Use of intravascular ultrasound and long-term cardiac death or myocardial infarction in patients receiving current generation drug-eluting stents

Abstract

Long-term follow-up data on differential effects of intravascular ultrasound (IVUS) according to lesion complexity are limited in patients undergoing percutaneous coronary intervention (PCI). The current study compared long-term clinical outcomes between IVUS-guided and angiography-guided PCI in patients with second-generation drug-eluting stents (DES). Between February 2008 and December 2015, 5488 patients undergoing PCI with second-generation DES were recruited from an institutional registry of Samsung Medical Center. The primary outcome was a composite of cardiac death or myocardial infarction (MI) during 46 months of median follow-up (interquartile range: 32-102 months). IVUS-guided PCI was performed in 979 patients (17.8%). IVUS-guided PCI was associated with a significantly lower risk of cardiac death or MI compared with angiography-guided PCI (5.7% vs. 12.9%, hazard ratio 0.408, 95% confidence interval 0.284-0.587, p < 0.001). Results were consistent after propensity score matching analysis with 801 matched pairs. In subgroup analysis, there was no significant interaction between lesion complexity (defined by complex procedures, P_interaction = 0.819, ACC/AHA lesion classification, P_interaction = 0.401 or SYNTAX score, P_interaction = 0.149) and use of IVUS for risk of cardiac death or MI. IVUS-guided second-generation DES implantation was associated with a significantly lower long-term risk of cardiac death or MI compared with angiography guidance, regardless of lesion complexity.

Figure 1

Study flow. A flow diagram is shown. DES, drug-eluting stent; IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention.

Figure 2

Proportion of IVUS-guided PCI according to lesion complexity. The bar chart shows proportion of IVUS-guided PCI according to lesion complexity. The proportion of IVUS-guided PCI (red bar) versus angiography-guided PCI (blue bar) are shown. *Complex procedure is defined as bifurcation, chronic total occlusion, left main disease, long lesion, multivessel PCI, multiple stent implantation, in-stent restenosis, or heavily calcified lesion. ^†AHA/ACC lesion classification. IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention; SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery.

Figure 3

Comparison of primary composite endpoint between IVUS-guided PCI versus angiography-guided PCI in overall and propensity score matched population. The Kaplan–Meier survival curve is shown for the comparison of primary composite endpoint (cardiac death or MI) between IVUS-guided PCI (red line) and angiography-guided PCI (blue line) in overall (A) and propensity-matched population (B). IVUS, intravascular ultrasound; MI, myocardial infarction; PCI, percutaneous coronary intervention.

Figure 4

Subgroup analysis according to lesion complexity and clinical complexity. A forest plot shows the subgroup analysis with comparative hazard ratio and 95% confidence interval of cardiac death or MI in overall population (A) and matched population (B) between IVUS- versus angiography-guided PCI. *Complex procedure is defined as bifurcation, chronic total occlusion, left main disease, long lesion, multivessel PCI, multiple stent implantation, in-stent restenosis, or heavily calcified lesion. ^†AHA/ACC lesion classification. CI, confidence interval; HR, hazard ratio; IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention.