Intravascular ultrasound (IVUS) guidance is associated with a lower risk of target lesion failure at 3 years in patients with acute myocardial infarction (AMI) who receive second-generation drug-eluting stent implantation compared with those who receive angiography guidance, according to a study published in the Journal of the American Heart Association.

Researchers assessed the long-term impact of IVUS-guided second-generation drug-eluting stent implantation in patients with AMI. They used data from the multicenter, prospective Korea Acute Myocardial Infarction–National Institutes of Health registry.

Among 13,104 patients enrolled in the registry, the study authors selected patients who received percutaneous coronary intervention (PCI) with second-generation drug-eluting stent implantation between November 2011 and December 2015.


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The primary outcome was target lesion failure at 3 years after the index procedure, which was defined as the composite of cardiac death, target vessel myocardial infarction (MI), and ischemia-driven target lesion revascularization.

A total of 1887 patients (21.0%; mean age, 62.4 years; 78.8% men) had IVUS guidance, and 7120 (79.0%; mean age, 63.6 years; 74.3% men) had angiography guidance for second-generation drug-eluting stent implantation. The median follow-up was 1099 days (IQR, 1058-1130 days).

The IVUS-guided group had a significantly lower 3-year risk of target lesion failure compared with the angiography-guided group (4.8% vs 8.0%; hazard ratio [HR], 0.59; 95% CI, 0.47-0.73; P <.001), which was driven primarily by a significantly lower risk for cardiac death and target vessel MI in the IVUS-guided group.

Sensitivity analyses with multivariable Cox regression, propensity score matching, and inverse probability weighting adjustment consistently showed a significantly lower risk of all-cause death, cardiac death, target vessel MI, target lesion failure, and major adverse cardiovascular events in the IVUS-guided PCI group compared with the angiography-guided PCI group.

The investigators also analyzed quartiles of IVUS-guided PCI volume in patients with AMI who had PCI with second-generation drug-eluting stent implantation in the 20 centers participating in the study. Institutional usage of IVUS guidance ranged from 3.7% in quartile 1 to 71.0% in quartile 4. Higher institutional IVUS use was associated with a reduced risk for 3-year target lesion failure (adjusted HR, 0.58; 95% CI, 0.45-0.75; P <.001 for quartile 1 vs quartile 4; P <.001 for trend comparison across all quartiles).

Subgroup analysis showed that the significantly lower risk for target lesion failure in the IVUS-guided PCI group compared with the angiography-guided PCI group was consistent in all subgroups except in patients aged less than 65 years.

Study limitations include the nonrandomized, observational registry data, which might have resulted in selection bias. In addition, data were not available regarding whether postdilation had been performed, as well as maximum balloon pressure, total procedure time, total radiation dose, amount of contrast volume, and occurrence of contrast-induced nephropathy. In addition, all types of second-generation drug-eluting stents were included in the analysis.

“Intravascular ultrasound-guidance for acute myocardial infarction PCI should be given greater consideration where the clinical and financial circumstances allow, to enhance long-term patient outcomes,” the researchers noted.

Disclosure: One of the study authors declared an affiliation with a device company. Please see the original reference for a full list of authors’ disclosures

Reference

Kim Y, Bae SA, Johnson TW, et al. Role of intravascular ultrasound-guided percutaneous coronary intervention in optimizing outcomes in acute myocardial infarction. J Am Heart Assoc. Published online February 18, 2022. doi: 10.1161/JAHA.121.023481