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. 2025 Jul 21:12:1604050.
doi: 10.3389/fcvm.2025.1604050. eCollection 2025.

Comparison of intravascular imaging, physiological assessment and angiography for coronary revascularization in acute coronary syndrome: a systematic review and network meta-analysis

Xuan-Yan Liu  1 , Bin-Hua Ye  1 , Xian-Dan Wu  1 , Yue Lin  1 , Xian Lin  1 , Yan-Yan Li  1 , Jing-Chao Sun  2
Affiliations

Comparison of intravascular imaging, physiological assessment and angiography for coronary revascularization in acute coronary syndrome: a systematic review and network meta-analysis

Xuan-Yan Liu et al. Front Cardiovasc Med. .

Abstract

Background: The optimal percutaneous coronary intervention (PCI) technique to treat acute coronary syndrome (ACS) requires further investigation. This network meta-analysis evaluated the effects of physiological assessment and intravascular imaging techniques on the prevalence of adverse cardiac outcomes following PCIs.

Methods: We reviewed PubMed, Cochrane, and EMBASE databases for the purpose of identifying all randomized control trials published up to October 30, 2024, comparing the impact of intravascular imaging, physiology assessment, or angiography techniques on outcomes. The primary outcome for this research was major adverse cardiovascular events (MACE) occurrences. Each PCI strategy was ranked as per the risk ratio (RR) at the 95% confidence interval (95% CI) for developing MACE.

Results: Twenty-eight RCTs with 18,221 patients were identified. Compared with angiography, intravascular ultrasound (IVUS)- (RR: 0.62; 95%CI: 0.46-0.85) and fractional flow reserve (FFR)-guided PCI (RR: 0.62; 95%CI: 0.46-0.85) reduced the risk of MACE. Patients who received quantitative flow ratio (QFR)-guided PCI experienced lower all-cause mortality (RR: 0.25; 95%CI: 0.07-0.92) vs. those receiving angiography. Similarly, the RR decreased to 0.64 after using FFR-guided PCI vs. angiographic procedures (95% CI: 0.44-0.91). Compared to angiography, the subgroup analysis showed inconsistent results for IVUS-guided PCI in preventing MACE for both the optimization (RR: 0.60; 95%CI: 0.49-0.74) and decision-making (RR: 0.55; 95%CI: 0.05-6.18). The likelihood of developing MACE was lower for FFR-guided CR than for angiography-guide culprit-only PCIs (RR-0.72; 95%CI: 0.53-0.97), as confirmed by sensitivity assessment results. The research unveiled no statistically significant differences between FFR-guided culprit-only PCIs and culprit-only PCIs or angiography-guided CR.

Conclusion: IVUS- and FFR-guided PCI lowers the MACE risk in patients with ACS. In addition, IVUS achieved the best results in ACS patients undergoing PCI.

Systematic review registration: INPLASY (inplasy.com), INPLASY202420092.

Keywords: acute coronary syndrome; angiography; coronary revascularization; intravascular imaging; physiology assessment.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Network plot of intravascular imaging-guided, physiology-guided, and angiography-guided PCI for MACE.
Figure 2
Figure 2
Network meta-analysis for MACE.
Figure 3
Figure 3
Rankogram of the six strategies for MACE.
Figure 4
Figure 4
Network meta-analysis for MACE in sensitivity analysis. Angiography1, angiography-guided CR; Angiography2, Angiography-guided culprit-only PCI; FFR1, FFR-guided CR; FFR2, FFR-guided culprit-only PCI; QFR1, QFR-guided CR; QFR2, QFR-guided culprit-only PCI.
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