[The impact of intravascular imaging-guided coronary stent implantation on clinical outcomes in patients with acute coronary syndrome].

Objective: To evaluate the impact of intravascular imaging-guided versus angiography-guided stent implantation on clinical outcomes in patients with acute coronary syndrome (ACS). Methods: This study was a retrospective cohort study. Between January 2023 and October 2023, 3 220 ACS patients who underwent coronary stent implantation at the Second Affiliated Hospital of Harbin Medical University were consecutively enrolled. Patients were divided into intravascular imaging-guided group (n=2 550) and angiography-guided group (n=670) based on whether intravascular imaging was used during the procedure. Patients from both groups were matched through 1∶1 propensity score matching according to clinical and angiographic characteristics, yielding 625 patients in each group. The primary endpoint was 2-year major adverse cardiovascular events (MACE), including cardiac death, non-fatal myocardial infarction, and ischemia-driven revascularization. Cumulative event rates were estimated using the Kaplan-Meier method and compared with the log-rank test; subgroup analysis was performed based on the presence or absence of complex lesions. Cox proportional hazards regression models were used to evaluate the impact of intravascular imaging guidance on patient prognosis. Results: The age of patients was (62.4±10.5) years, and 2 203 (68.4%) were male. Compared with the angiography-guided group, the intravascular imaging-guided group had fewer stents implanted, larger maximum diameters of both stents and post-dilation balloons, and a higher proportion of post-dilation (all P<0.05). The intravascular imaging-guided group had a significantly lower cumulative incidence of 2-year MACE than the angiography-guided group (7.3% vs. 13.0%, Plog-rank<0.001); which was primarily attributed to a lower incidence of cardiac death (2.1% vs. 7.5%, Plog-rank<0.001) and non-fatal myocardial infarction (0.9% vs. 2.4%, Plog-rank=0.002). After propensity score matching, the intravascular imaging-guided group still had a lower risk of MACE, cardiac death, and non-fatal myocardial infarction compared with the angiography-guided group (all Plog-rank<0.05). Multivariable Cox regression analysis showed that intravascular imaging guidance was an independent protective factor for 2-year MACE (HR=0.61, 95%CI 0.44-0.85), non-fatal myocardial infarction (HR=0.45, 95%CI 0.21-0.96), and cardiac death (HR=0.44, 95%CI 0.27-0.71). Subgroup analysis further demonstrated that, regardless of lesion complexity, the cumulative incidence of MACE was lower in the intravascular imaging-guided group compared with the angiography-guided group (all Plog-rank<0.05), with no interaction effect observed (Pinteraction=0.928). Conclusion: Compared with angiography guidance, intravascular imaging-guided stent implantation significantly reduces the risk of 2-year MACE in ACS patients, regardless of the presence of complex lesions.