Percutaneous coronary angioplasty (PCI) in patients with acute coronary syndrome (ACS) has reduced mortality in the acute phase. However, recurrent ACS and target vessel failure (TVF) continue to be the subject of clinical analysis. A previous study reported that approximately 7% of patients with ACS developed TVF within one year. These chronic-phase coronary events frequently occur in patients with complex lesions, including culprit lesions with residual lipid-rich plaque, bifurcation lesions, and heavily calcified lesions.
Intravascular imaging, including optical coherence tomography (OCT) and intravascular ultrasound (IVUS), has become an effective modality to improve lesion assessment and procedural precision. Imaging-guided PCI improves lesion characterization, enables accurate stent positioning and implantation, and helps detect complications such as malapposition or edge dissection, which often go unnoticed when angiographic guidance alone is used.
Following guideline recommendations for chronic coronary syndrome, the use of intravascular imaging in ACS patients with complex lesions has become a Class I recommendation in current guidelines. A recent large-scale randomized controlled trial (RCT) reported that IVUS-guided PCI in ACS reduced target vessel failure compared with angiography-guided PCI. However, evidence supporting intravascular imaging–guided PCI in routine clinical practice remains limited.
The objective of this retrospective study was to investigate the association between OCT- and IVUS-guided PCI in patients with ACS and recurrence of the syndrome.
The primary endpoint (PEP) was recurrence of ACS after hospital discharge and during a 3-year follow-up. The secondary endpoint (SEP) was a composite of all-cause death and ACS recurrence.
OCT- and IVUS-Guided PCI in Acute Coronary Syndrome: Significant Reduction in ACS Recurrence at 3 Years
A total of 355,811 patients were analyzed, most of whom were in the 70–79-year age group, with a higher prevalence of male sex. Among patients with ACS, angiography-guided PCI, OCT-guided PCI, and IVUS-guided PCI were performed in 32,044, 22,748, and 297,944 patients, respectively.
During the study period, the rates of OCT- and IVUS-guided PCI increased from 4.7% to 6.9% and from 77.0% to 87.9%, respectively. OCT-guided PCI was associated with a lower risk of ACS recurrence (HR: 0.81; 95% CI: 0.71–0.91; p < 0.001), and IVUS-guided PCI was also associated with a lower risk of ACS recurrence (HR: 0.76; 95% CI: 0.71–0.82; p < 0.001).
Intravascular Imaging in PCI for Acute Coronary Syndrome: OCT and IVUS Associated with Lower Recurrence of Events
In this study, OCT- and IVUS-guided PCI were associated with a reduction in ACS recurrence. These findings highlight the benefits of imaging-guided PCI in the management of ACS. In patients with ACS, greater use of intravascular imaging could translate into clinical benefit by reducing the recurrence of acute coronary events.
Original Title: Intravascular imaging-guided percutaneous coronary intervention in patients with acute coronary syndrome.
Reference: Koki Takegawa et al EuroIntervention 2026;22:e292-e300.
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