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Meta-Analysis
. 2023 Nov 16:383:e077848.
doi: 10.1136/bmj-2023-077848.

Intravascular imaging guided versus coronary angiography guided percutaneous coronary intervention: systematic review and meta-analysis

Safi U Khan  1 , Siddharth Agarwal  2 , Hassaan B Arshad  1 , Usman Ali Akbar  3 , Mamas A Mamas  4   5 , Shilpkumar Arora  6 , Usman Baber  7 , Sachin S Goel  1 , Neal S Kleiman  1 , Alpesh R Shah  1
Affiliations
Meta-Analysis

Intravascular imaging guided versus coronary angiography guided percutaneous coronary intervention: systematic review and meta-analysis

Safi U Khan et al. BMJ. .

Abstract

Objective: To assess the absolute treatment effects of intravascular imaging guided versus angiography guided percutaneous coronary intervention in patients with coronary artery disease, considering their baseline risk.

Design: Systematic review and meta-analysis.

Data sources: PubMed/Medline, Embase, and Cochrane Library databases up to 31 August 2023.

Study selection: Randomized controlled trials comparing intravascular imaging (intravascular ultrasonography or optical coherence tomography) guided versus coronary angiography guided percutaneous coronary intervention in adults with coronary artery disease.

Main outcome measures: Random effect meta-analysis and GRADE (grading of recommendations, assessment, development, and evaluation) were used to assess certainty of evidence. Data included rate ratios and absolute risks per 1000 people for cardiac death, myocardial infarction, stent thrombosis, target vessel revascularization, and target lesion revascularization. Absolute risk differences were estimated using SYNTAX risk categories for baseline risks at five years, assuming constant rate ratios across different cardiovascular risk thresholds.

Results: In 20 randomized controlled trials (n=11 698), intravascular imaging guided percutaneous coronary intervention was associated with a reduced risk of cardiac death (rate ratio 0.53, 95% confidence interval 0.39 to 0.72), myocardial infarction (0.81, 0.68 to 0.97), stent thrombosis (0.44, 0.27 to 0.72), target vessel revascularization (0.74, 0.61 to 0.89), and target lesion revascularization (0.71, 0.59 to 0.86) but not all cause death (0.81, 0.64 to 1.02). Using SYNTAX risk categories, high certainty evidence showed that from low risk to high risk, intravascular imaging was likely associated with 23 to 64 fewer cardiac deaths, 15 to 19 fewer myocardial infarctions, 9 to 13 fewer stent thrombosis events, 28 to 38 fewer target vessel revascularization events, and 35 to 48 fewer target lesion revascularization events per 1000 people.

Conclusions: Compared with coronary angiography guided percutaneous coronary intervention, intravascular imaging guided percutaneous coronary intervention was associated with significantly reduced cardiac death and cardiovascular outcomes in patients with coronary artery disease. The estimated absolute effects of intravascular imaging guided percutaneous coronary intervention showed a proportional relation with baseline risk, driven by the severity and complexity of coronary artery disease.

Systematic review registration: PROSPERO CRD42023433568.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: no support from any organization for the submitted work; NSK has received grants or contracts from Boston Scientific for work as a clinical trial investigator; SSG has received consulting fees from Medtronic, JC Medical, and WL Gore Associates and honorariums from Abbott Structural Heart; MAM has received institutional grants from Abbott Vascular and Terumo and honorariums from Terumo, Amgen, and Abbott Vascular Biosensors; UB has received honorariums from Boston Scientific and Abbott; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Flowchart of study selection
Fig 2
Fig 2
Forest plot comparing intravascular imaging guided with coronary angiography guided percutaneous intervention for cardiac death. Data obtained from randomized controlled trials using random effect meta-analysis and expressed as rate ratio. CI=confidence interval; M-H=Mantel-Haenszel
Fig 3
Fig 3
Forest plot comparing intravascular imaging guided with coronary angiography guided percutaneous intervention for myocardial infarction (bottom). Data obtained from randomized controlled trials using random effect meta-analysis and expressed as rate ratio. CI=confidence interval; M-H=Mantel-Haenszel
Fig 4
Fig 4
Forest plot comparing intravascular imaging guided with coronary angiography guided percutaneous intervention for stent thrombosis. Data obtained from randomized controlled trials using random effect meta-analysis and expressed as rate ratio. CI=confidence interval; M-H=Mantel-Haenszel
Fig 5
Fig 5
Forest plot comparing intravascular imaging guided with coronary angiography guided percutaneous intervention for target vessel revascularization. Data obtained from randomized controlled trials using a random effect meta-analysis and expressed as rate ratio. CI=confidence interval; M-H=Mantel-Haenszel
Fig 6
Fig 6
Forest plot comparing intravascular imaging guided with coronary angiography guided percutaneous coronary intervention for target lesion revascularization. Data obtained from randomized controlled trials using random effect meta-analysis and expressed as risk ratio. CI=confidence interval; M-H=Mantel-Haenszel
Fig 7
Fig 7
Forest plot comparing intravascular imaging guided with coronary angiography guided percutaneous coronary intervention for all cause death. Data obtained from randomized controlled trials using random effect meta-analysis and expressed as risk ratio. CI=confidence interval; M-H=Mantel-Haenszel
See this image and copyright information in PMC

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