Individuals with coronary artery disease, which involves plaque accumulation in the arteries leading to symptoms like chest pain, shortness of breath, and heart attacks, often undergo a non-surgical procedure known as percutaneous coronary intervention (PCI). This procedure, conducted by interventional cardiologists, involves using a catheter to place stents in the obstructed coronary arteries to improve blood flow. Typically, angiography guides PCI, using a special dye and X-rays to visualize blood flow and identify blockages in the heart arteries. However, angiography has its shortcomings, such as difficulty in accurately assessing the true size of the artery, the composition of the plaque, and issues in confirming whether a stent is properly expanded after PCI. It's also less effective in spotting other conditions impacting the procedure's early and late results.

Introduced over three decades ago, intravascular ultrasound (IVUS) offers a more precise and detailed view of the coronary arteries. Studies have demonstrated that IVUS-guided PCI is more effective than angiography-guided PCI in reducing cardiovascular events. Despite this, IVUS is utilized in only about 15-20% of PCI cases in the United States, partly due to the complexity of interpreting the images and incomplete reimbursement for the procedure. Optical coherence tomography (OCT), another method that employs light rather than sound to create images, delivers higher resolution, more accurate, and detailed images than IVUS and is easier to interpret. However, OCT is only used in about 3% of PCI cases, largely due to limited research data.

Now, a new study by researchers at Mount Sinai (New York City, NY, USA) has found that using intravascular imaging to guide stent placement during PCI significantly enhances patient survival and reduces adverse cardiovascular events compared to relying on angiography-guided PCI alone. This study, the largest and most comprehensive of its kind, compared IVUS and OCT against angiography-guided PCI. It is the first study to demonstrate that these high-resolution imaging techniques can lower the rates of all-cause death, heart attacks, stent thrombosis, and the necessity for revascularization.

In this study, the researchers evaluated data from 15,964 patients undergoing PCI across 22 trials in various centers from the United States, Europe, Asia, and other regions between March 2010 and August 2023. Patients received either angiography-guided PCI or intravascular imaging-guided PCI using IVUS or OCT. During a follow-up period ranging from 6 to 60 months, averaging two years, those who received guidance via intravascular imaging saw a 25% reduction in all-cause death, 45% reduction in cardiac death, 17% reduction in all myocardial infarctions, and 48% reduction in stent thrombosis compared to those who had angiography guidance. The study also indicated that intravascular imaging reduced target vessel myocardial infarction by 18% and target lesion revascularization by 28%, with similar outcomes for both OCT-guided and IVUS-guided PCI.

“With these results, we now need to shift from performing more studies to determine whether intravascular imaging is beneficial, to increasing efforts to overcome the remaining impediments to the routine use of OCT and IVUS, including better training of physicians and staff and increasing reimbursement,” said Gregg W. Stone, MD, Director of Academic Affairs for the Mount Sinai Health System. “In this regard, we now have better ‘hard evidence’ that intravascular imaging guidance of PCI procedures makes a greater impact to improving our patients’ lives than other routine therapies which are more widely used and reimbursed.” 

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