Intravascular imaging guidance for percutaneous coronary intervention and clinical outcomes: meta-analyses of randomized controlled trials.

Recent randomized trials have questioned the incremental benefit of intravascular imaging-guided PCI, and the populations most likely to benefit remain uncertain. This study evaluates the long-term outcomes of intravascular imaging-guided PCI and associated factors with greater treatment benefit. Randomized controlled trials (RCTs) comparing PCI guided by intravascular ultrasound (IVUS), optical coherence tomography (OCT), or angiography were systematically identified. The primary outcome was major adverse cardiac events (MACE), defined as a composite of cardiovascular death, target-vessel myocardial infarction, and target-vessel or target-lesion revascularization. Pairwise and network meta-analyses were performed. Subgroup analyses were conducted according to lesion complexity, clinical presentation (acute coronary syndrome [ACS] vs. chronic coronary syndrome [CCS]), and trial region (Asian vs. non-Asian). A total of 23,338 patients from 29 RCTs were included (8,443 IVUS-guided PCI, 5,115 OCT-guided PCI, and 9,780 angiography-guided PCI). Imaging-guided PCI was associated with a significantly lower risk of MACE compared with angiography-guided PCI (HR, 0.74; 95%CI, 0.63-0.87). No significant difference in MACE risk was observed between IVUS- and OCT-guided PCI. The benefit of imaging-guided PCI was greater in trials enrolling patients with complex lesions, ACS, and Asian populations, but a significant interaction was observed only between Asian vs. non-Asian populations (P < 0.01 for interaction). Intravascular imaging-guided PCI was associated with a lower risk of MACE compared with angiography-guided PCI, and its benefit was more consistently observed in trials enrolling patients with Asian populations than non-Asian trials. Further investigation into the benefits of imaging guidance according to patient profiles is warranted. IVUS, intravascular ultrasound; MACE, major adverse cardiovascular events; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; RCT, randomized controlled trial.