Efficacy of intravascular ultrasound-guided primary percutaneous coronary intervention in acute coronary syndrome: a meta-analysis of randomized controlled trials with meta-regression.

Abstract

<h4>Background</h4>Acute coronary syndrome (ACS) is effectively managed with primary percutaneous coronary intervention (PCI), enhanced by intravascular ultrasound (IVUS) for precise stent placement. This meta-analysis evaluates the efficacy and safety of IVUS-guided PCI compared to non-IVUS-guided PCI (e.g., angiography or optical coherence tomography) in ACS patients.<h4>Methods</h4>Following PRISMA guidelines, we searched PubMed, Embase, Cochrane CENTRAL, and ClinicalTrials.gov for randomized controlled trials (RCTs) from January 2014 to August 2024 comparing IVUS-guided PCI with non-IVUS-guided PCI in ACS patients. Nine RCTs involving 11 843 patients (6230 IVUS and 5613 non-IVUS) were included. Outcomes included target lesion revascularization (TLR), target vessel failure (TVF), post-procedural myocardial infarction (MI), stent thrombosis, major adverse cardiac events (MACE), and all-cause mortality. Data were pooled using a random-effects model, with risk ratios (RRs) and 95% confidence intervals (CIs) calculated. Heterogeneity was assessed via <i>I</i> ² statistics, and meta-regression explored study-level influences.<h4>Results</h4>IVUS-guided PCI significantly reduced TLR (RR 0.62, 95% CI 0.48-0.80, <i>P</i> = 0.0002, <i>I</i> ² = 0%), TVF (RR 0.71, 95% CI 0.57-0.89, <i>P</i> = 0.003, <i>I</i> ² = 22%), and post-procedural MI (RR 0.72, 95% CI 0.60-0.87, <i>P</i> = 0.0005, <i>I</i> ² = 0%). Stent thrombosis showed a non-significant reduction (RR 0.62, 95% CI 0.34-1.12, <i>P</i> = 0.11, <i>I</i> ² = 2%). MACE (RR 0.87, 95% CI 0.67-1.11, <i>P</i> = 0.26, <i>I</i> ² = 63%) and all-cause mortality (RR 0.91, 95% CI 0.66-1.26, <i>P</i> = 0.57, <i>I</i> ² = 22%) were not significantly different.<h4>Conclusion</h4>IVUS-guided PCI significantly lowers risks of TLR, TVF, and post-procedural MI in ACS patients, with a trend toward reduced MACE, supporting its use for improved PCI outcomes.