Systematic review and meta-analyses have found a benefit to IVUS, including reduced risk of cardiovascular death and major adverse cardiac events.1  However none to date have demonstrated reductions in all-cause death or all MI.

On August 27th, 2023 the results of the Intravascular Imaging Guidance for PCI: A “Real-Time” Updated Network Meta-analysis were presented in a Hot Line Session at ESC Congress 2023.  The purpose of this study was to integrate data from the ILUMIEN IV and OCTOBER trials, both presented on the same day at ESC comparing OCT to angiography, with 18 other randomized trials in order to examine the effects of intravascular imaging guidance versus angiography guidance. The analysis compared: 1) the overall effects of intravascular imaging (IVUS and OCT) in improving outcomes of the PCI procedure versus angiography; 2) IVUS versus angiography; 3) OCT versus angiography; and 4) IVUS versus OCT. The primary endpoint was TLF, defined as a composite of cardiac death, target vessel myocardial infarction (TV-MI), or target lesion revascularization (TLR).  In addition to the individual components of the primary endpoint, secondary endpoints included stent thrombosis, all-cause death, all MI, and target vessel revascularization (TV-R).

Overall 12,428 patients with acute or chronic coronary syndromes were included in the analysis, including 3,120 patients randomized to IVUS guidance, 2,826 patients randomized to OCT guidance, 1,092 patients randomized to IVUS or OCT, and 5,390 randomized to angiography.  They were followed for 6 months to 5 years.

Compared to angiography alone, IVI  was associated with a reduction in the primary endpoint of TLF (RR 0.69, 95% CI 0.61-0.78, p<0.001).  There was no heterogeneity observed between studies.  There was also network estimates indicating IVI was significantly associated with lower risk of each of the individual components of the primary endpoint as well as lower risks of stent thrombosis (RR 0.48 95% CI 0.31-0.76), all cause death (RR 0.75, 95% CI 0.60-0.93), and all MI (RR 0.82, 95% CI 0.69, 0.98).   In pairwise comparisons of OCT vs IVS, no significant differences were found in the primary endpoint of TLF (RR 1.22 95% CI 0.96, 1.56), nor any of the secondary endpoints, including stent thrombosis, all-cause death, or all MI.

According to principal investigator Dr. Gregg Stone of Icahn School of Medicine at Mount Sinai, New York, USA: “The present network met-analysis demonstrates compared with angiography-guided PCI, IVI-guided PCI reduced TLF by 31% driven by 46%, 20%, and 29% reductions in cardiac death, TV-MI and TLR respectively.  In addition, we saw a reduction in stent thrombosis by 52% and for the first time found a reduction in all MI by 18% and all-cause death by 25%.”